Older Breast Cancer Survivors' Views and Preferences for Physical Activity
Identifieur interne : 001C12 ( Istex/Corpus ); précédent : 001C11; suivant : 001C13Older Breast Cancer Survivors' Views and Preferences for Physical Activity
Auteurs : Sarah Whitehead ; Katrina LavelleSource :
- Qualitative Health Research [ 1049-7323 ] ; 2009-07.
Abstract
Evidence suggests that physical activity improves quality of life and physical functioning among breast cancer patients and survivors. However, previous studies have tended to focus on younger patients, despite higher incidence and lower survival among older breast cancer survivors. In this study we explored physical activity preferences of older breast cancer survivors to inform the development of future targeted interventions. Twenty-nine female breast cancer survivors (1 to 5 years postdiagnosis) aged 59 to 86 (mean 66.54, SD 6.50) took part in either a semistructured interview or a focus group exploring physical activity patterns, motivators, facilitators, barriers, and preferences. The main factors influencing physical activity were body image, weight issues, vitality, mood, and the desire to carry on as normal. Preference was expressed for activities that were gentle, tailored to age and cancer-related abilities, holistic, involving other older breast cancer survivors, and with an instructor who was knowledgeable about both breast cancer and aging.
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DOI: 10.1177/1049732309337523
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Older Breast Cancer Survivors' Views and Preferences for Physical Activity</title><author wicri:is="90%"><name sortKey="Whitehead, Sarah" sort="Whitehead, Sarah" uniqKey="Whitehead S" first="Sarah" last="Whitehead">Sarah Whitehead</name><affiliation><mods:affiliation>University of Manchester, Manchester, United Kingdom</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Lavelle, Katrina" sort="Lavelle, Katrina" uniqKey="Lavelle K" first="Katrina" last="Lavelle">Katrina Lavelle</name><affiliation><mods:affiliation>University of Manchester, Manchester, United Kingdom</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:3D527612FA45E56C29BDD3E2133C4D97D29207C8</idno><date when="2009" year="2009">2009</date><idno type="doi">10.1177/1049732309337523</idno><idno type="url">https://api.istex.fr/document/3D527612FA45E56C29BDD3E2133C4D97D29207C8/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">001C12</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">001C12</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Older Breast Cancer Survivors' Views and Preferences for Physical Activity</title><author wicri:is="90%"><name sortKey="Whitehead, Sarah" sort="Whitehead, Sarah" uniqKey="Whitehead S" first="Sarah" last="Whitehead">Sarah Whitehead</name><affiliation><mods:affiliation>University of Manchester, Manchester, United Kingdom</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Lavelle, Katrina" sort="Lavelle, Katrina" uniqKey="Lavelle K" first="Katrina" last="Lavelle">Katrina Lavelle</name><affiliation><mods:affiliation>University of Manchester, Manchester, United Kingdom</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Qualitative Health Research</title><idno type="ISSN">1049-7323</idno><idno type="eISSN">1552-7557</idno><imprint><publisher>SAGE Publications</publisher><pubPlace>Sage CA: Los Angeles, CA</pubPlace><date type="published" when="2009-07">2009-07</date><biblScope unit="volume">19</biblScope><biblScope unit="issue">7</biblScope><biblScope unit="page" from="894">894</biblScope><biblScope unit="page" to="906">906</biblScope></imprint><idno type="ISSN">1049-7323</idno></series><idno type="istex">3D527612FA45E56C29BDD3E2133C4D97D29207C8</idno><idno type="DOI">10.1177/1049732309337523</idno><idno type="ArticleID">10.1177_1049732309337523</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1049-7323</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Evidence suggests that physical activity improves quality of life and physical functioning among breast cancer patients and survivors. However, previous studies have tended to focus on younger patients, despite higher incidence and lower survival among older breast cancer survivors. In this study we explored physical activity preferences of older breast cancer survivors to inform the development of future targeted interventions. Twenty-nine female breast cancer survivors (1 to 5 years postdiagnosis) aged 59 to 86 (mean 66.54, SD 6.50) took part in either a semistructured interview or a focus group exploring physical activity patterns, motivators, facilitators, barriers, and preferences. The main factors influencing physical activity were body image, weight issues, vitality, mood, and the desire to carry on as normal. 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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Whitehead</surname><given-names>Sarah</given-names></name><aff>University of Manchester, Manchester, United Kingdom</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Lavelle</surname><given-names>Katrina</given-names></name><aff>University of Manchester, Manchester, United Kingdom</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>07</month><year>2009</year></pub-date><volume>19</volume><issue>7</issue><fpage>894</fpage><lpage>906</lpage><abstract><p>Evidence suggests that physical activity improves quality of life and physical functioning among breast cancer patients and survivors. However, previous studies have tended to focus on younger patients, despite higher incidence and lower survival among older breast cancer survivors. In this study we explored physical activity preferences of older breast cancer survivors to inform the development of future targeted interventions. Twenty-nine female breast cancer survivors (1 to 5 years postdiagnosis) aged 59 to 86 (mean 66.54, <italic>SD</italic> 6.50) took part in either a semistructured interview or a focus group exploring physical activity patterns, motivators, facilitators, barriers, and preferences. The main factors influencing physical activity were body image, weight issues, vitality, mood, and the desire to carry on as normal. Preference was expressed for activities that were gentle, tailored to age and cancer-related abilities, holistic, involving other older breast cancer survivors, and with an instructor who was knowledgeable about both breast cancer and aging.</p></abstract><kwd-group><kwd>breast cancer</kwd>
