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The effects of physical self-management on quality of life in breast cancer patients: A systematic review
The Breast, Volume 28, August 2016, Pages 20-28
The aim of this systematic review is to report on the effects of different physical self-management techniques on quality of life (QoL) of patients with breast cancer. Therefore a systematic literature search was performed using four different databases (PubMed, Cochrane, Embase, Web of science). The inclusion criteria were: 1) adults >18 y, 2) patients with breast cancer, 3) physical self-management techniques during or after initial treatment, 4) outcome measure needed to be an indicator of patients' quality of life 5), Randomized Controlled Trials of all ages. The methodological quality of the selected articles was assessed. The results concerning quality of life outcomes were extracted. A total of 13 RCT's, representing 2180 participants were included. Different self-management techniques were identified such as a booklet, brochure, multimedia and recommendations. Disregarding the type of intervention, most studies found a positive effect of physical activity on QoL outcomes such as fatigue, physical functioning, emotional and/or social wellbeing. The results of the interventions during or after primary treatment of breast cancer are discussed separately. Studies that started their intervention during primary treatment found an improvement in QoL or a slower decrease in QoL. Studies that started the intervention after primary treatment found an increase in QoL. In conclusion, physical self-management interventions during breast cancer treatment as well as after the primary treatment seem to generate beneficial effects on QoL.
- Self-management after BCT can be performed by different physical activity protocols.
- During BCT self-management by physical activities limit or slow down the decrease in QoL.
- After BCT self-management by physical activities increases QoL.
Keywords: Breast neoplasms, Physical activity, Self-care, Self-management, Quality of life.
Breast cancer is the most common cancer among women in Europe with an incidence of 89.7 per 100.000 . Due to better screening services and improved treatment, the mortality rate has decreased and survival rates have increased accordingly . When survival rates improve, the Quality of Life (QoL) of these patients becomes a key element in the treatment. Unfortunately, QoL is hampered by the morbidities caused breast cancer treatment , , , and . Common morbidities described in the scientific literature are fatigue, hot flashes, pain, sexual dysfunction, arthralgia, neuropathy, cognitive dysfunction, lymphedema, cardiac morbidity, numbness, tightness in breast, loss of range of motion, fatigue, psychological problems , , , , , , , and . A number of these problems persist at a high rate even one year after treatment , , , , and . Due to morbidities, breast cancer patients will experience a decrease in QoL; a generic term that implies physical, psychological and social aspects of daily life.
Self-care or self-management could be an important tool to minimize the number of morbidities in breast cancer treatment. Dean et al. stated that self-care not only includes health maintenance, lifestyle behaviour, utilization of preventive services, symptom evaluation, and various self-treatment activities. Additionally, an interaction with the professional sector is warranted . Different definitions of self-care or self-management are available. A common definition is “the systematic provision of education and supportive interventions by health care staff to increase patients' skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem-solving support” . The importance in this definition is that the patient is in control of his own health. In the current review we will explore self-management techniques that focus on the use of physical activities as a self-management intervention. It is important that patients are responsible for executing, at least part of the intervention. Physical activities can be seen as a universally applicable self-management technique. Most of the breast cancer survivors remain physically inactive after treatment . Physical inactivity implies side-effects such as decrease in muscle strength, fatigue, weakness, decrease in aerobic capacity and decrease in bone density . Research has shown that physical activity is positively related to QoL  and . Additionally, several studies provide evidence that physical activity or exercises are beneficial in breast cancer patients and has an impact on many different domains that influence health related QoL (HRQoL) , , , , and . The next step is to understand whether self-management by physical activities has the same effect as supervised exercises. Therefore, this systematic review focuses on the available evidence of physical self-management techniques used in breast cancer patients. The following research question was addressed: ‘What are the existing self-management programs based upon physical activity and what are the effects of these programs on the QoL in breast cancer patients?
