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AN EXERCISE PROGRAM FOR CANCER PATIENTS:

PHYSICAL AND EMOTIONAL WELL-BEING AS
INDICATORS OF QUALITY OF LIFE

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AN EXERCISE PROGRAM FOR CANCER PATIENTS: PHYSICAL AND
EMOTIONAL WELL-BEING AS INDICATORS OF QUALITY OF LIFE

By

Joan Marlene Borst

A DISSERTATION
Submitted to
Michigan State University
In partial fulﬁllment of the requirements
For the degree of
DOCTOR OF PHILOSOPHY
School of Social Work

2005

ABSTRACT

AN EXERCISE PROGRAM FOR CANCER PATIENTS: PHYSICAL AND
EMOTIONAL WELL-BEING AS INDICATORS OF QUALITY OF LIFE

By
Joan Marlene Borst

The diagnosis and treatment of cancer often includes biological and psychological
side effects that interfere with a cancer patient’s quality of life. The symptoms include
nausea, fatigue, weakness, depression, anxiety, helplessness, and hopelessness.
Increasingly, exercise is recognized as an effective adjunctive therapy to traditional
cancer treatments. Participation in a low to moderate intensity exercise program may
improve physiological as well as psychological condition.

The purpose of this study was to examine the effect of a ten-week exercise
program on the physical and emotional well-being of patients in active treatment for a
variety of cancer diagnoses. In addition, the study examined which of the variables
“physical well-being” or the “emotional well-being”, improved more, and whether the
change was inﬂuenced by gender, age range, cancer type, or type of cancer treatment.

Sixty-two subjects (F = 36, M = 26) between the ages of 21 and 80, and all in
cancer treatment for a variety of cancer types, served as participants in the study. Before
and after the exercise program, participants completed the Functional Assessment of
Chronic Illness Therapy - Fatigue [FACIT -F] subsections entitled, “physical well-being”
and “emotional well-being”.

Results indicated that subjects experienced a statistically signiﬁcant improvement
in physical and emotional well-being aﬁer participation in the ten-week exercise

program. The results did not demonstrate a statistically signiﬁcant difference in the

improvement between physical and emotional well-being, although the results did
indicate the effect size for physical well-being was somewhat larger.

Gender, age range, cancer type and cancer treatment showed no statistically
signiﬁcant inﬂuence in the improvement of physical well-being, but the inﬂuence of
cancer type on improvement of physical well-being suggested that this relationship might
be worthy of additional study.

The results of this study have implications for the practice of social work in the
ﬁeld of health care and social policy. Exercise offers a cost-effective and an alternative
way of supporting improvement in the physical and emotional well-being of people living
with cancer. Low to moderate physical activity is a way for people living with cancer to
be personally involved in their health care. This form of self-care may inﬂuence both the
reduction of the physical side-effects of cancer and cancer treatment, but may also
decrease levels of depression, hopelessness, and helplessness. Future studies should be
directed toward understanding the relationship between gender, age range, type of cancer
and type of cancer treatment on the improvement in physical and emotional well-being.
In addition, studies should continue in understanding the role of exercise in improving the

physical and emotional well-being of individuals living with other chronic illnesses.

Copyright by
Joan Marlene Borst
2005

To the courageous men and women who enthusiastically participated in this project —
people living with cancer and hope and the caring, professional and dedicated

professionals who support them.

ACKNOWLEDGMENTS

This dissertation represents the ﬁnal lap of the run to earn my doctoral degree. As
I now experience the end of this journey, I celebrate the acquisition of what I perceived
as the impossible. I must humbly acknowledge the presence and support of God in my
life and all the additional supports divinely placed to anchor, encourage, and cheer me.
First in support and love is my dear husband, Jim. He continually and cheerfully believes
in me, often more than I am able to believe in myself. Second, I thank my children,
Abigail and Benjamin, for their love for me and for sharing my attention to them with the
attention demanded by this piece of work.