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<kwd>exercise</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>894 Older Breast Cancer Survivors' Views and Preferences for Physical Activity SAGE Publications, Inc.200910.1177/1049732309337523 SarahWhitehead University of Manchester, Manchester, United Kingdom KatrinaLavelle University of Manchester, Manchester, United Kingdom Evidence suggests that physical activity improves quality of life and physical functioning among breast cancer patients and survivors. However, previous studies have tended to focus on younger patients, despite higher incidence and lower survival among older breast cancer survivors. In this study we explored physical activity preferences of older breast cancer survivors to inform the development of future targeted interventions. Twenty-nine female breast cancer survivors (1 to 5 years postdiagnosis) aged 59 to 86 (mean 66.54, SD 6.50) took part in either a semistructured interview or a focus group exploring physical activity patterns, motivators, facilitators, barriers, and preferences. The main factors influencing physical activity were body image, weight issues, vitality, mood, and the desire to carry on as normal. Preference was expressed for activities that were gentle, tailored to age and cancer-related abilities, holistic, involving other older breast cancer survivors, and with an instructor who was knowledgeable about both breast cancer and aging. breast cancer exercise older people older people exercise B reast cancer is the most commonly occurring cancer in women in the United Kingdom, with around 44,000 women being diagnosed with breast cancer each year (Cancer Research UK, 2007). Early detection and improved treatments for breast cancer have led to increased survival rates, and the current 5-year relative survival rate for women in England is estimated to be 81% (Coleman et al., 2004; Office for National Statistics [ONS], 2007). However, the 5-year relative survival for breast cancer in England reduces substantially with increasing age, from 88% of 50- to 59-year-olds to 63% of women aged ≥80 years (ONS, 2007). In addition, the grueling treatments that cancer patients endure can often result in a significant decrease in quality of life (Courneya & Friedenreich, 1999). The role of physical activity in enhancing quality of life in cancer survivors has received increasing attention in recent years, with many reviews suggesting that physical activity might be an effective quality-of-life intervention, particularly among breast cancer survivors (Courneya, 2003, 2005; Courneya, Mackey, & McKenzie, 2002). Findings from a recent review of the effects of exer- cise on breast cancer patients and survivors suggest that exercise is an effective intervention to improve quality of life, cardiorespiratory fitness, physical functioning, and fatigue (McNeely et al., 2006). Recent evidence also suggests that moderate levels of physical activity might reduce the risk of death from the disease after a breast cancer diagnosis (Holmes, Chen, Feskanich, Kroenke, & Colditz, 2005). Physical activity might therefore prove to be valuable to breast cancer survivors not only in improving quality of life, but also in overall survival. The American Cancer Society recommends that all cancer survivors engage in regular physical activity (Brown et al., 2003); however, research has shown that participation in physical activity in the United States decreases during treatment for breast cancer, and can remain decreased even years after treatment is completed. This is particularly true with reference to moderate and vigorous physical activity levels among obese women, the proportion of whom increases with age (Irwin et al., 2003; Irwin et al., 2004). Among the general population of women in the United Kingdom, Authors' Note:We thank all of the participants as well as Cancer Help Preston and Macmillan Cancer Support for all their help with this study. The study was funded by the School of Nursing, Midwifery and Social Work's Pump Priming Fund. 895 data from the Allied Dunbar National Fitness Survey (Sports Council and Health Education Authority, 1992) also shows a dramatic increase, with age, in individuals below an estimated healthy physical activ- ity threshold. It seems likely, therefore, that physical activity participation will be particularly problematic for older breast cancer survivors. Although many randomized controlled trials (RCTs) have focused on physical activity and quality of life (QOL) during breast cancer treatment, only a handful of them have concentrated specifically on the posttreatment period, and many of these have been methodologically flawed (Courneya, 2003). Furthermore, RCTs to date have not targeted recruit- ment of older breast cancer survivors, and therefore severely underrepresent them (Courneya et al., 2004). This is not reflective of the higher incidence of breast cancer and lower survival rate among older patients (ONS, 2007, 2008). Courneya et al. (2004) do argue that studies finding benefits of physical activity in populations of breast cancer survivors of all ages, as well as in the general population of older people, are tentatively generalizable to older breast cancer survi- vors, but they also highlight a need to target older age groups in future studies. Finally, RCTs have been based on the “prescrip- tion” of physical activity, and have not taken into account the preferences and needs of breast cancer survivors themselves, despite evidence to suggest that tailoring physical activity programs to the prefer- ences of the target population can increase adoption and maintenance of the program (Mills, Stewart, Sepsis, & King, 1997; Thompson & Wankel, 1980). Research examining the physical activity preferences of cancer survivors has been limited: Although a postal survey investigated the preferences of survi- vors aged 31 to 81 of prostate, breast, colorectal, or lung cancer (Jones & Courneya, 2002), no located research has explored preferences among age- and cancer-specific subgroups, where preferences, moti- vators, and barriers are likely to differ (Courneya et al., 2004). The purpose of this study was to explore the physical activity preferences of older female breast cancer survivors. Specifically, we explored physical activity patterns before the illness, during the course of and immediately after the illness, and in the pres- ent day. We also examined physical activity motiva- tors, facilitators, and barriers. Finally, we investigated participants' views of and preferences for a tailored physical activity program. Methods Participants Participants were 29 female breast cancer survi- vors aged between 59 and 86 years (M = 66.54, SD = 6.50), who were between 1 and 5 years postdiagnosis, and not undergoing any treatment other than hormone therapy at the time of the study. Three participants declined to give their date of birth but confirmed that they were 60 years old or older at the time of their interview. Participants were recruited from a number of breast cancer support groups in and around the cities of Manchester and Derby in the United Kingdom, and via a cancer charity based in Preston, also in the United Kingdom. Following a presenta- tion, information sheets and response slips were left at the meeting to enable those interested to contact the researchers for more details. The cancer charity maintained a database of older female breast cancer survivors who had used the charity's services. Women listed in this database were contacted via letter invit- ing them to take part in the study. A participant infor- mation sheet and reply slip were included with the letter so that those interested could again contact the researchers for more information. The participants were predominantly White European. Socioeconomic status was not measured. Procedure Of the 29 women who agreed to participate, 19 were interviewed individually, and 10 took part in one of three focus groups. Individual interviews took place either at the participants' homes or at the cancer charity's premises; all three focus groups took place at the charity's premises. The participants were fully briefed before they were interviewed and were given the opportunity to ask questions. They were also informed that the sessions would be tape-recorded and that they were free to end the interview at any time. They were then asked to sign consent forms before the interviews