ARTICLE IN PRESS

European Journal of Oncology Nursing (2005) 9, 56–63

www.elsevier.com/locate/ejon

A pilot study of a supervised group exercise

programme as a rehabilitation treatment for
women with breast cancer receiving adjuvant
treatment
Anna Campbella, Nanette Mutriea,*, Fiona Whiteb, Fiona McGuirec,
Nora Kearneyd

a
Institute of Biomedical and Life Sciences, Glasgow G12 8RZ, UK
b
Macmillan Education Unit, Nursing and Midwifery School, University of Glasgow, Glasgow G12 8LW, UK
c
GGNHSB, Dalian House, 350 St Vincent St, Glasgow G3 8YT, UK
d
Cancer Care Research Team, Department of Nursing and Midwifery, University of Stirling,
Stirling FK9 4LA, UK

KEYWORDS Summary This pilot study examined whether exercise as an adjunctive rehabilita-
Breast cancer; tion therapy could benefit women who have early stage breast cancer and are
Exercise; currently receiving chemotherapy/radiotherapy. The study was designed as a
Fatigue; randomised controlled trial (RCT). Physical functioning, fatigue and Quality of Life
(QoL) outcomes were evaluated pre and post a 12-week intervention. The results
Quality of life
showed that after 12 weeks the women who participated in the exercise programme
(n ¼ 12) displayed significantly higher levels of physical functioning and reported
higher QoL scores than the controls (n ¼ 10). Changes in fatigue and satisfaction with
life favoured the intervention group but did not reach significance. These results are
encouraging and suggest that a structured group exercise programme during
adjuvant treatment is a safe, well tolerated and effective way of providing physical
and psychological health benefits to women during treatment for early stage breast
cancer. Since this was a pilot study the numbers did not allow appropriately powered
analyses of some variables of interest and favoured relatively young and socio-
economically advantaged women. Future studies need to address these issues and
determine if these short-term benefits can be sustained.
& 2004 Elsevier Ltd. All rights reserved.

Zusammenfassung In dieser Pilotstudie wurde untersucht, ob Korper . .

ubungen als
erga. nzende Rehabilitationsmanahme fur .
. Frauen von Vorteil sein konnten, die erst
vor kurzem an Brustkrebs erkrankt waren und gegenwa. rtig mit Chemotherapie bzw.
Strahlentherapie behandelt werden. Die Untersuchung wurde als kontrollierter
Zufallsversuch (RCT: randomised controlled trial) ausgelegt. Vor und nach einem
. ochigen
zwolfw . .
Ubungsprogramm .
wurden allgemeine Korperfunktionen, Erm-
.udungserscheinungen (Fatigue) und Lebensqualita. t (QoL: Quality of Life) gemessen
und bewertet.
.
Die Resultate zeigen, dass die Frauen, die am Ubungsprogramm teilgenommen
hatten (n ¼ 12), am Ende der zwo. lf Wochen im Vergleich zur Kontrollgruppe (n ¼

*Corresponding author. Tel.: þ 44-141-357-7563; fax: þ 44-141-337-2389.

1462-3889/$ - see front matter & 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2004.03.007
 ARTICLE IN PRESS
A pilot study of a supervised group exercise programme as a rehabilitation treatment 57

.
10) ein signifikant hoheres .
Niveau bei den Korperfunktionen .
aufwiesen und hohere
QoL-Werle erzielten. Vera. nderungen hinsichtlich der Variablen ’Erm-
.
udungserscheinungen’ und ‘Zufriedenheit mit dem Leben’ sahen die Programm-
gruppe im Vorteil, bewegten sich aber nicht im Signifikanzbereich.
Diese Untersuchungsergebnisse sind ermutigend und legen es nahe, gut aufge-
.
baute Korper .
ubungsprogramme . Gruppen als eine sichere, effektive und
fur
bereitwillig akzeptierte Manahme zu betrachten, um Frauen im Fruhstadium . der
Brustkrebserkrankung schon wa. hrend der Behandlung Hilfe zur Erhaltung der
physischen und psychischen Gesundheit zukommen zu lassen. Da es sich jedoch
nur um eine Pilotstudie handelte, konnten wegen der beschra. nkten Anzahl von
.
Probandinnen einige Variable von Interesse nicht grundlich genug analysiert werden.
Weiter waren einschra. nkend vor allem jungere,
. .
bezuglich ihres sozio-o. konomischen
.
Status privilegierte Frauen betroffen. In zukunftigen Untersuchungen sollten diese
.
Fragen berucksichtigt werden. Zudem sollte gekla. rt werden, ob die festgestellten
kurzfristigen positiven Auswirkungen la. ngerfristig von Bestand sein konnen.
.
& 2004 Elsevier Ltd. All rights reserved.