Literature search and selection
A systematic literature search based upon the PRISMA (www.prisma-statement.org) guidelines, was performed using four different electronic databases: Pubmed, Web of Science, EMBASE and the Cochrane library for clinical trials. All searches were performed in August 2015. To define relevant keywords a PICO(S) method (http://editorial-unit.cochrane.org/cochrane-pico) was used. The following keywords were combined in a Boolean search: ‘breast cancer’(P), ‘self-management’(I), ‘self-care’(I), ‘training programs’(I), ‘quality of life’(O) and ‘activities of daily living’(O). Further elaboration on the search strategies can be found in Table 1. We limited our review to articles written in English or Dutch. Titles and abstracts were independently assessed twice to determine relevance to the topic of this review. Two raters (P.N. and S.V.D.) screened the selected full-text articles, based on the inclusion and exclusion criteria listed in Table 2. In case the raters had diverging opinions, consensus was sought during a meeting. A detailed flowchart of the search and study selection is provided in Fig. 1.
|Pubmed||(“breast neoplasms”[MeSH] OR “breast neoplasms”[All Fields] OR “breast cancer”[All Fields]) AND (“self-care”[MeSH] OR “self care”[All Fields] OR “self-management”[All Fields] OR “self-education”[All Fields] OR “education”[Subheading]) AND (“quality of life”[MeSH] OR “quality of life”[All Fields] OR “activities of daily living”[MeSH] OR “activities of daily living”[All Fields])|
|Web of Science||TS=(“breast neoplasms” OR “breast cancer”) AND TS=(“self-care” OR “self-management” OR “self-education” OR “training programs” OR “training program” OR “courses”) AND TS=(“quality of life” OR “activities of daily living”)|
|EMBASE||('breast neoplasms' OR 'breast cancer') AND ('self care' OR 'self management' OR 'self education' OR 'training program' OR 'training programs' OR 'courses') AND ('quality of life' OR 'activities of daily living')|
|Cochrane Library for clinical trials||(breast neoplasms OR breast cancer) AND (self care OR self management OR self education OR patient education) AND (quality of life OR activities of daily living)|
TS = Topic Specific.
The methodological quality of the selected studies was assessed independently by 2 researchers (PN and SVD). The checklist (10 items) for randomized controlled trial provided by the Dutch Cochrane Centre (http://Netherlands.cochrane.org/) was used to score all studies. An item was rated “1” if sufficient information was available and bias was unlikely. An item was rated ‘‘0’’ if it was certain that a criterion was lacking. An item was rated ‘‘?’’ if no information was available. If disagreement persisted about the assignment of a score to an item, a consensus meeting was held. The total quality is expressed as the sum of all criteria that were scored “1”; see Table 3. The level of evidence was determined for every study .
|Author, year, reference||Sample size||Duration and follow-up||Population||Intervention||Physical activity used in intervention||Control||Assessment||Results||QA/LoE|
|Basen-Engquist et al.  (2006)||n = 60
C = 25
I = 35
|6 months||Patients who ended primary treatment||Home-based
|Moderate intensive activity. Patients were free to choose exercise, walking was recommended||Written information||Questionnaires QoL:
- minutes/day spend being physical active
- SF-36: I > C (p = 0.006)
- aerobic capacity (6MWT): I > C (p = 0.005)
- minutes/day spend being physical active: I vs. C: ns
|Cadmus et al.  (2009)||Impact
n = 50
C = 25
I = 25
n = 74
C = 38
I = 37
|6 months||Patients who ended primary treatment (YES) and patients during treatment (IMPACT)||IMPACT: Home-based
Information session + booklet + provided heart monitor YES: Combination of supervised with additional home-based exercise
|Moderate to vigorous physical activity, most woman chose walking||Received same material, only at 6-months follow-up||Questionnaires
- QoL: FACT-B, SF-36
- 7-day PAL, 7-day pedometer log