commenced. The interviews and focus groups took a semistructured format and examined current and previous physical activity pat- terns, physical activity motivators and facilitators, perceived and actual barriers, and preferences for a physical activity program targeted toward older breast cancer survivors. At the end of each session participants were asked if there was anything they would like to add or if there was anything that we should have discussed but had not. Each session 896 lasted between 30 and 90 minutes. Each participant was given a £10 voucher to thank them for taking part in the study. All interviews were audiotaped and tran- scribed verbatim. Ethical approval for the study was granted by the Research Ethics Committee of the School of Nursing, Midwifery and Social Work at the University of Manchester. Analysis A thematic analysis (Joffe & Yardley, 2004) was carried out using the following steps. First, all tran- scriptions were read and reread several times to enable the researchers to become fully familiar with the data. Data were then analyzed into predetermined themes in line with the interview topics. Within each interview, meaningful segments of text were identi- fied that contained one idea, episode, or piece of information (Tesch, 1990). Each segment of text was then examined to determine which topic it belonged to. Once all meaningful pieces of text had been iden- tified and allocated to a topic, constant comparison, an approach drawn from grounded theory (Glaser & Strauss, 1967), was used to identify similarities and differences in opinions within each theme. Quotes considered to represent the same concept were clus- tered together to allow the emergence of categories of data within the overarching themes. To ensure the trustworthiness of the data, the two researchers ana- lyzed the data independently before meeting to dis- cuss their findings. Following the recommendation of Tesch (1990), the whole process remained flexible, meaning that labels and themes could be modified and refined until the most “`reasonable' reconstruc- tion of the data” had been developed (Lincoln & Guba, 1985; Tesch, 1990). Findings Physical Activity Levels Before Diagnosis, and During and Immediately After Treatment The women told us that prior to their breast cancer diagnoses they participated in a wide range of physi- cal activities, from mild-intensity activities such as walking, dancing, and other gentle exercises, to more moderate activities such as cycling, through to those who took part in more vigorous activity such as aero- bic gym sessions several times a week. A small group of women also identified that their busy lifestyles were the main source of their physical activity, whether this was from housework and childcare or from paid work, which was mainly highlighted by women who were employed in manual jobs: Yeah, I was [working in a shop] which was filling shelves up and everything like that, and I had a cleaning job as well. I think I had, by then two clean- ing jobs, so yeah, they were quite physical, I mean one was 4 hours a week, and it was a strenuous, it was a big house. During and immediately after their treatment, however, the women informed us that their physical activity levels were greatly reduced. Reasons for this included being sore after operations, feeling ill from chemotherapy and radiotherapy, and generally not “feeling like it.” When they did resume physical activity, the types and intensity of activity were greatly reduced as a result of the treatments and after effects: I had to have a mastectomy so that took virtually 6 months out of my life of exercise. I did go back after I had the operations, but I really only did swimming and light work in the gym. The women also reported a lack of motivation immediately after the completion of their treatment, and that this resulted in reduced levels of physical activity: Oh yes, greatly reduced. Obviously I did walk and I don't think I cycle very much even now, I just didn't feel like it. You do get some periods when you just can't be bothered to do anything, it's very tiresome. Those are the days I just didn't get things going; I didn't do the housework or anything. This might be indicative of a period of posttreat- ment depression, and was identified by some of the women in our study as affecting their physical activity levels: I think your emotions do affect your physical activity as well, because you tend to go a bit depressed, don't you? Current Physical Activity Levels A wide range of physical activities was again rep- resented in women's current exercise patterns. Two activities that seemed to be particularly popular were swimming and walking. Gardening and lifestyle-related 897 activities also seemed to be more prevalent. Although a couple of women told us that the intensity and fre- quency of activities was similar to before the illness, the general trend was for physical activity levels to now be reduced: Previously I loved physical activity. I used to do aerobics and Pilates I liked very much and I would like to get back into it I think, I really would because I know I would feel better if I did. I would have a better self-image and I would feel better. Various factors that might have contributed to cur- rent physical activity levels are now discussed. Motivators for Physical Activity The participants identified physical activity moti- vators that could be grouped under four main cate- gory headings. First, participants spoke of health as a motivator, both in terms of the fact that being physi- cally active “does you good,” and that it can help to fight the aging process. Many were also motivated to be physically active so as to control other medical conditions: No, I mean really I would say it's not all that impor- tant, apart from the fact that without it I wouldn't keep going, because I know very well me legs would seize up, and so on, and it's the old saying, use it or lose it, so I shall keep going for that more than any- thing, just to make sure that I can keep going. I've got arthritis, I've got osteoarthritis, so um, I feel like I've felt at a level where I thought, yeah, I should be doing something more. The second motivator related to weight loss and a better self-image. Many of the participants spoke of wanting to lose weight to feel better about them- selves, and felt that physical activity could help with this: It's just knowing what to do, really, which exercise would be better for me . . . it's just what is going to be best for me to (a) lose some weight, and (b) to feel better about myself. I think walking is very good. Third, the women expressed a desire to carry on, to be “normal.” Many of them felt that they didn't want to let having had cancer interfere with their lives. They felt that having had cancer did not make them invalids, and that the best approach was to just carry on with things as they always had done: I just think I've had me breast off, but that's it, it shouldn't stop you doing anything, really, I'm not an invalid, so why shouldn't I do the things that I used to do, just the same, so that's me, that motivates me, I want to carry on to be as normal as possible. The final motivator identified by the participants was enjoyment. For those women who had found an activity they particularly enjoyed, this was their main reason for taking part. There was also acknowledge- ment that trying to force oneself to do unenjoyable activities would not lead