Introduction health that are typically diminished in patients

Breast cancer is the most commonly occurring
cancer among women and in Scotland accounts
for 25% of the female cancer burden excluding non-
melanoma skin cancer (Cancer Surveillance Group,
2000). Incidence of breast cancer increased by
27.4% over the period 1986–1995 (Cancer Surveil-
lance Group, 2000). For any woman free from other
life-threatening disease, the risk of developing
breast cancer up to the age of 74 is approximately
8% (Harris et al., 1998). Survival has improved over
the last 20 years in Scotland with a 75.3% 5 year
relative survival reported for those diagnosed
between 1991 and 1995 compared to 56% for those
diagnosed between 1968 and 1972 (Harris et al.,
1998). This has placed an increased emphasis on
addressing the quality of life (QoL) issues for
women with a breast cancer diagnosis. A recent
meta-analysis (Meyer and Mark, 1995) has shown
that there are a number of QoL interventions that
may help individuals cope with the cancer experi-
ence including cognitive-behavioural therapies,
information and educational strategies, individual
counselling, psychotherapy and social support.
However, one common feature among these inter-
ventions is that they do not adequately address the
physical and functional problems encountered by
patients such as fatigue, nausea and weight gain.
An intervention that may address a broad range of
QoL issues following breast cancer diagnosis is
exercise (Courneya and Friedenreich, 1997). The
rationale for the use of exercise as a QoL interven-
tion for patients with cancer is strong. Exercise is
associated with improved cardiovascular fitness,
pulmonary function and self-esteem, and with
decreased anxiety and depression – all aspects of
with cancer (Bouchard et al., 1994). Recent studies
have reported that exercise has a positive effect on
the physiological outcomes of women with breast
cancer such as fatigue (Mock et al., 2001),
functional capacity (MacVicar et al., 1989), body
composition (Winningham et al., 1989) and nausea
(Winningham and MacVicar, 1988) and psychological
outcomes such as locus of control, mood states,
self-esteem, QoL and satisfaction with life (Cour-
neya and Friedenreich, 1997; Mock et al., 2001;
Segar et al., 1998; Kolden et al., 2002). However,
many of the earlier studies were methodologically
limited, using quasi-experimental, cross-sectional
or retrospective research designs. To date, only
three research groups (all based in North America)
(Mock, 2001; Winningham and MacVicar, 1988;
Segal et al., 2001) have conducted randomised
controlled trials on the effects of exercise following
breast cancer diagnosis. Their results, most of
which are based on individually supervised exercise
or home-based self-reported exercise, show that
the women who exercised reported less fatigue and
emotional distress as well as a higher functional
ability and QoL than the control groups. Only two
studies have examined the feasibility of a struc-
tured group exercise programme during treatment.
Kolden et al. (2002) recruited 40 women over the
age of 45 with breast cancer to participate in a
course of group exercise training (GET) delivered in
a structured format three times a week for 16
weeks. The results showed that the participants
experienced significant physical and psychological
health benefits by attending the group exercise
sessions. In this study the participants served as
their own controls and therefore the efficacy of
GET was not fully established. Segal et al’s study
 ARTICLE IN PRESS
58
(Segal et al., 2001) of women with breast cancer
receiving adjuvant therapy compared self-directed
and supervised exercise with usual care in a
controlled clinical trial. They found decreased
physical functioning in the control group and
increased physical functioning in both intervention
groups. However there were no significant differ-
ences in QoL scores. Only the supervised group
showed increased aerobic capacity and reduced
body weight.
Although the literature is strongly suggestive of a
positive link between physical exercise and QOL
following breast cancer diagnosis, there are a
number of shortcomings that need to be addressed:
* There have been few studies with control groups
equivalent on all relevant criteria to the experi-
mental condition. In spite of the challenges of
conducting a randomised controlled trial with an
intervention that may be viewed as desirable,