Thanks to my most loving parents, Fanny and John Harvey Vander Veen. They
taught me that education was important, that I could do what I set out to do, and that I
could always depend on them. Mom’s death from cancer in 1998 planted my interest in
how she, and others like her, courageously c0pe in the face of cancer. I miss you, Mom.
Also thanks to Julia, who has made my Dad so happy again. I love you, too.

My deep appreciation goes to Dr. Rena Harold. I could not have made it through
this process without her. She edited, reviewed, revised, counseled and cheered me despite
her incredibly full personal and professional life. Rena, you are my role model. In
addition, my gratitude also goes to my committee, Dr. Clifford Broman, Dr. Martha
Ewing, and Dr. Margie Rodriguez LeSage. Thank you for your time and attention to my
work.

Thank you to my colleagues at Grand Valley State University who always asked

me about my dissertation work and encouraged me to stay the course. Thanks especially

vi

to my colleague, Dr. Soon Hong, for your patience and assistance with my statistical
testing. You were invaluable. Finally, my gratitude to Dr. Mark Eastburg at St. Mary’s
Cancer Center for your ideas, your structured thinking, and your desire to know if and

why interventions work. You are a gifted man.

vii

TABLE OF CONTENTS

LIST OF TABLES ........................................................................... xi
LIST OF FIGURES ........................................................................ xii
Chapter

I. INTRODUCTION .......................................................... 1
Introduction and Problem Statement ..................................... 1
Purpose of the Study ........................................................ 3
Rationale for the Study ..................................................... 3
Research Questions ......................................................... 6
Research Hypotheses ....................................................... 7
Overview ..................................................................... 8
11. REVIEW OF THE LITERATURE ....................................... 9
Cancer ........................................................................ 9
Overview ............................................................ 9

Types of Cancer .................................................... 10

Cancer Treatments ................................................. 1 1

Cancer and Gender ................................................. 14

Cancer and Age ..................................................... 16

Aging Women and Cancer ........................................ 18

Coping with Cancer ................................................ 19

Quality of Life ............................................................... 20

Overview ............................................................ 20

Deﬁnition of Quality of Life ...................................... 21

Improvement of Quality of Life .................................. 25

Physical Well-Being ............................................... 26

Emotional Well-Being ............................................. 28

Exercise ...................................................................... 30

Overview ............................................................ 30

Exercise and Cancer ............................................... 31

Summary ..................................................................... 37

III. METHODOLOGY ......................................................... 38

Epistemology ................................................................ 38

Description of Program .................................................... 43

viii

Subjects and Sampling ..................................................... 46

Design and Procedures ..................................................... 48
Instrumentation .............................................................. 50
Validity and Reliability ..................................................... 53
Assumptions of the Study .................................................. 54
Summary ..................................................................... 54
RESULTS .................................................................... 56
Overview ..................................................................... 56
Characteristics of Subjects ................................................. 57
General Findings ............................................................ 62
Results by Research Hypothesis .......................................... 62
Physical Well-Being ............................................... 62
Hypothesis 1 ............................................... 63
Results 1 .................................................... 63
Emotional Well-Being ............................................. 66
Hypothesis 2 ............................................... 66
Results 2 .................................................... 66
Difference between Physical Well-being and
Emotional Well-Being ............................................. 69
Hypothesis 3 ............................................... 70
Results 3 .................................................... 70
Inﬂuence of Variables on Improvement in Physical
Well-Being .......................................................... 72
Hypothesis 4 ............................................... 72
Results 4.1: Gender ...................................... 72
Results 4.2: Age Range .................................. 74
Results 4.3: Cancer Type ................................. 76
Results 4.4: Cancer Treatment ........................... 79
Summary ..................................................................... 81
DISCUSSION AND IMPLICATIONS .................................. 83
Overview ..................................................................... 83
Major Findings ............................................................... 85
Improvement in Physical Well-Being .................. 85
Improvement in Emotional Well-Being ................ 86
Difference in Improvement Between Physical and
Emotional Well-Being .................................... 87
Inﬂuence on the Independent Variables on
Improved Physical Well-Being .......................... 90
Implications .................................................................. 95
Practice Implications ..................................... 95
Policy Implications ....................................... 98
Limitations of the Study .................................................... 101
Recommendations ........................................................... 105

ix

Conclusion .................................................................... 1 O6

APPENDICIES
A. Lance Armstrong Grant ........................................... 109
E. Patient Information and Consent Form .......................... 112
F. Physician Release of Information ................................ 118
G. Cancer Wellﬁt Training and Education Schedule ............. 120
H. MSU Human Subjects Review Approval ....................... 123
1. Cancer Wellﬁt Physician Notiﬁcation ........................... 125

REFERENCES ....................................................................... 127

10.

