Wechsler-led research published in nursing journal is first to examine how breast cancer survivors approach exercise dose

It’s well known that exercise does a body good, and that’s especially the case for breast cancer survivors battling cancer-related fatigue (CRF). But how do breast cancer survivors with CRF think about and work to achieve the right amount of exercise to help reduce CRF and live a normal life?
New research led by Dr. Stephen Wechsler, a post-doctoral research fellow in the MGH Institute’s Cancer Rehabilitation (CaRe) Lab, is the first to explore how breast cancer survivors with cancer-related fatigue perceive and manage exercise dose in the context of daily life.

Recently published in the Oncology Nursing Forum, the research is titled, Finding the optimal exercise dose while living with cancer-related fatigue: A qualitative study. Dr. Kathleen Lyons, director of the CaRe Lab, is a co-author, as is Mei Rosemary Fu, PhD, RN, FAAN, associate dean for research in the School of Nursing and Health Studies at the University of Missouri, and Lisa Wood Magee, PhD, RN, FAAN, a professor at the Connell School of Nursing at Boston College. 

“Within the conversations we were having with breast cancer survivors about their experiences exercising while living with CRF, a lot of the women spoke about how much exercise they do and the decisions they make on a daily basis to identify the right dose in the context of their daily lives,” said Wechsler. “We found that interesting because available evidence suggests that exercise dose is a critical moderator for how effective exercise is to reduce CRF; essentially, more exercise is more effective and less exercise may be ineffective.” 

That evidence has led to the development of specific exercise recommendations to reduce CRF among cancer survivors with exercise dose being an important consideration. 

“But breast cancer survivors largely aren’t meeting those exercise recommendations,” said Wechsler. “With exercise dose being such an important factor in the effectiveness of exercise to reduce CRF, we felt it was important to gain insight into how breast cancer survivors perceive and identify an optimal exercise dose after cancer treatment. Therefore, we looked at how breast cancer survivors think about, approach, and self-manage exercise dose in their own lives.”

The study examined 11 breast cancer survivors from the Massachusetts General Hospital Cancer Center's Center for Breast Cancer; each had CRF and exercised weekly. Despite varying exercise preferences, levels of participation, and severity of CRF, participants shared common processes and pitfalls related to finding an optimal exercise dose after cancer treatment. Participants described using a trial-and-error approach to finding the right exercise dose after cancer treatment, which often resulted in discouraging setbacks.

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Much of Dr. Wechsler’s research involved one-to-one virtual conversations with breast cancer survivors about what the “just right” amount of exercise is, otherwise known as the “Goldilocks Zone.”

The “Goldilocks” Zone

Like the children’s tale of the little girl experimenting with the porridge, beds, and chairs of three bears until she found one “just right,” the right amount of exercise is a guiding factor in the difference between encouragement and discouragement among breast cancer survivors. 

The study quotes some participants who realized that exercising at too high an intensity or too long a duration “resulted in negative consequences, such as worsened fatigue, disruptions to daily life, and a fear of overexertion.” Said one woman: “I would be wiped out for days. Not even just one day, two days, three days. I didn't know I could even be that low.”

On the other side were women who saw negative consequences from not exercising enough - worsened fatigue, increased stiffness, and depressed mood. Said another: “I started to learn by day three in this pattern of ‘don't walk, don't walk, don't walk,’ and ugh... I can’t get out of bed.”

For other breast cancer survivors in the study, trial and error was the order of most days, learning the fine line of, “What's the good kind of push?"… Every day I gauge, is this too much or is this just enough?” asked one participant. 

“The Goldilocks analogy is a good one because when the exercise dose is just right, you get all those benefits related to exercise - you actually can feel reduced cancer related fatigue, your mood is better, your thinking is clearer. That's what we heard from these women,” said Wechsler. “But when exercise dose is too much, it's discouraging, and it can set you back. When exercise dose is too little, it can be discouraging and set you back. So, what we need to do is find a way to keep them in that Goldilocks zone, because when exercise feels good, behaviorally, it's reinforcing. So, you're going to exercise again.”

Wechsler and his team highlight that the recommended exercise doses set forth by the American Cancer Society and the American College of Sports Medicine are relatively static doses (e.g., exercise aerobically three times per week for 30 minutes) and don’t allow much wiggle room or guidance on adapting this exercise dose into daily life. These static guidelines are in contrast to what Wechsler heard from participants as they described the need for exercise dose to be dynamic as they adapted exercise on a daily basis to accommodate life roles and to adjust for fluctuations in fatigue or other bodily symptoms.

“This whole problem is so dynamic and that's one of the challenges in meeting cancer survivors where they are with an exercise recommendation,” said Wechsler. “Oftentimes, someone's capacity to exercise changes from before cancer treatment to after treatment. And what we heard from a lot of the women in this study is that it was distressing when they attempted to exercise after cancer treatment and found that they couldn't do what they used to do and even attempting to do the exercise that they used to do, it resulted in a litany of sort of bad consequences like worse fatigue and that was discouraging.”

Activity Snacks

One idea Wechsler and the research team will look into is developing exercise prescriptions that are adaptive, flexible, and manageable. First comes an initial exercise dose for a patient and based on how it goes, that dose can be ramped up or down in lesser amounts. And if it needs to be put off because something came up, the next exercise dose can be the same or a little less than the previous one, all to avoid fluctuations and setbacks. Perhaps the most important idea are what Wechsler calls bite-size “activity snacks.”

“It’s moving from the guidelines that recommend these longer bouts, these 30-minute chunks of exercise and breaking it down into ten, five or even two minutes of exercise that you can fit in throughout your day,” said Wechsler. “So, it's the idea of getting up from your desk and going for a walk, or taking the stairs instead of the elevator, or walking the dog, or even playing with your children. You could fit in physical activity and movement throughout the day which should accumulate and there's evidence that it's the accumulation of movement and physical activity that really counts.”

Given the research was published in a nursing journal, the study calls on nurses in the cancer field to be proactive with a patient’s exercise regimen.

“Oncology nurses are in a prime position to educate patients about initiating exercise during and after cancer treatment,” noted Wechsler, who added a previous study of his found that some women highlighted their nurses as key players in their exercise support system. “One idea of how to deliver a Goldilocks intervention is having nurses educate patients and guide them to exercise during and after treatment.”

Because cancer-related fatigue is one of the most prevalent side effects of breast cancer survivors, leading to higher rates of unemployment and hospitalizations and lower quality of life, it’s critical more research is conducted to improve the quality of life. That’s what Wechsler plans to do, building on his team’s findings.

“This article helps to illuminate the reality that a lot of breast cancer survivors living with cancer related fatigue are facing,” concludes Wechsler. “We know what's best. We know exercise works but that can only go so far. We have to know how breast cancer survivors living with cancer related fatigue think about, perceive, and approach exercise on their own. That really will help us develop interventions to help meet these survivors where they are and help optimize how we're delivering exercise as medicine as an intervention to them.”

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