research using this design is needed to minimise
the bias inherent in previous studies.
* In most studies, the results were based on self-
reported levels of exercise or on individually
supervised exercise. More studies are needed
with objective indicators of physical exercise,
such as attendance at structured fitness classes,
in order to study whether exercise in a group
setting influences QOL changes and/or exercise
motivation and adherence.
* Many of the earlier intervention studies com-
menced many months or even years after the
end of treatment for breast cancer.
This pilot study attempts to address these issues.
The study is also the first in the United Kingdom
conducted within the National Health Service and
linked with a local authority.
Methods
Recruitment of subjects
The procedures for this study were approved by the
West Ethics committee, North Glasgow University
Hospitals NHS Trust. Women undergoing treatment
for newly diagnosed breast cancer were recruited
from a large West of Scotland Cancer Centre during
a defined recruitment period. Eligible women had
received breast surgery and were currently receiv-
ing adjuvant radiotherapy/chemotherapy. Women
were excluded from the study if they had con-
current major problems such as uncontrolled
cardiac or hypertensive disease, respiratory disease
and cognitive dysfunction. Women who were
A. Campbell et al.
already exercising vigorously three times a week
for 20 minutes or more were excluded from the
study but invited to attend the exercise sessions.
Women were made aware of the programme
through their consultant oncologist, breast care
nurse and radiotherapy and chemotherapy nurses
and were invited to join the study around the time
of 2nd or 3rd chemotherapy cycles and during 2nd
and 3rd weeks of radiotherapy treatment. This
ensured that treatments had been established with
no particular problems noted.
Instruments
Sociodemographic data
Standard demographic data and physical activity
level prior to cancer diagnosis was noted. DEPCAT
score, an index of deprivation, was derived from
post code (Morris and Carstairs, 1991). The DEPCAT
score obtained ranges from 1, indicating the lowest
level of deprivation, to 7 indicating the highest
level of deprivation. Clinical information regarding
the treatment regime was requested from the
healthcare team.
Psychological/quality of life
Cancer-specific quality of life was measured using
Functional Assessment of Cancer Therapy – General
(FACT-G) and Functional Assessment of Cancer
Therapy – Breast (FACT-B) scales (Cella et al.,
1993): FACT-G was the primary outcome of interest
and is intended for all patients with cancer; FACT-B
is intended for patients with breast cancer. The
FACT B includes 5 well-being subscales: physical,
social, emotional, functional and breast cancer
specific. These scales present a series of state-
ments to the respondent who answers on a 5-point
scale of agreement from ‘‘not at all’’ to ‘‘very
much’’. An example from the functional section
would be ‘‘I am able to work (include work at
home)’’.
Satisfaction with Life Scale (SWLS) is a global
QoL tool (Diener et al., 1985). It is a short 5-item
instrument with questions such as ‘‘in most ways
my life is close to my ideal’’ with a 7-point scale of
agreement. SWLS was developed to assess satisfac-
tion with the respondent’s life as a whole. The
scale does not assess satisfaction with life domains
such as health or finances but allows subjects to
integrate and weight these domains in whatever
way they choose. SWLS shows good convergent
validity with other scales and with other types of
assessments of subjective well-being yet the scale
has shown sufficient sensitivity to be potentially
valuable to detect change in life satisfaction during
 ARTICLE IN PRESS
A pilot study of a supervised group exercise programme as a rehabilitation treatment
the course of clinical intervention. The SWLS is
recommended as a complement to scales that focus
on psychopathology or emotional well-being be-
cause it assesses an individual’s conscious evalua-
tive judgment of his or her life by using the person’s
own criteria.
Perceived expectations and benefits of total care
package – this questionnaire was designed specifi-
cally for this study. At baseline subjects were asked
(using a standard 5-point Likert scale) to indicate
their expectations that the total care package will
affect their QoL (a great deal, some improvement,