to prolonged participation: There was once a program on television, and it was about doing. It was on a Sunday evening, it was a really good time because people watched it, it was about doing activities, and the important thing was you had to enjoy them, it was no good, it's like me saying I'll go jogging. I wouldn't enjoy jogging, you know, I'd go a few times, I wouldn't do it anymore, because I, I don't, I don't think they're happy when they jog. I think, you know, it's just not for me, so it's no good my going jogging. Benefits of Being Physically Active Many of the benefits of being physically active identified by the participants were similar in nature to the motivators. Here, however, the participants spoke of positive outcomes as opposed to factors that made them wish to be active in the first place. The first and by far the most common benefit identified was that of positive well-being and increased energy levels, with many of the participants emphasizing how much better physical activity made them feel: I feel better for doing something, I love going out and swimming, I feel so much better. If I don't do physical activity I feel a bit sluggish because I've always done it. And I love getting out, doing things, you know. Many of the participants again spoke about physi- cal activity in relation to their weight, and mentioned that being physically active could help them to reduce and manage their weight. Some of the participants also felt that being active had prevented them from gaining weight while taking Tamoxifen: I was talking to [name], who's the lymphedema nurse at [hospital], and she was the one who recom- mended I went swimming, so I, I see her at, she goes to the same place, and I said, “I finished my Tamoxifen in May.” “Oh have you?” she said. “You 898 didn't put any weight on, did you?” and we're stand- ing there in our swimming costumes. “Well probably put a bit on.” “Oh,” she said, “the amount of women I see who come to the lymphedema clinic, and pile the weight on, and they always blame the Tamoxifen.” And she said, “I think it's lack of exercise.” Participants also spoke about the role of physical activity in helping them to still be able to carry out their daily activities. Although for some women this related distinctly to fighting the aging process, for others it was a case of being fit for a specific purpose, such as walking or looking after grandchildren: You know there are women, I hear people of the same age saying, “I don't do that anymore, I don't drive a car at night, or I don't do this, I don't do that.” And I am thinking, hang on a minute—if you're giving out you know, that's the beginning. Within limits most things are possible and that is the big benefit, and I know people who struggle with their legs with circulation and things and say, “Oh I can't walk very far,” or “I don't go there,” it's you know, I don't want to go down that road yet, until it comes. I've got a little grandson and I'm going down to look after him for a day which I haven't done before, so I'm going to need all my strength for that. The final benefit identified related to physical activity giving participants a reason to get out of the house and see other people. Here participants spoke of their days being more empty since retirement, and how physical activity could provide some structure. They also stated that through physical activity they had met new friends and enhanced their social lives: I have met people and at the end we had said, “We must have coffee together,” and things like this, so it just widens my social life, my husband says that I am never in. Barriers to Physical Activity Unfortunately, the participants identified many more barriers to physical activity than they did ben- efits. These related to a variety of topics, ranging across practical, health-related, and psychological issues. Many of the participants spoke of a lack of time preventing them from being as active as they would like. Many of them had full and busy lives with family commitments, and felt that they simply could not fit any more in: Maybe it's simply because I haven't time. I think if I have more time I would be more inclined to think, right, well once a week, or twice a week I would go swimming, or I would go to the gym or something. I think it is, it all is down to the timescale because there's so much going on now, and I feel I don't want to go too far and leave my mother anyway, so when I come home I just want to sit down and relax. Several health-related barriers emerged, related to both having had cancer and other complications asso- ciated with growing older. Participants spoke of being afraid of getting lymphedema and soreness from che- motherapy burns. One woman also spoke of a lack of muscle tissue following reconstructive surgery: Because I had the reconstruction and they took my stomach muscles it was the stomach that had given me the problem. It has not been so much the recon- struction or my arm, it's the stomach surgery because as you are aware that is quite traumatic and quite intense, and I am only now just trying to get back and get some shape and strength back into my stom- ach, and that is where I feel as though I have been let down, and I asked about it, although they just said, “Just take it easy, just do what you're capable of doing,” but you're frightened. I find that with the arm and everything you need really somebody as you say sort of an exercise class that are aware of the arm and of pushing yourself too much, or be careful here. Other health-related barriers were wide-ranging. Participants spoke of side effects from medications and other illnesses. The main health-related barrier, however, related to the fact that the participants were simply getting older and were starting to feel stiff: I just feel I have stiffened up completely now. I just ache all over now, it's very, very difficult, when you stop, and like they say, if you don't use it you lose it. Several of the participants spoke of a lack of moti- vation preventing them from being physically active. Many of them felt that if only they could motivate themselves to get going, they would benefit from it. A further complication arose for some women in that they now had to battle increased feelings of fatigue or low mood: I think there is a general tiredness as well that is, per- haps my biggest demotivator is that I am constantly tired, I can't do this and it's a real push. 899 Two main psychological barriers relating to having had breast cancer emerged. The first centered around feelings of self-consciousness while being physically active, especially among those who had undergone mastectomies or lumpectomies. Many of the participants spoke of feeling self-conscious in changing rooms and in swimming pools. Concerns were also expressed over prostheses that took a long time to dry after swimming, or even “flew out” while doing aerobics: One of the things that is important is, I remember the first time I went in the swimming pool, it was a women's weekend thing in a hotel and you could have beauty treatments and a swim and I was extremely anxious. It was before my reconstruction and I had a pad, so when you come out of the swim- ming pool you have to put your arm there and squeeze the water out or sometimes you get water running from it, and I thought, I have got to go into that changing room. As I say, when I go swimming I get undressed in a communal changing [area], they're all little