IMPACT: I vs. C: ns
YES: I vs. C: ns
|Haines et al.  (2010)||n = 89
C = 43
I = 46
|12 months||Patients during treatment||Home-based
|Strength, balance, shoulder mobility exercises + cardiovascular endurance program||Flexibility, relaxation exercises||Questionnaires
- QoL: EORTC-C30
- Fatigue: MFI
- Aerobic capacity: 6MWT
- Strength: grip strength, leg press
- Balance: functional reach
- EORTC-C30: I > C (3 m follow-up p = 0.005, 6 m follow up p = 0.03), not at 12 m follow-up
- MFI: I vs. C: ns
- aerobic capacity (6MWT): I vs. C: ns
- strength (grip strength, leg press): I vs. C: ns
- balance (functional reach): I vs. C: ns
|Headley et al.  (2004)||n = 32
C = 16
I = 16
|3 months||Patients during treatment||Home-based
|Moderate intensity. Seated exercise program||No material, permitted to continue exercise||Questionnaires
- QoL: FACIT-F
- Fatigue: FACIT-F
- FACIT-F: Qol ↘ less decrease in intervention (p = 0.0254)
- FACIT-F: fatigue ↗ less increase in intervention (p = 0.0078)
|Heim et al.  (2007)||n = 63
C = 31
I = 32
|During inpatient rehabilitations (duration unknown)
Follow- up: 3 months
|Patients who ended primary treatment||Combination home-based/supervised Information session + booklet + group exercises||Aerobic, strength stretching, coordination and relaxation exercises||Information session + physiotherapy + group exercises||Questionnaires
- QoL: FACT
- Fatigue: MFI
- Aerobic capacity: Harvard step test
- Muscle strength: digimax multifunktionstest
- FACT: I > C (p = 0.0015)
- MFI: I > C (p = 0.028)
- aerobic capacity (Harvard step test): I vs. C: ns
- muscle strength: I vs. C: ns
|Jones et al.  (2004)||n = 450
C = 150
I1 = 150
I2 = 150
|1 month||Patients during treatment||Home-based Recommendation (I1)
Recommendation + referral (I2)
|Patients were free to choose exercise, brisk walking was recommended||No recommendation||Questionnaires
- Self-reported exercise behaviour
- Recall of the recommendation
|Physical activity level
- Total exercise (METhr/week): I1 > C (p = 0.011), I2vs. C: ns
- Total frequency (MET times/week): I1 > C (p = 0.007), I2 vs. C: ns
In an ancillary analysis they compared patients who remembered the recommendation and patients who didn't.
- Total exercise (METhr/week): remembering > not-remembering (p < 0,001)
- Total frequency (MET times/week): remembering > not-remembering (p < 0,001)
|Lee et al.  (2014)||n = 59
C = 29
I = 30
|I: 5 months
Follow- up: 12 weeks
|Patients who ended primary treatment||Home-based
Web based program
|Patients were free to choose an aerobic exercise||Educational booklet||Questionnaires/web based survey:
- 3-day dietary recall
- DQI = Diet Quality Index
- QoL: EORTC QLQ C30
- Depression: HADS
- Fatigue: BFI
- Stage of Change
- Perceived self-efficacy
- EORTC-QLQ-C30: I > C (p = 0.023)
- BFI: I > C (p = 0.032)
|Mock et al.  (2001)||n = 52
I and C not specified
|6 weeks if RT
3–4 months if CT
|Patients during treatment||Home-based
Information sessions + booklets
|Walking intervention||Standard practice||Questionnaires
- QoL: MOS SF36
- Fatigue: PFS
- MOS SF 36
- MOS SF36: Qol ↘ less decrease in intervention (p ≤ 0.05)
- Diary: I > C
- POMS fatigue: I > C (p = 0.00)
- MOS- SF 36 physical functioning: I > C
- 12 min walk test: I > C (p = 0.01)
|Purcell et al.  (2011)||n = 110
C = 28
I1 = 27
I2 = 28
I3 = 27
|6 weeks||Patients during treatment||Home-based
Information sessions + booklets
- Pre- and post radiotherapy fatigue and support (RFES) = I1
- Pre RFES = I2
- Post RFES = I3
|Not-specified||Standard care: one-to-one verbal communication||Questionnaires:
- QoL: EQ 5D
- Self-care activities: FAI
- Anxiety and depression: HADS
- Sleep disturbances: MOSS
- Employment and domestic work: HLQ
- Fatigue: MFI
- Karnofsky performance status scale
- EQ-5D: I2 vs. C: ns, I3 > C (p < 0.05)
- MFI mental fatigue: I2 vs. C: ns, I3 > C (p < 0.05)
Combination of pre- and post sessions (I1) did not show any significant benefit compared to the single session interventions pre or post radiotherapy.