LIST OF TABLES

Paired Sample T-Test Statistics based on Pre and Posttest

Results Measuring Physical Well-Being ..................................... 65
Paired Sample T-Test Statistics based on Pre and Posttest

Results Measuring Emotional Well-Being .................................... 69
T-Test for Improved Physical Well-Being and Improved

Emotional Well-Being ........................................................... 71
Difference in Improvement Between Genders ............................... 73
Regression Summary of Age Range .......................................... 75

AN OVA Test Results on Improved Physical Well-Being
by Type of Cancer ............................................................... 77

AN OVA Test Statistics of Improved Physical Well-Being
by Type of Cancer Type ........................................................ 78

Kruskal Wallis Test Statistics of Improved Physical Well-Being
by Type of Cancer ............................................................... 78

AN OVA Test Results on Improved Physical Well-Being
and Type of Cancer Treatement ................................................ 80

Kruskal Wallis Test Statistics of Improved Physical Well-Being
by Type of Cancer Treatment .................................................. 81

xi

10.

11.

12.

13.

LIST OF FIGURES

Percentage of Participants Based on Age Range ......................... ‘. .. 57
Percentage of Participants Based on Cancer Type .......................... 58
Percentage of Participants Based on Type of Cancer Treatment .......... 59
Percentage of Participants Based on Goal of Cancer Treatment .......... 60
Frequency of Physical Well-Being Pretest Scores ........................... 63
Frequency of Physical Well-Being Posttest Scores ......................... 64
Frequency of Emotional Well-Being Pretest Scores ........................ 67
Frequency of Physical Well-Being Posttest Scores ......................... 68
Difference Between the Mean in Improved Physical Well-Being

and Emotional Well-Being ..................................................... 70
Difference in the Mean of Improved Physical Well-Being

Between Female and Male Participants ....................................... 73
Scatterplot of Improved Physical Well-Being and Age Range ............ 74

Side-By-Side Boxplot of Improved Physical Well-Being
and Type of Cancer .............................................................. 76

Side-By-Side Boxplot of Improved Physical Well-Being
by Type of Cancer Treatment .................................................. 80

xii

CHAPTER I

INTRODUCTION

Introduction and Problem Statement

Research suggests that people diagnosed with cancer are living longer than ever
before (Bohen, 2002; Burnham & Wilcox, 2002; Courneya, Mackey, & Jones, 2000).
Despite this good news, people living with and being treated for a variety of cancers
continue to experience physical and emotional symptoms that affect their quality of life
(Courneya, 2001). The most common emotional symptoms are depression and anxiety,
and the most common physical symptoms are fatigue and body weakness (Ahlberg,
Ekman, Gaston-Johansson, & Mock, 2003; Coumeya, 2001; MacVicar & Winningharn,
1986; Richardson, 1995). Depending on the type of cancer and cancer treatments,
symptoms and side effects can cause cancer patients to experience disintegration in their
quality of life (Courneya & Friedenreich, 1999; MacVicar & Winningham, 1986).

Patients experiencing the physical and emotional side effects from cancer
and cancer treatments are often advised to decrease activity and may choose to rest from
routine activities (Courneya, et al., 2000; Watson, 2002; Watson & Mock, 2003).
Research shows that inactivity in response to the increased physical and emotional
weakness experienced by individuals in response to cancer and cancer treatments may

exacerbate these side-effects (Courneya, et al., 2000; MacVicar & Winningharn, 1986).