booths, and you only go, but I don't bother, and I just take off my top, and I always feel self-conscious, because I've got this lumpectomy, I've got sort of half of a boob here, but I don't wear anything, because one I've got my bra on, you can't possibly tell. But when I'm get- ting undressed I always think, oh is anybody looking, you know, and I think if I'd had a mastectomy I'd feel very conscious, I would go in a cubicle. Finally, many of the participants spoke of a fear of overdoing it post-illness. This fear stemmed from the period immediately posttreatment. Most women reported being visited by the physiotherapist in hos- pital immediately after their surgery, and being given written information concerning specific exercises to aid recovery and minimize complications. They gen- erally felt, however, that the information was too brief, and was given at a time when they had too much other information to take in: I think the exercises when you leave the hospital, if somebody could have just explained them a little bit more, that was all. It was very much, “Here is the paper, you do this and you put your hand up the wall,” and she had gone before you, you didn't have time to take it all in, because you're a bit bombarded by lots of information at the beginning. You get so much thrown at you and you get home and think, “What did they say?” and you find you have to sit down and think about it. Although the women acknowledged the support and advice given by members of the breast team in follow-up clinics at a later date, when they were more able to take the information in, they still felt uncer- tainty regarding which types of exercise were safe, and what period of time they should wait before returning to physical activity. Furthermore, they felt unsure about recontacting the breast care team for advice once their treatment had finished: All the bumf [brochures, leaflets, handouts] that they give you says try not to carry heavy shopping, but I'm just wondering whether it's the same sort of thing to aqua aerobics. There is a lot of legs but there are also arm weights that you do in the water, so I suppose it's the same really but I thought it would be different. It does actually say that if you have had the left side you can drive after two weeks, if it's the right after four weeks, but that is just for driving, there is nothing else. Like I say the other things, is it for the rest of your life? I do have a breast care nurse which I could ring up but you wonder if you still need them. Some of the women found ways of addressing these issues and eventually returned to their activities. For others, however, this uncertainty regarding the safety of physical activity continued to hinder a return to their prediagnosis activity levels: I think I was a bit frightened to do some of the activity to start with, but what they did recommend was swimming. And I actually was a bit afraid of going swimming, it shows how it affected me. Mentally I think you are scared that you're going to do some damage, and I actually went and had swimming lessons, because I could swim, but once I got it, I had lost my confidence, so I went for a block of swimming lessons, and the same with the sporting things, I think I was worried about getting injured or was I going to undo something, was I going to do some irreparable damage? I didn't think it was worth the gym membership [when I went back] because I could only do, I thought I could only do aqua aerobics, I only did that and it wasn't worth paying just to do that. I only went twice a week to aqua aerobics. I did enjoy it, but I was afraid of doing Pilates or yoga, I didn't want to chance that. Views of a Tailored Program Views regarding the idea of a physical activity program specifically for breast cancer survivors were 900 generally positive, although a couple of the partici- pants did state that they weren't interested in group activities, so such a program might not be appropriate for them. The main benefits identified were that a tailored program would offer support from others in the same situation, and would give breast cancer sur- vivors the commitment and motivation to be physi- cally active. Indeed, one participant stated that it was this type of group support that had enabled her to continue being physically active after her illness: I think for me it was actually having friends, like [a friend] and I still garden, and we've both, she actually she's taken a leaf out of my book, it doesn't stop you doing anything, but most of the other activities, it's because there's a group, and there are, I know there are other women that have had the same, or they've had cancer, because my friend across the way she's had womb cancer, and we both go to aerobics and both do Pilates, and I think it's that group thing that made me continue really, and the support of other people. Taking part in activities in a group with other breast cancer survivors was seen as being beneficial in that the activity could be tailored to specific needs such as restricted arm movements. In addition, some partici- pants said that they would feel less self-conscious within a group of women who had been through the same experience as they had: Of course women who wear prosthetics and bras and exercise, there could be problems you know, jump- ing up and down and it comes out, so in some ways it is more comforting for a group on that. Preferences for a Tailored Program No consensus emerged in terms of the specific types of physical activities participants wanted to take part in. However, although the participants suggested a range of activities, the general consensus was that these activities should be gentle in nature. Suggestions included walking groups, swimming, gentle exercise to music, and “mind–body” types of exercise such as Pilates, tai chi, and yoga. There was a general feeling that the emphasis should be on not overdoing it, and that the women might not have the energy or inclination for more vigorous forms of physical activity: I think if things were done and gradually introduced I don't think there is a problem because I think the emphasis should be on you do as much as you can as well as you can and if you can't, don't. Well I don't know about the jogging and that sort of thing, I don't think people that have just been through this have got the energy for that sort of thing so it's a gentle build-up I think of exercise. Many of the participants also expressed a desire for a wider focus than just physical activity, and requested the inclusion of weight loss and stress man- agement techniques. A strong consensus emerged that the activities should be tailored to the needs and abilities of the older age group. Many women expressed a prefer- ence for a program to be exclusive to their age group. This appeared to be important not only in the practi- cal sense of making it easier to tailor the class to their abilities, but also because they would feel less self- conscious with other older women: I think people think of [keeping] fit as young women, lithe young women in leotards jumping about like you see them on these videos, and I think if they are told that the exercises would be toned down to some- thing that they could cope with quite easily and that it would all be women of their age group that would be there, that might make it more attractive. I think sometimes when you're older and you are weighty, and things have slipped kind of thing that you