|Saarto et al.  (2012)||n = 573
C = 271
I = 302
3 years (including follow up)
|Patients who ended primary treatment||Combination of supervised with additional home-based exercise||Supervised:
Step aerobics + circuit training class
Endurance training such as walking
|Encouragement to maintain previous level of physical activity||Questionnaires:
- QoL: EORTC QLQ C30
- Fatigue: FACIT F
- Depression: RBDI
- Menopausal symptoms: WHQ
- Aerobic capacity: 2 km walk test
- Neuromuscular performance: Figure 8 running test
- EORTC-QLQ-C30: I vs. C: ns
- neuromuscular performance (figure 8 running time): I > C (p < 0.001)
- aerobic capacity (2 km walk test): I vs. C: ns
- sleeping problems: I vs. C: ns
Although there was no significant improvement in QoL or fatigue, a significant linear trend was found between higher physical activity and improved QoL and recovery from fatigue.
|Segal et al.  (2001)||n = 123
C = 41
I1 = 40
I2 = 42
|26 weeks||Patients during treatment||Home-based (I1) + combination of supervised with additional home-based exercise (I2)||Progressive walking program||Usual care (Oncologist's advice)||Questionnaires:
- QoL: SF 36, FACT-G, FACT-B
- Aerobic capacity: mCAFT
I1 > C (p > 0.05), I2vs. C: ns
- FACT-G, FACT-B:
I1 vs. I2: ns, I1vs. C: ns
I2vs. C: ns
- Aerobic capacity:
I1 vs. I2: ns, I1vs. C: ns
I2vs. C: ns
|Vallance et al.  (2007)||n = 377
C = 96
PM = 94
PED = 94
COM = 93
Follow up: 12 weeks
|Patients who ended primary treatment||Home-based
- printed materials (PM) group: booklet
- pedometer (PED) group: pedometer
- combination (COM): booklet + pedometer
|Moderate to vigorous physical activity: walking||No additional intervention materials||Questionnaires:
- QoL: FACT B
- Fatigue: FACT F
- Self report physical activity: LSI
- 7 day step test
- FACT-B: COM > C (p = 0.003), PED vs. C: ns, PM vs. C: ns
- COM, PED, PM vs. C: ns
Self-reported physical activity:
- PM vs. C: ns
- PED > C (p = 0.017)
- COM > C (p = 0.022)
No change was found in objectively measured walking across all groups.
|Wang et al.  (2011)||n = 72
C = 37
I = 35
|6 weeks||Patients during treatment||Home-based
Booklet + provided heart monitor
|Walking intervention||Usual care||Questionnaires:
- QoL: FACT-G
- Fatigue: FACIT-F
- Sleep Quality: PSQI
- Self efficacy: ESES
- Exercise behaviour: GLTEQ
- Exercise capacity: 6 MWD
- FACT-G: I > C (p < 0.001)
- FACIT-F: I > C (p = 0.003), only at 9 days after chemotherapy and at 6 weeks follow-up
- sleep disturbances (PSQI): I > C (p = 0.006)
Legend and abbreviations:
I: intervention, C: control.
>: significant difference between groups (in favour of the intervention-group).
ns: no significant difference between groups.
Results apply to the whole duration of the study, unless otherwise specified.
Quality assessment (QA): methodological quality score (x/10) and level of evidence (LoE) are listed.
EORTC QLQ C30 The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30.
SF 36 Short form 36 health survey.
EQ-5D EuroQoL five dimension scale.
FACT-B Functional Assesment of Cancer Therapy-Breast definition.
FACT-G Functional Assesment of Cancer Therapy-General.
LSI Leisure Score Index.
MFI Multidimensional Fatigue Inventory.