However, recent work suggests that rest and reduction in levels of activity add to
the “dc-conditioning” or loss of physical strength in cancer patients (Courneya, et al.,
2000; MacVicar & Winningharn, 1986; Nieman, 1999; Williamson, 1998). This
inactivity leads to a need for a higher degree of effort by the patient to perform daily
activities, and may explain why many patients experience persistent weakness weeks and
months after the end of cancer treatments (Dimeo, Rumberger, & Keul, 1998). Coumeya
and Friedenreich (1999) propose that an intervention that may tackle a broad range of
quality of life issues following a cancer diagnosis is physical activity or exercise.

Recent studies suggest that the symptoms of depression, anxiety, and fatigue are
often reduced through the use of a well-designed exercise program for cancer patients
(Coumeya & F riedenreich, 1999). In fact, some cancer patients who participated in
regular exercise reported a reduction in negative side effects and an improvement in their
quality of life (Courneya, 2001; Schwartz, Mori, & Gao, 2001).

Because exercise appears to inﬂuence the quality of life for many people living
with and receiving treatment for cancer (Coumeya & F riedenreich, 1999), exploration of
the role that increased activity and exercise plays in improving cancer patients’ physical
and emotional health is growing. However, many there are many limitations to the
current body of research.

For example, few studies examine exercise as an intervention for individuals
living with cancer and in cancer treatment. Most intervention studies are initiated after
cancer treatment (Courneya, Mackey, & Jones, 2000). An additional limitation was noted
by Courneya and Friedenreich (1999) after the examination of 24 studies on exercise and

cancer. They found that a signiﬁcant number of studies were small, with an average

sample size of only 25 participants per study. Studies this small interfere with the use of
multivariate statistical techniques and reduce the power of a study. In addition, there are
few studies that examine the relationship between individuals participating in cancer
treatment and the independent variables of gender, age range, cancer type and cancer
treatment. Finally, while studies exist that acknowledge the beneﬁt of exercise for a
cancer patient’s physical and emotional health, no studies were discovered that explore
whether physical health or emotional health improves more when using exercise as
adjunctive therapy in the treatment of cancer.
Purpose of the Study
The purpose of this research study is to gain a better understanding of the effect of
exercise on the quality of life for people in treatment for cancer. The pre-exercise and
post-exercise test results of the quality of life variables physical and emotional well-being
are examined using the Functional Assessment of Chronic Illness Therapy, with Fatigue
[FACIT-F] questionnaire. The study explores change in well-being before and after an
exercise program. The results are also examined to distinguish if one area of well-being
(physical or emotional) improves more than the other. Finally, the purpose of the study is
to examine the role of the variables gender, age range, cancer type, and cancer treatment,
in improving quality of life.
Rationale for the Study
Physical exercise is an intervention therapy that addresses the broad range
of quality of life issues for people living with chronic illnesses. Research indicates that
exercise may also address quality of life issues for cancer patients (Coumeya &

Friedenreich, 1999). The rationale for the use of physical exercise in cancer patients is

very strong.

First, physical exercise is linked to many emotional and physical health beneﬁts
for people in the healthy population (Gunnarsson & Judge, 1997; Oweis & Spinks, 2001;
Scully, Kremer, Meade, Graham, & Dudgeon, 1998; Shepard, 1995; Zittel, Lawerence, &
Wodarski, 2002). Physicians frequently prescribe exercise for individuals with chronic
illness as a means to obtain an increase in energy, improve overall health and to improve
symptoms of depression (Moffat, 2001; Rochester, 2003; Prohaska & Warren-Findlow,
2002). These areas of concern are the same for people with a cancer diagnosis or
experiencing cancer treatments. However, an assumption is sometimes made that cancer
patients are “too ill” or do not have the stamina to participate in physical activities.

Second, physical exercise offers a natural, effective, and inexpensive way for
cancer patients to participate in self-care. In addition to common cancer treatments such
as chemotherapy, radiation, and surgery, exercise offers cancer patients an opportunity to
actively participate in their own treatment, empowers them, and assists them in possibly
controlling some of the physical and emotional symptoms caused by their cancer and
cancer treatment (Zittel, et al., 2002). As an adjunctive therapy, an exercise program
supports an improved quality of life (Patterson, Neuhouser, Hedderson, Schwartz, et al.,
2003). People living with cancer have an opportunity to feel better, less hopeless, and
more in control of their lives.