know you don't want to be getting undressed and putting things on you know, whereas if you are all in the same boat does it matter kind of thing. The women also emphasized the importance of having an instructor who understands issues faced by those who have had breast cancer and who are also older and might have other health complications. He or she needed to be able to suggest alternative exer- cises where necessary: I think it is important to have the right personality in the tutor, and it's nice to have an older person, sort of not some bright young twenty-odd-year-old that thinks you should be doing this, that and the other, but someone who can tailor it so that it's relaxing and at the right pace, because doing things slowly you get a lot of benefit as to do things quickly. You have got to get the person that has the spark to moti- vate you, and not sort of say you should do this, this and this. Finally, some logistical preferences for activities were highlighted, such as accessibility of location, reasonableness of price, and consideration of women's other responsibilities and working patterns: 901 I think location is important and I think price is important for some people, you know you have got to look at the whole range of women involved in this, and some people are on their own on pensions, some people are with partners, some people are still work- ing. There is a whole range of factors out there, so it's accommodating them all really. Discussion Breast cancer is the most commonly occurring cancer for women in the United Kingdom, and the treatments that cancer patients endure can often result in a decreased quality of life. Many reviews suggest that physical activity can increase quality of life among breast cancer survivors, but research has shown that participation in physical activity decreases during breast cancer treatment and remains decreased years after treatment is completed. Research examin- ing the physical activity preferences and experiences of older breast cancer survivors is limited, necessitat- ing tentative generalizations from studies of all ages of breast cancer survivors and healthy older popula- tions (Courneya et al., 2004). The purpose of this study was to explore physical activity as it relates to older female breast cancer survivors. Decline in Activity Levels The women in our study told us that their physical activity levels declined during the course of their ill- ness, and that their current (posttreatment) activity levels remained lower than they had been prior to their breast cancer diagnosis. Declining physical activity levels during the course of breast cancer treatment have been well documented. For example, Rhodes, Courneya, and Bobick (2001) found that although 43% of breast cancer patients were active before treatment, only 20% were active during treat- ment. Pinto, Trunzo, Reiss, and Shiu (2002) followed women with early-stage breast cancer every 3 months during the 12 months following the completion of their treatment, and found that the majority of women either did not exercise at all or exercised below rec- ommended levels. Further studies have also shown that physical activity levels decrease during breast cancer treatment, and can remain decreased even years after treatment is completed. The decline during and after breast cancer treatment means that it is vitally important to promote the benefits of being physically active to older breast cancer survivors. Key Influences on Activity Levels The participants identified several influences on their physical activity levels, some of which—namely, weight, body image, vitality/energy, and mood— emerged as key themes throughout the women's can- cer journeys. The process of diagnosis and treatment for breast cancer often has a negative influence on these factors; that is, incidence of weight gain, poor body image, fatigue, and low mood have been found to increase in the posttreatment period (Pinto & Maruyama, 1999). These factors were also consis- tently identified by our participants as barriers to returning to physical activity. However, physical activity can help to either improve or maintain these factors at prediagnosis levels (Goodwin et al., 1998; Mock et al., 1994; Schwartz, 2000). Hence, the potential benefits of physical activity on weight man- agement, improved body image, reduced fatigue, and improved mood/self-esteem presented considerable motivators and benefits to our participants. This piv- otal role of physical activity in the recovery process was recognized by participants who expressed the desire to “carry on to be normal,” and perceived physical activity as an effective route to achieving this. This process, for each factor, is explained in more detail below. Weight Management and Body Image Self-consciousness relating to their appearance and body image posttreatment was reported by many of our participants as a barrier to taking part in activ- ities. The women expressed the fear that during the course of the activity or in communal changing facilities their scar or prosthesis would be seen by others. This corroborates results of previous studies in which 20% to 60% of women treated for breast cancer became embarrassed to show their body or scars, and felt uncomfortable with changes to their physical appearance up to 2 years postdiagnosis (Schag et al., 1993; Schain, d'Angelo, Dunn, Lichter, & Pierce, 1994). However, Pinto et al. (2002) found that participation in a structured exercise program improved the body image of participants who had been diagnosed with breast cancer within the previous 3 years, whereas Mock et al. (1994) reported that sat- isfaction with body image remained constant among breast cancer patients who exercised but decreased among the inactive control group. Moreover, Pinto and Trunzo (2004) demonstrated that, among early- stage breast cancer survivors treated in the previous 902 5 years, both younger (<50 years) and older (≥50) breast cancer survivors who exercised reported better body esteem (as measured by the Body Esteem Scale) than their sedentary peers. This suggests that being physically active might offer a protective effect against decreased body image for both older and younger breast cancer survivors. Weight gain is a frequent side effect of breast cancer treatment (Pinto & Maruyama, 1999), with Holmes and Kroenke (2004) reporting that up to 60% of women might gain weight after a breast cancer diagnosis. This weight gain is mainly because of chemotherapy and treatment-related menopause (Holmes & Kroenke, 2004), but might also be due in part to reduced physical activity levels (Mark-Wahnefried et al., 2001). Irwin et al. (2004) reported a trend of increased body mass index (BMI) with age among breast cancer survivors, indicat- ing that this problem might be more pronounced for older survivors. Many of the participants in our study expressed a desire to lose some weight and to feel better about themselves, and acknowledged the role that physical activity could play in this area. The positive role of physical activity during and after breast cancer treatment has been highlighted in previous studies. Although no located research inves- tigates the impact of physical activity on older breast cancer survivors specifically, among all ages, Goodwin et al. (1998) found that maintaining higher levels of vigorous physical activity limited weight gain, and Pinto and Maruyama (1999) found that physical activity is beneficial