7-DPARQ 7 Day Physical Activity Recall Questionnaire.
7-day PAL 7 Day Physical Activity Log.
BFI Brief Fatigue Inventory.
PFS Piper Fatigue Scale.
FACIT-F Functional Assesment of Cancer Therapy-Fatigue.
FAI Frenchay Activities Index.
GLTEQ Goldin Leisure Time Exercise Questionnaire.
MOSS Medical Outcomes Study Sleep.
PSQI Pittsburgh Sleep Quality Index.
HADS Hospital Anxiety and Depression scale.
RBDI Finnish modified version of Beck's 13-item depression scale.
POMS Profile of Moods States.
ESES Exercise Self-Efficacy Scale.
DQI Dietary quality index.
HLQ Health and Labour Questionnaire.
WHQ Women's Health Questionnaire.
6MWD 6 min walking distance.
6MWT 6 min walking test.
mCAFT Modified Canadian Aerobic Fitness Test.
QoL Quality of life.
MET Metabolic equivalent of task.
Selection of studies
Initially, the search yielded 1209 references. After removal of duplicates and a first screening, 60 abstracts were selected of which full texts were retrieved. Two reviewers independently assessed the full texts based upon the defined criteria (see Table 2); finally a total of 13 RCT-studies , , , , , , , , , , , , and  were included in this review, representing in total 2180 participants. The literature search and study selection process are shown in Fig. 1.
The risk of bias and the level of evidence of the different studies are reported in Table 3. In all cases, the two researchers agreed. Scores for study quality ranged from 5/10 to 10/10 with a median score of 7/10. The item that was scored negatively in most studies: ‘Were patients and clinicians blinded to the treatment/trial? Two studies  and  scored level A2 of evidence while all other studies scored level B, according to the Dutch Cochrane Centre guidelines.
Different questionnaires were used to measure outcomes related to QoL. Table 3 includes an overview of the questionnaires used as an assessment in the selected articles.
Types of interventions
Different kinds of interventions were found. Nine studies described an intervention that was executed by the patients at home independently , , , , , , , , , and . Among these 9 studies different methods were used: a web based program , information sessions , multimedia  and , information sessions and booklets  and  and recommendations .
Several studies provided a combination of methods to introduce the physical intervention , , and . Four studies used a supervised and home-based intervention , , , and . Only one study had a three-arm design with an isolated home-based intervention, a supervised intervention and a control group . The used interventions are incomparable; therefore the specific results of each study are listed in Table 3.
Effects of interventions
To describe the effects of the different interventions a distinction had to be made between studies that started their intervention during initial treatment and studies that started their intervention after the initial treatment for breast cancer was completed. First we discuss the studies that started their self-management intervention while participants were receiving primary treatment for breast cancer , , , , , , , and . Primary treatment is considered to be chemotherapy and/or radiotherapy, alone or in combination with surgery. Four studies , , , and  showed an actual improvement in QoL, whereas two studies  and  showed a decrease in QoL. In both studies the decline in the intervention group was less prominent in contrast to the control group. The interventions conducted by Mock et al. , Purcell et al.  and Jones et al.  showed greater improvement in physical functioning compared to the control group. Of the studies that investigated fatigue, two studies  and  found a significant decrease in fatigue; one study  found a slower increase in fatigue and two studies found no effect of their intervention on fatigue  and . In the study of Purcell et al., the decrease was only significant in the group that received the intervention right after radiotherapy instead of before . Wang et al. demonstrated significant less sleep disturbances compared to the control group . This may also have an effect on overall fatigue on long term.
All studies that investigated the effect on physical performance found a higher performance in their intervention group compared to the control group , , and . Segal et al. found that patients who received the home-based intervention, had better physical functioning than those in the supervised intervention, who scored the same as the control group .