To further understand the role of exercise as an adj unctive therapy for cancer
patients, in April of 2002, the Cancer Center at Mercy Health Center in Grand Rapids,
Michigan, initiated a yearlong research study on the effect of an exercise program for

people living with cancer. The Cancer Center was interested in learning about the effects

of exercise on the physical health and the emotional health of individuals living with and
receiving treatment for a variety of cancer diagnoses. The study also examined the
physical and emotional health of supporters of the cancer patients in the program and the
effect of the exercise program on the patients’ perception of support.

Within one year, the Cancer Center, with support from two collaborating sports
centers in the city and a private grant, registered 75 cancer patients for the pilot study. All
75 participants were diagnosed with cancer and were in cancer treatment or had received
cancer treatment within the previous six months.

The study offered cancer patients ﬁ'om any physician in Western Michigan a ten-
week exercise program with the supervision and support of physical trainers. The cancer
patients met in small groups, of six to eleven, with the certiﬁed personal trainers to learn
about exercise and to design a plan of activity that offered the most beneﬁts to each
individual patient. Patients completed a series of standardized tests measuring their
emotional and physical condition prior to the ten-week exercise program and after
completing the program.

After one year of positive feedback from cancer patients, their supporters, and
physicians in the community, the Cancer Center applied for and received 3 Lance
Armstrong grant (Appendix A) allowing the Center to continue to offer this valuable
adjunctive treatment at no personal cost to cancer patients in the community. As of this
writing, the Cancer Center has over 300 individuals who have been involved in active
cancer treatment, participate in this exercise program.

As research assistant in the original pilot study, I assisted in the initiation of the

study, the coordination, the collection, and entering of the data. The study presented here

examines the effect of the ten-week exercise program on the physical and emotional
health of the participants in cancer treatment in the pilot study.

Rest and other limitations that interfere with physical activity during cancer
treatment may contribute to a process called “deconditioning”. Deconditioning is the
progressive loss of physical strength due to the underutilization of muscles and occurs to
cancer patients because inactivity is frequently the cancer patient’s response to the side-
effects of cancer treatment (Ahlberg, Ekman, Gaston-Johansson, & Mock, 2003;
MacVicar & Winningharn, 1986; Williamson, 1998).

Loss of physical strength is believed to decrease quality of life by interfering with
the ability of a person to participate in physical activities previously experienced. In
addition, the loss of physical strength creates a challenge for cancer patients to participate
emotionally (Cohen & Herbert, 1996; Gignac, Cott, & Badley, 2000). To understand how
exercise inﬂuences the quality of life for people living with and receiving treatment for
cancer, it is important to examine the role of deconditioning in the cancer patients and to
explore the role of increased activity and exercise in improving the cancer patients’
physical and emotional health (Schwartz, 1999).

Research Questions

The overarching question for this study was: Did participation in an exercise
program improve both the physical and emotional well-being for people living with a
variety of cancer diagnoses? The speciﬁc questions guiding the research fell into four
categories. The ﬁrst category explores the physical well-being for all of the subjects in
the exercise program. The second category examines the emotional well-being for

subjects in the exercise program. The third category examines the area of well-being most

improved for the subjects with cancer after participation in the exercise program. The
ﬁnal category examines the relationship between the area of well-being exhibiting the
greatest improvement and the independent variables gender, age range, cancer type, and
cancer treatment.

Speciﬁcally, the following research questions guided the inquiry:

1. Will people in active treatment for a variety of cancer types who
participate in a lO-week exercise program improve in physical well-being as
measured by the “physical well-being” subheading of the Functional Assessment
of Chronic Illness Therapy [FACIT]?

2. Will people in active treatment for a variety of cancer types who
participate in a lO—week exercise program improve in emotional well-being as
measured by the “emotional well-being” subheading of the Functional
Assessment of Chronic Illness Therapy [FACIT]?