not sure, not much, not at all). At week 12,
subjects were asked to indicate whether the total
care package had helped to improve their QoL.
Fatigue
Revised Piper Fatigue Scale (PFS) (Piper et al.,
1998). The PFS is a 22-item, 10 point self-report
scale that measures overall fatigue. This scale
consists of 22 questions divided into four subscales
that measure the following dimensions of fatigue:
behavioural/severity, affective meaning, sensory
and cognitive/mood. Each question was scored on
an 11-point numerical scale. The overall score and
each subscale score is given on a scale of 0–10 with
0 indicating no fatigue and 10 indicating the most
severe fatigue. The scores for each question are
summed and then divided by the total number of
questions 22 to obtain an overall average score for
the questionnaire. The PFS has demonstrated
validity and reliability in a number of other studies
of patients with cancer.
Physical
The Scottish Physical Activity Questionnaire [SPAQ]
(Lowther et al., 1999) was used to measure self-
reported physical activity. Respondents were asked
to recall all moderate or vigorous activity com-
pleted at home, at leisure or at work over the
previous 7 days. The SPAQ has been shown to be
quick and easy to complete and practical for use
with large subject numbers in a variety of situa-
tions. Lowther et al. (1999) developed this ques-
tionnaire for use with Scottish populations and
showed that it had good test–retest reliability and
strong concurrent validity with the stage of
exercise behaviour change model.
The 12-minute walking test (McGavin et al.,
1976) was performed as a measure of physical
function. This test is a measure of the distance in
metres an individual can cover in 12 minutes. The
test is conducted indoors on a level surface using a
stopwatch. The subject is instructed to walk as far
as possible in 12 minutes but not to be concerned if
she needs to slow down or stop to rest at any time
59
that discomfort occurs. Baseline and post-test
measures were used to assess changes in physical
condition resulting from exercise. The 12-minute
walk test has been successfully used in studies with
women with breast cancer (Schwartz et al., 2001)
and is used extensively in cardiac rehabilitation as
a measure of functional ability. Using an estimate
of standard walking pace, in which 1 mile [1.6
kilometres] can be covered in 20 minutes at an
average pace or 15 minutes at a fast pace, we have
estimated that an average person will be able to
complete around 960–1280 m in 12 minutes, de-
pending on their pace.
Design and procedures
The study was a 2 (group) by 2 (time points)
randomised controlled trial with a structured
exercise programme as the treatment variable. If
a woman expressed an interest in taking part in
the study, an appointment was made to meet
the senior researcher, at which point informed
consent was obtained. The volunteer then com-
pleted all baseline questionnaires and performed
the 12-minute walking test. The women were
randomly allocated by computer-generated num-
bers into one of two groups in equal proportion.
The randomisation was stratified by treatment
(chemotherapy, radiotherapy or combination). Let-
ters were sent to participants General Practi-
tioners’ (GPs) to inform them of the person’s
involvement in the study.
The time points were pre-treatment (baseline)
and 12 weeks. The exercise programme lasted 12
weeks because there is evidence that exercise can
be effective during this time-frame (Marcus et al.,
1994) and it provided sufficient time to encourage
subjects in the exercise group to become indepen-
dent exercisers.
A demographic questionnaire was completed at
baseline. The SPAQ, 12-minute walk test, FACT-G,
FACT-B, SWLS, PFS, and the expectations & benefits
questionnaires were completed at entry and at 12
weeks. The questionnaires were self-administered
and returned to the researcher in a sealed
envelope.
Treatment groups
Group A – usual care plus monitoring
This group received usual care from the healthcare
team and completed the questionnaires and walk-
ing test at baseline and week 12. At the end of the
study period they were assisted by the senior
 ARTICLE IN PRESS
60
researcher in constructing their own personalised
exercise plan using recognised person-centred
guidelines (Loughlan and Mutrie, 1995) and invited
to join the local general practice (GP) exercise
referral scheme.