Secondly, we discuss the studies that have implemented their intervention after patients had ended their initial treatment , , , , , and . All studies, except two  and , found an increase in QoL. Specifically, Basen-engquist et al.  showed an increase in general health QoL and pain but not in mental or social QoL and Lee et al.  found that the QoL subscale physical functioning improved. Few studies investigated the effect of their self-management on fatigue , , and . Only one study concluded that fatigue improved significantly more in the intervention group in comparison to their control group . The other studies found no difference  and . Another outcome measured by two studies was the physical performance  and . One study measured aerobic capacity, strength and balance; they found that the only significant result was a better aerobic capacity in the intervention group, measured with a 6 min walking test . In contrast, the other study that measured aerobic capacity found no difference between intervention and control group . Additionally they were unable to demonstrate an improvement in strength. Noteworthy, Heim et al. were the only researchers that investigated the effect on anxiety and depression and were able to demonstrate a significant improvement .
The aim of this study was to systematically review the scientific literature to answer the question: ‘What are the existing self-management programs based upon physical activity and what are the effects of these programs on the QoL in breast cancer patients?’.
The results clearly revealed that different methods of self-management are available in the rehabilitation of breast cancer. First of all, most studies, disregarding the type of intervention, found a positive effect of physical activity on QoL and other outcomes regarding QoL such as fatigue, physical functioning and emotional or social QoL , , , , , , , , , and . On the one hand, almost all studies that started their intervention after patients ended their primary treatment for breast cancer, found positive results , , , and . On the other hand, the studies that started their intervention during primary treatment found more inconsistent results , , , , , , , and . Several studies , , , , and  demonstrated an improvement in QoL, whereas other studies  and  found a slower decline in QoL. Both can be seen as positive results. In regard to the other outcome measures, the evidence is ambiguous. The authors cannot provide evidence that one self-management method can be recommended over another since most interventions found good results. This is confirmed by another systematic review that researched self-management methods in a broad cancer population . If we consider a more practical approach, multiple methods can be offered to the patient to engage in self-management by physical activities.
However, not all studies found beneficial results of their intervention, the reason was not always clear  and . Cadmus et al., a study of good methodological quality, found no effect of home-based exercise on QoL . Even if they adjusted for variables such as age, treatment, stage at diagnosis, baseline physical activity and time since diagnosis. An explanation could be that although the study participants increased their activity levels in comparison to baseline, only 34% met the study goal of 150 min/week. This could indicate that a certain amount of physical activity is required to obtain an increase in QoL. The study only measured QoL at baseline and at 6 months follow-up. The long duration between measurements could be a potential reason why there was no benefit found. There is a possibility that benefits of physical activity occur early and then fade away. Another explanation could be that most participants already had a high QoL .
In the study by Mock et al., the control group became more physical active and the researchers decided to divide their participants in a ‘high-walk’ and ‘low-walk’ group instead of comparing intervention and control group . They found that the ‘high walk’ group (>90 min/week) had a better outcome then the ‘low walk’ group on QoL, fatigue and physical functioning. Again this could be an indicator that a certain amount of physical activity is needed to obtain benefit from being physical active .
All studies assessed whether participants adhered to their program and to the prescribed amount of physical activity , , , , , , , , , , , , and . This is a valuable outcome because it indicates whether an intervention has led to a behavioural change. Adherence is more pronounced when sufficient time is invested in the intervention. Time-investment can be achieved by means of an activity diary or goal setting in advance to the intervention  and . Another method that seemed to increase adherence was providing a measuring tool, such as a pedometer or a heart monitor  and . The most common method to assess the amount of adherence and physical activity was done by a self-reported diary , , , , , , and . One study even used recall-interviews . Because of the self-report activity through diaries, results may not be authentic because patients can alter their results (recall bias). Vallance et al. found an increase in self-reported physical activity, but the physical activity measured with a pedometer indicated no change compared to baseline measurements . However, this could be because participants used more vigorous walking instead of more steps overall.