3. Will people in active treatment for a variety of cancer types who
participate in a 10-week exercise program experience greater improvement in
their physical well-being (physical well-being as measured by FACIT) or in their
emotional well-being (emotional wellibeing as measured by FACIT) ?

4. What is the relationship between the more-improved condition
(physical well-being or emotional well-being) and the variables gender, age range,
cancer type, and cancer treatment?

Research Hypotheses

Hypothesis 1: There will be a statistically signiﬁcant improvement in the

posttest average scores of physical well-being reported by cancer patients

who are in active treatment for a variety of cancer diagnoses and
participate in a lO-week exercise program when compared to the pretest

7

average scores. (Higher mean score on the “physical well-being” subscale

as measured by the Functional Assessment of Cancer Therapy - Fatigue
[FACIT-F] will be associated with improved physical well-being.)

Hypothesis 2: There will be a statistically signiﬁcant improvement in the
posttest average scores of emotional well-being reported by cancer
patients who are in active treatment for a variety of cancer diagnoses and
participate in a 10-week exercise program when compared to the pretest
average scores. (Higher mean score on the “emotional well-being”
subscale as measured by the Functional Assessment of Chronic Illness
Therapy — Fatigue [FACIT-F] will be associated with improved emotional
well-being).

Hypothesis 3: There will be statistically signiﬁcant difference in
improvement in the sample mean of physical well-being when compared
to the sample mean of emotional well-being reported by cancer patients

who are in active treatment for a variety of cancer diagnoses and
participate in a lO-week exercise program.

Hypothesis 4: There will be a statistically significant relationship between

the variables 1) gender, 2) age range, 3) cancer type, and 4) cancer

treatment and improvement in physical well-being reported by cancer

patients who are in active treatment for a variety of cancer diagnoses and

participate in a 10-week exercise program. The literature does not specify

an identiﬁable direction of change.

Overview
Chapter I contained the introduction and problem statement, the description of the

original study and the plan and purpose of the study. The research question and
hypotheses were also introduced. Chapter 11 provides a review of the relevant literature
pertaining to this study. The research methodology is described in Chapter III, and the
ﬁndings are presented in Chapter IV. Chapter V contains a summary of the study, major

ﬁndings and conclusions drawn from the ﬁndings, implications, and recommendations.

CHAPTER 11

REVIEW OF THE LITERATURE

A review of three thematic strands of research served to develop the research
questions of this study: cancer, quality of life, and exercise. Each topic is explored by
examining the specialized research about each area presented in the literature. These
three broad research topics overlap and connect in ways that may be beneﬁcial to the
treatment of cancer. Research suggests that exercise may be an effective intervention for
enhancing quality of life in cancer patients (Burnham & Wilcox, 2002; Courneya &
Friedenreich, 1999; Courneya, Mackey, Lee, & Jones, 2000; Courneya, 2003;). As a case
in point, Courneya (2003) provides an overview of 47 research studies and four clinical
trials from the University of Alberta that examined exercise in cancer patients and the
effect on quality of life. The author found that “almost all studies showed beneﬁcial
effects of exercise in breast and nonbreast cancer groups alike as well as during and after
cancer treatment” (p. 1).

Cancer
Overview

The diagnosis of cancer is a common occurrence. The National Cancer Institute

[NCI] (2004) estimates that in 2004, 1,368,030 new cases of cancer will be diagnosed in

the United States. Men and women in the United States experience an average probability

of 41% for developing cancer, with 80% of that group diagnosed before they are 55 years
old (Courneya, 2001; Nieman, 1999). Living with cancer or knowing someone who is
living with cancer is a familiar experience.