Group B – usual care plus adjunctive group
exercise treatment
Women assigned to this group received usual care
and also attended a supervised exercise programme
twice weekly for 12 weeks. The exercise interven-
tion was based on Courneya’s exercise prescription
guidelines for cancer patients and survivors
(Courneya et al., 2000). The classes consisted of a
warm-up, 10–20 minutes exercise (which varied
from week to week and included walking, cycling,
low-level aerobics, muscle-strengthening exer-
cises, circuits etc.), a cool down and relaxation
period. The women’s heart rates were monitored
throughout the class to ensure that they were
exercising at a moderate level (60–75% age-
adjusted heart rate maximum). Each week, for 6
weeks, a specific theme was addressed, with the
intention of guiding the women into becoming
independent exercisers. These themes were based
on a model of behaviour change (Marcus et al.,
1994) and addressed the health benefits from
exercise, enhancing self-efficacy, overcoming bar-
riers, achieving a supportive environment, setting
goals and finding appropriate activity options in the
community (Mutrie et al., 1997). The 6-week block
was repeated on a rolling basis allowing all
participants to hear the same themes. At the end
of the study, the women were assisted in con-
structing an individual exercise programme tailored
to suit each person’s needs to encourage them to
move on to exercising independently. They were
also invited to join the local GP exercise referral
scheme.
Data analysis
Data were analysed using SPSS for Windows (Version
9). Baseline subjects’ characteristics in the two
groups were compared using independent t-tests
for continuous variables and w2 tests for categorical
variables. For primary analysis, the change in FACT-
G scores between baseline and 12 weeks for each
participant was calculated. The primary outcome
of change over baseline at 12 weeks in FACT G score
was compared between the two randomised groups
using a two sample two-sided t-test. Secondary
measures of FACT-B, SWL, SPAQ, PFS, 12-minute
walking distance were analysed in the same way.
Alpha level was set as Po0.05.
A. Campbell et al.
Results
Recruitment and adherence to exercise
programme
Over a recruitment period of 12 weeks, 22 women
undergoing chemotherapy and/or radiotherapy
were recruited into the study. 19 women out of
22 completed the study. One woman discon-
tinued due to travel constraints, one due to
secondary cancer and one declined to provide
the reasons for discontinuing. There were no
adverse reactions to taking part in the exercise
intervention and participants completed an aver-
age of 70% of the total number of sessions
(SD ¼ 720%).
Table 1 shows the comparisons of the two groups
at baseline. There were no baseline differences
between groups for the physical functioning, QoL,
fatigue and demographic characteristics. However,
those then allocated to the exercise group were
more positive in their expectations of the effect
that the total care package would have on their
quality of life.
Table 2 shows the differences in the measure-
ments post-intervention between the exercise
group and the control group. After 12 weeks, the
women who participated in the exercise pro-
gramme reported significantly higher levels of
physical functioning (12-minute walking test),
physical activity (SPAQ) and general QoL (FACT-G)
than the controls. Changes in fatigue and satisfac-
tion with life favoured the intervention group but
did not reach significance.
Discussion
An important finding of the study was that the
women recruited into the exercise group were able
to consistently and progressively increase physical
activity levels over the course of chemotherapy and
radiotherapy treatments whereas the usual care
group experienced a progressive decrease in
physical activity levels. The women recruited into
the study demonstrated a high level of motivation
and adherence to engage in the structured group
exercise. There was only a 13% dropout during the
12 weeks and all participants completed an average
of 70% of all sessions.
By the end of this study’s 12 week programme the
women in the exercise group spent on average, an
additional hour almost each day carrying out
routine activities such as walking, housework and
leisure pursuits whereas the controls remained at
 ARTICLE IN PRESS
A pilot study of a supervised group exercise programme as a rehabilitation treatment 61