in maintaining weight. Toth, Beckett, and Poehlman's (1999) meta-analysis also indicates that exercise attenuates the accumulation of body fat that tends to accompany the aging process in the general population. It would seem then that there is merit in promoting the potential benefits of physical activity to older breast cancer survivors, both in terms of weight man- agement and improved body image. Becoming more physically active might give breast cancer survivors an increased sense of themselves as being healthy, while the improvements in body strength and muscle tone, combined with potential weight loss, might bring about beneficial changes in body image (Pinto et al., 2002). Vitality, Energy, and Fatigue The majority (61% to 99%) of breast cancer patients report experiencing fatigue that can interfere with provision of self-care and the ability to function adequately at work or home (Pinto & Maruyama, 1999). There is evidence that fatigue is a greater problem for breast cancer survivors compared to women of similar age with no history of cancer (Jacobsen et al., 2007; Robb et al., 2007). Moreover, although the exact relationship between increasing age and fatigue is uncertain among healthy popula- tions, for those with somatic disease fatigue appears to worsen with increasing age (Watt et al., 2000). Fatigue is therefore a problem which might dispro- portionately affect older breast cancer patients. Exercise has been shown to reduce fatigue among studies of breast cancer survivors of all ages (Mock et al., 1997; Schwartz, 2000). In addition, ancillary subanalysis of the GROUP-HOPE trial, which dem- onstrated reduced fatigue among cancer survivors taking part in a home-based exercise program, found no differences in results across the trial groups accord- ing to age, indicating that reduced fatigue was a ben- efit for the participants in this study who were age 60 and above (Courneya et al., 2004). Although fatigue was reported by our participants as a barrier to returning to physical activity posttreat- ment, reduced fatigue was perceived by our partici- pants as a benefit of already being physically active as opposed to a motivator to become more active. This suggests that the positive effect of physical activity on fatigue could be presented to recovering breast cancer patients as a motivation to return to or increase activity levels. Mood and Psychological Well-Being Higher incidence of low mood and depression in the posttreatment period has been demonstrated in previous studies (Pinto & Maruyama, 1999), and was reported by our participants to be a barrier to increas- ing activity levels. However, there is evidence that physical activity improves both psychosocial well- being and depression among breast cancer patients and survivors (Mock et al., 1994; Pinto & Maruyama, 1999; Parry, 2008). Moreover, in a cross-sectional study by Pinto and Trunzo (2004), older breast cancer survivors (aged ≥ 50 years) participating in regular exercise reported better mood than their sedentary age peers and younger sedentary survivors. Many of our participants also felt that being physically active gave them a sense of positive well-being and did them good. In a qualitative study of middle-aged breast cancer patients, Rogers et al. (2004) also found feeling good after exercising to be a motivator. Courneya (2003) carried out a randomized controlled trial of exercise training among postmenopausal breast 903 cancer survivors and found exercise training to have a beneficial effect on happiness. This effect was thought to be clinically relevant because happiness represents an indicator of overall psychological well- being. These potential improvements in psychologi- cal well-being could therefore be used to promote physical activity among breast cancer survivors. Returning to Normal The key role of physical activity in reversing some of the above negative impacts of breast cancer diagno- sis and treatment was recognized by our participants, who perceived returning to physical activity as a way to “carry on to be normal,” and to get back to their day-to-day lives, carrying out their daily activities as they always had done; they did not want having had cancer to stand in the way of their lives now. In a ret- rospective study of middle-aged women, Courneya and Friedenreich (1999) found the beliefs that exer- cise would help women “maintain a normal lifestyle” to be associated with greater levels of exercise during breast cancer treatment. Courneya and Friedenreich (1997) also found that being able to function normally was perceived as the most important dimension underlying overall satisfaction with life. Recommendations for a Tailored Program For those women who suffer from weight gain, poor body image, fatigue, and/or low mood after the completion of their treatment, and who are unsure of whether physical activity is appropriate for them, the positive benefits of physical activity in improving these factors and thus enabling them to return to their normal lifestyles must be emphasized. A consistent message from the participants in our study was that they were afraid of “overdoing it” post-illness in terms of physical activity. The women spoke of a lack of knowledge and confidence regard- ing the safety of physical activity in the period fol- lowing their treatment, and for some women this lasted and hindered their return to prediagnosis activities. Although advice given as inpatients and at follow-up clinics was appreciated, the women reported a lack of ability to assimilate this informa- tion in these settings. They expressed confusion over when it was “safe” to return to physical activities and what types of physical activity were safe, and expressed that any information they were given was not in-depth enough to answer these concerns. This lack of information was also observed by Rogers et al. (2004), who found that the majority of their par- ticipants reported that their physician had not pro- vided them with information concerning breast cancer and exercise. The delivery of posttreatment advice on returning to physical activity should therefore be reviewed. Limitations of written treatment informa- tion for breast cancer patients has been discussed by Davis (2008) in terms of constructing an idealized patient identity focused on early breast cancer experi- ence, where the patient is treatable and the cancer controlled or cured. Health and community services need therefore to be co-coordinated to establish a continuity of care that provides tailored and timely written and verbal advice on safe and appropriate physical activity posttreatment. This advice should be comprehensive enough to alleviate any concerns that breast cancer survivors might have, and to reassure them that a return to physical activity is not only safe but also beneficial. In terms of the type of program that should be offered to older breast cancer survivors, there was a general consensus among our participants that more gentle forms of exercise were preferable, especially those that were tailored to their abilities and treatment- related concerns. The women also told us that they would like activities to be holistic in nature, focusing on stress management and healthy eating/weight management. They indicated a preference for activi- ties that primarily involved other older breast cancer survivors, with an instructor who is knowledgeable about both cancer and their age-related needs. Finally, they stated that location, price, and timing should be considered to take into account participants' individ- ual circumstances. These findings are consistent with those of previous qualitative research in which breast cancer survivors aged 44 to 66 years were asked what aspects would be required for them to participate in and comply with an exercise program (Rogers et al., 2004). Responses included being able to exercise with other cancer patients in a private setting, having an instructor who was knowledgeable in the area of cancer, having a focus on nutritional information as well as exercise, and a holistic approach. In addition, our participants expressed a preference for more gentle forms of exercise undertaken with other older breast cancer survivors, indicating that these factors are of particular importance to older breast cancer survivors. Providers of a tailored program might also like to consider offering programs that provide opportunities for socialization and the chance to meet new people. 