In the United States, there is a massive amount of information available to the
general public about prevention, education, early screening, and early detection of cancer.
In 2004, the American Cancer Society [ACS] issued an update on the guidelines for
reducing the risk of cancer. The guidelines inform people of “healthy lifestyle choices”
that could reduce the risk of cancer diagnosis. Current cancer prevention guidelines
include four recommendations: 1) eat a variety of healthy foods, 2) adopt a physically
active lifestyle, 3) maintain a healthy weight throughout life, and 4) limit consumption of
alcoholic beverages (ACS, 2004; Ressel, 2002). Prevention of cancer is the ultimate goal,
but there are additional considerations. Attention must remain on the continued research
into early cancer detection, the advancement of affordable and effective cancer treatment,
and improved quality of life for cancer patients and survivors. These goals remain vital.

Types of Cancer

Cancer develops as a result of a complex physiological process called
transformation. The ﬁrst step, or the initiation of cancer, is when a change takes place in
the cell’s genetic structure. The change in genetic structure may be due to a variety of
reasons. Environmental factors, chemicals, tobacco, viruses, and radiation are
carcinogens, or agents, that cause cancer (ACS, 2004; Baquet, 1995; Moniz & Gorin,
2003).

The second step in the development of cancer is called promotion. Promoters are

deﬁned as substances in the environment that allow an initiated cell to become cancerous.

10

Some carcinogens are strong enough to cause cancer without promotion. Cancer grows
directly into surrounding tissues or spreads to other tissues and organs. This process is
called metasticism. Cancer can also spread through the bloodstream. Malignancies, or
cancerous tissues, can be divided into blood and blood forming tissues, such as Ieukemias
and lymphomas, or into “solid tumors”, also referred to as carcinomas or sarcomas (ACS,
2004; Baquet, 1995).

Cancer is diagnosed in many forms (N ieman, 1999). ACS (2004) suspects that
there are more than 100 types of malignant tumors or neoplasms. The cancers most
ﬁ'equently diagnosed in the United States include Bladder Cancer, Breast Cancer, Colon
and Rectal Cancer, Kidney Cancer, Leukemia, Lung Cancer, Melanoma, Non-Hodgkin’s
Lymphoma, Ovarian Cancer, Pancreatic Cancer, Prostate Cancer and Non-melanoma
Skin Cancer (NCI, 2004). The process all cancers have in common is the uncontrolled
growth and spread of abnormal cells (ACS, 2004; Nieman, 1999).

Cancer affects people very differently and some of the differences are related to
the stage and type of the cancer. Individuals living with a less invasive cancer and treated
at an early stage may beneﬁt the most from an exercise program to improve quality of
life.

Cancer Treatments

Today, cancer treatment has some proven beneﬁts and cancer patients
are far more likely to beneﬁt and experience prolonged life than they were in the ﬁrst half
of the twentieth century. Historically, cancer treatment gave cancer patients little hope of
long-term survival (N ieman, 1999). Cancer patients in the 1930s experienced a survival

rate in which only one in ﬁve people diagnosed with cancer lived ﬁve years after

11

treatment. In 1999, 40 percent of patients living with cancer lived ﬁve or more years after
diagnosis (N ieman).

The most common cancer treatments include chemotherapy, radiation
therapy, and surgery (Baquet, 1995). Chemotherapy is drug therapy, and it is commonly
associated with cancer treatment (ACS, 2004). This cancer treatment uses drugs to
destroy cancer cells. The patient takes the drug either by mouth or intravenously, and the
drug is administered in repeated courses over three to six months. The chemotherapy is
used to interrupt the cells’ ability to replicate. Chemotherapy destroys “quickly dividing
cells” and does not distinguish between cancerous and non-cancerous cells. This systemic
treatment results in the destruction of some non-cancer cells and accounts for the frequent
side-effects of chemotherapy, such as loss of hair, mouth sores, dry skin, nausea and
vomiting, and fatigue (ACS, 2004; Courneya, 2003). Side effects of chemotherapy vary
in intensity and are strongly related to the type of drug being used to treat the cancer
(Baquet, 1995).