Several limitations concerning the included studies need to be discussed. Six out of thirteen studies conducted a trial with patients after they ended their treatment , , , , , and . These patients are often addressed as survivors. There is no clear definition of a breast cancer survivor. According to Lee et al. , survivors were patients diagnosed two years prior to their study, whereas Cadmus et al.  reckoned survivors 1–10 years post-diagnosis. Vallance et al. defined patients as survivors when there was an absence of current breast cancer . The duration of the survivorship may alter results. Comorbidities change over time, even in a short time span of a year and are different dependent on treatment method . Consequently, rehabilitation needs are different. This can also have effects on the use of questionnaires, because some may be less responsive or accurate . Different questionnaires were used to measure QoL, whereas not every questionnaire is as responsive in breast-cancer patients. The EQ-5D is unable to detect small changes in health, in comparison to the EORTC QLQ C30 that is found to be responsive in breast cancer patients . Also, the QLQ C30 has better responsiveness to the detection of ceiling effects . In comparison to this, the FACT-G questionnaire showed better precision in HRQoL . The SF-36 is a more generic questionnaire, not disease-specific, and might be less suitable for breast cancer patients, where the FACT-B is disease-specific and might be more appropriate in the research of QoL in breast cancer patients.
Blinding of participants is difficult in behavioural studies. Therefore, participants were mostly aware of the purpose of the study and this itself may have an effect on the intervention. Knowing the purpose of the trial, could be seen as an intervention itself . Patients of the control group may take initiative into their own hands. In some studies, the control group also became more active , , , , , and . This could have biased the results because the difference between both groups could be less and this can make the difference between being statistically significant or not.
Four studies conducted a combination of home-based and supervised-intervention , , , and . Of these studies, only one did this in comparison to an isolated home-based intervention . They found that their home-based intervention scored better than their supervised intervention and that the supervised intervention had similar results to the control group . Another study found no significant difference between their home-based and home-based in addition to supervised intervention . However there are advantages of supervised exercise training, it can improve patient's motivation  and it offers the possibility to interact with fellow patients in group sessions .
Finally, in behavioural studies it is important to know the long-term effect. It is generally known that employing a more physical active lifestyle is hard to maintain on the long run, this is not different for patients with breast cancer. A long-term follow-up is essential to assess the ceiling effect of physical activity. Not every study demonstrated an adequate follow-up. The authors defined an adequate follow-up as 12 months or more. Only two studies met this criterion  and . Studies with a short follow-up had different results in comparison to those with a longer follow-up. For example the study by Haines et al. found significant differences between intervention and control group at 3 and 6 months follow-up, however at 12 months follow-up this result was no longer present . This may be due to the fact that the patients reached their maximum. Of the studies that reported on different follow-up assessments, a decrease in effect over time was seen in four studies , , , and . This decrease occurred mostly after 3 months. Nonetheless two studies found an increase in effect at their follow-up of respectively 3 and 12 months  and .
Lastly, the strengths and weaknesses of this review are discussed. The strength of this review is the fact that the reviewed studies are all randomized controlled trials and that they all had a fair to good methodological quality. Another strength is that four databases were used to retrieve all eligible studies. The first limitation is that the interventions described in the different studies are too different to compare and so only a conclusion in general can be made. A second limitation is that the selection of studies may have been biased due to an unclear definition of self-management.
There are different methods of physical self-management that provide beneficial effects on QoL and outcomes regarding QoL. It is likely that the implementation of physical self-management after adjuvant therapy increases QoL. It is also likely that starting the self-management intervention during adjuvant therapy is beneficial, as it results in an increase or a slower decline in QoL. Nevertheless, it should be noted that at this moment no self-management technique could be chosen over another. Most studies did not organize long-term follow-up, leading to uncertainty of long-term outcome. Therefore, further research on the implementation of self-management in breast cancer patients is highly warranted.
We certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on us or on any organization with which we are associated AND, if applicable, we certify that all financial and material support for this research (eg, NIH or NHS grants) and work are clearly identified in the title page of the manuscript.
Conflict of interest statement
The authors have no conflict of interest to declare.
First two authors participated equally.
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a Department of Rehabilitation Sciences and Physiotherapy (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
b Multidisciplinary Breast Clinic, Antwerp University Hospital (UZA), Wilrijkstraat 10, 2650 Edegem, Belgium
c Department of Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
∗ Corresponding author. Tel.: +32 496 18 43 46; fax: +32 32652501.
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