904 The social aspect of physical activity was highlighted as a benefit by many of the women in our study. For those who were retired or widowed, physical activity offered a chance to socialize with others, and many of the women had met new friends through their chosen activities. Having friends to go with was also felt by some to be one of the main factors contributing to their continued participation. Pinto et al. (2002) found social support to be positively associated with vigorous- intensity exercise among middle-aged women who had completed breast cancer treatment. Among breast cancer survivors of all ages, the vigorous and com- munal activity of dragon boat racing has been found to foster social connections and solidarity (Parry, 2008). Social support is also positively associated with exercise participation among women in the gen- eral population (Sallis, Hovell, & Hofstetter, 1992; Sallis et al., 1989). Further research is needed into the differing ways that social support can act as a facilita- tor for physical activity participation for older breast cancer survivors. Tailored physical activity programs that are deliv- ered as one of the interventions in the posttreatment period might increase the knowledge and confidence of older breast cancer survivors to return to physical activity in the wider community. To test this assump- tion, randomized controlled trials of such tailored programs should be developed in line with the Medical Research Council guidance on the development of complex interventions (Campbell et al., 2000). Strengths and Weaknesses of the Study Although the interviews and focus groups provided a great deal of rich data, this study was not without its limitations. Some of the women had other health com- plaints associated with getting older, and these were seen to influence physical activity levels just as much as having had breast cancer did. Although our sample was selected and analyzed as a whole group of older breast cancer survivors (aged >59 years), age group subanalysis might have been useful. However, this was precluded as the vast majority recruited were aged <70 (22/29). Further studies of activity prefer- ences specifically targeting women aged ≥70 would help to confirm our findings among this older age group. Although the sample size meant that a wide range of opinions was represented, the participants were predominantly White European, so we cannot be sure whether their viewpoints would be shared by people from different ethnic backgrounds. Selection bias might also have occurred in that those who were interested in the idea of a physical activity program might have been more likely to take part than those who were not. Data saturation was reached, however, with participants voicing the same opinions and no new topics emerging. This suggests that these partici- pants' views were representative. Conclusion We studied the physical activity views and prefer- ences of older breast cancer survivors and found that physical activity declined during the course of treat- ment and did not return to normal prediagnosis levels. The main factors found to have influenced physical activity were body image and weight issues, vitality, mood/psychological well-being, and the desire to carry on as normal. Participants also expressed some consistent views on the type of physical activity pro- gram they would prefer to be offered. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Older Breast Cancer Survivors' Views and Preferences for Physical Activity</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Older Breast Cancer Survivors' Views and Preferences for Physical Activity</title></titleInfo><name type="personal"><namePart type="given">Sarah</namePart><namePart type="family">Whitehead</namePart><affiliation>University of Manchester, Manchester, United Kingdom</affiliation></name><name type="personal"><namePart type="given">Katrina</namePart><namePart type="family">Lavelle</namePart><affiliation>University of Manchester, Manchester, United Kingdom</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article"></genre><originInfo><publisher>SAGE Publications</publisher><place><placeTerm type="text">Sage CA: Los Angeles, CA</placeTerm></place><dateIssued encoding="w3cdtf">2009-07</dateIssued><copyrightDate encoding="w3cdtf">2009</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Evidence suggests that physical activity improves quality of life and physical functioning among breast cancer patients and survivors. However, previous studies have tended to focus on younger patients, despite higher incidence and lower survival among older breast cancer survivors. In this study we explored physical activity preferences of older breast cancer survivors to inform the development of future targeted interventions. Twenty-nine female breast cancer survivors (1 to 5 years postdiagnosis) aged 59 to 86 (mean 66.54, SD 6.50) took part in either a semistructured interview or a focus group exploring physical activity patterns, motivators, facilitators, barriers, and preferences. The main factors influencing physical activity were body image, weight issues, vitality, mood, and the desire to carry on as normal. Preference was expressed for activities that were gentle, tailored to age and cancer-related abilities, holistic, involving other older breast cancer survivors, and with an instructor who was knowledgeable about both breast cancer and aging.</abstract><subject><genre>keywords</genre><topic>breast cancer</topic><topic>exercise</topic><topic>older people</topic><topic>older people</topic><topic>exercise</topic></subject><relatedItem type="host"><titleInfo><title>Qualitative Health Research</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1049-7323</identifier><identifier type="eISSN">1552-7557</identifier><identifier type="PublisherID">QHR</identifier><identifier type="PublisherID-hwp">spqhr</identifier><part><date>2009</date><detail type="volume"><caption>vol.</caption><number>19</number></detail><detail type="issue"><caption>no.</caption><number>7</number></detail><extent unit="pages"><start>894</start><end>906</end></extent></part></relatedItem><identifier type="istex">3D527612FA45E56C29BDD3E2133C4D97D29207C8</identifier><identifier type="DOI">10.1177/1049732309337523</identifier><identifier type="ArticleID">10.1177_1049732309337523</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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