Table 1 Comparison of randomised groups at baseline.

Measurements Exercise group Control group
Number of subjects 12 10
Age (years) 48 [710] 47 [75]
Treatment
Chemotherapy 3 3
Radiotherapy 2 4
Combination 7 3
Carstairs Deprivation Index 3.0 3.8
SPAQ (minutes of physical activity 330 [7171] 421 [7191]
per week)
12-minute walking test (metres) 1026 [7237] 1087 [7136]
Piper Fatigue Scale 5.24 [72.2] 4.87 [72.5]
Fact-B 92.3 [725] 96 [719]
Fact-G 72 [718] 79 [715]
Satisfaction with Life Scale 4.45 [71.5] 3.68 [71.9]
Perceived expectation of treatment 1.3 [70.5] 0.3 [71.3]
packagen
n
P ¼ 0.02.

Table 2 Change in measurements from baseline to 12 weeks.

Measurements Exercise group Control group P-value
(10 women) (nine women) group
Mean (SD) Mean (SD) comparison
12-minute walk (metres) þ 328 [7145] 5 [7139] 0.001nn
SPAQ (minutes) 343 [7190] 5 [7214] 0.003nn
FACT B þ 14.3 [719.8] 1.7 [719.4] 0.094
Subscales
Functional wellbeing þ 3.67 [75.24] 1.5 [75.97] 0.062
Physical wellbeing þ 4.33 [74.03] 1.2 [77.61] 0.066
Breast cancer specific þ 2.44 [76.93] þ 1.2 [75.14] 0.666
FACT G þ 11.9 [713.8] 2.9 [716.1] 0.046n
Piper Fatigue Scale 2.11 [72.3] 0.25 [72.5] 0.115
Satisfaction with Life Scale þ 0.4 [70.9] 0.02 [70.7] 0.315
Perceived benefits of treatment 1.78 [70.4] 0.44 [71.7] 0.004nn
package
n
P ¼ o0.05.
nn
P ¼ o0.01.

the baseline level of physical activity. The self-
reported levels of physical activity at baseline for
both groups and at follow up for the control group
were similar to those found in sedentary popula-
tions (Lowther et al., 1999). The intervention group
increased their activity to levels associated with
regularly active people and improved their 12-
minute walk distance to what would be expected of
those walking at a fast pace. This increase in
routine activities correlated (Pearson’s correlation
0.456; P ¼ 0.025) with the significant increase in
the distance the women could walk in 12 minutes
after the programme – a measurement of physical
fitness.
With FACT-B, which includes breast cancer
specific concerns, no significant differences were
observed between groups although the results
favoured the intervention. However, when changes
over 12 weeks were analysed for FACT-G, the
general quality of life questionnaire for cancer
patients, the difference between groups was
significant, with the physical and functional sub-
scales showing the most difference between
groups. The women in Kolden’s (2002) group
exercise study showed similar QoL improvements –
they also found a significant improvement in the
FACT functional subgroup. However, in Segal’s RCT
(Segal et al., 2001), no significant differences
 ARTICLE IN PRESS
62
amongst the groups in FACT-G and FACT-B were
reported over a 26-week intervention period.
In this pilot study, the mean difference between
groups for the change in FACT G score over the 12
weeks was about 15 units. This change represents a
shift from requiring bed rest half the waking day to
being fully ambulatory with symptoms (Brady et al.,
1997). These differences in physical functioning
and QoL between the two groups therefore may
have a practical significance in that limitations
during and after treatment may prevent the women
getting back to work, coping with family life, etc.
All the participants enthusiastically endorsed the
group exercise programme. An open-ended item
was included in a questionnaire to assess the
women’s views on the intervention. One woman
described the programme as ‘‘a life-saver’’ and
other comments included ‘‘feeling less tired and
sleeping better’’, ‘‘giving me confidence to go out
and do things again’’ and ‘‘being able to push
myself in a safe environment’’. The popularity of
the class was demonstrated by the women in the
exercise group arranging to exercise together, on a
weekly basis, after the 12-week supervision had
finished. We recognise that part of the success of a
group programme will involve the support that the
women provide for each other. This support may be
responsible for some of the psychosocial benefits
noted in this study and future studies should
employ qualitative techniques to determine if
women do perceive the group itself as a benefit
beyond the exercise effect.
Recruitment was not as successful as predicted.
At the end of the study a focus group with the
recruitment nurses highlighted some reasons.
These included lack of time and priority as main
factors, plus the nurses’ own perceptions of
whether the women were eligible, i.e. ‘‘fit for
exercise’’. Women who were reluctant to join the
study cited reasons such as discouraged by ‘‘ex-
ercise’’, class at unsuitable time, travel problems
or not interested in group activities.
While these results are encouraging, future
studies should look at offering classes at a variety
of times and settings within the community as this
study favoured relatively young and socio-econom-
ically advantaged women.
In addition there is a need to determine if these
short-term benefits can be sustained in the longer
term, to find out the perceived benefits and
difficulties surrounding exercise for this patient
group and the cost benefit of the intervention.
This study showed that group exercise may be a
safe and effective way of improving the quality of
life for this group of patients with cancer. Cancer
care teams within the health service may be able to
A. Campbell et al.
use this evidence to consider exercise as part of
rehabilitation during adjuvant therapy.
Acknowledgements
We would like to acknowledge the support of
Greater Glasgow NHS trust for the funding to
complete this pilot study.
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