Radiation therapy is a form of localized cancer therapy (ACS, 2004).
Courneya (2003) suggests that radiation is experienced by about 50% of cancer patients.
This treatment is targeted directly toward the area of the body where the cancer is located
and it delivers radiation to destroy or shrink cancerous tumors through repeated small
doses. Despite attempts to minimize damage to normal cells, toxicity to normal tissue
does occur and is dependent on the site that is irradiated. Potential side effects are pain,
blistering, reduced elasticity, decreased range of motion, nausea, fatigue dry mouth,
diarrhea, lung ﬁbrosis and cardiomyopathy (Courneya, 2003).

Surgery is a useful treatment for cancer and is performed on about 60% of cancer

12

patients (Courneya, 2003). Surgery may be recommended as a preventative measure by
removing tissue at high risk of cancer, or it may be recommended to gain access to tissue
sample for diagnosis. Surgery is also used to assist in the staging of the cancer,
determining the extent and amount of cancer (ACS, 2004). Surgery removes affected
tissue with the goal of improving patient comfort, supporting other forms of cancer
treatment, and curing the disease. Curative surgery is thought of as the primary treatment
when used with other types of cancer treatment such as chemotherapy and radiation
(ACS, 2004). Possible side-effects of surgery include wound complications, infections,
loss of function, decreased range of motion, diarrhea, dyspeanea, pain, numbness, and
lymphedema (Courneya, 2003).

In some cases, an individual with cancer may experience all of these treatments,
or a combination of treatments. The type of treatment is based on the cancer and stage of
the disease. (Baquet, 1995; Courneya, 2003). Some cancer treatments have physical side
effects that are more severe than others. The side effects of cancer treatment are often
temporary, and many are successfully treated to allow the patient to feel as comfortable
as possible. Despite efforts to improve patient comfort during cancer treatment, living
with cancer and cancer treatment interrupts normal ways of living and is both physically
and emotionally challenging (Courneya, 2003).

Research conﬁrms that cancer treatments such as radiation, surgery, and
chemotherapy, frequently last for months and may greatly reduce the quality of life
(Courneya, Mackey, & Jones, 2000; Kieren, Nabholtz, Makar, Cumming, et al., 1997;
Pinto & Trunzo, 2004; Rowland, Desmond, Meyerowitz, Belin, et al., 2000). Courneya

and colleagues (2000) state that a reduction in the physical quality of life results in

13

“depression, anxiety, stress, body-image concerns, decreased self-esteem, and loss of a
sense of control” and the challenging physical and ﬁrnctional results of cancer and cancer
treatments include “asthenia, ataxia, cachexia, reduced cardiovascular and pulmonary
function, muscle weakness and atrophy, weight change, difficulty sleeping, fatigue,
nausea, vomiting, and pain” (p.1).

In some cases, patients with cancer may opt to not participate in the most
common cancer treatments. The prognosis and their individual circumstances may cause
them to decline traditional medical treatments. The side-effects of different treatments
impact the quality of life and informed choices must be made (Fallowﬁeld, Leaity,
Howell, Benson, & Cella, 1999; Rowland, et al., 2000). Individuals with a health crisis
such as cancer, face profound issues of life, death, and quality of life that inﬂuence the
decisions made for treatment. The values and self-determination of the patient must
assume a prominent role in formulating health care plans (May, 2001).

The literature is limited in the examination of physical exercise while cancer
patients are in treatment and so unclear about the inﬂuence of speciﬁc types of cancer
treatment on the beneﬁt of physical exercise as an intervention to improve quality of life.
Patients experiencing radiation treatment may beneﬁt the most from exercise to improve
quality of life given the treatment is not as systemic as chemotherapies nor as invasive as
surgery.

Cancer and Gender

Beatty (2000) predicts that by the year 2030, more than 25% of the population in

the United States will be women 65 years or older, and 13% of that group will live to be

over 80 years old. Health care providers frequently fail to diagnose disease accurately and

14

early in women. Women continue to be under-diagnosed with diseases that are thought
to be “men’s disease” such as heart disease, and while women are educated to fear breast
cancer and participate in breast cancer prevention, lung cancer is also a signiﬁcant threat
(Cooley, Short, & Moriarty, 2002).

Prior to 1986, the women’s health issue given the most attention was child-birth
(Beatty, 2000). Clinical trials for disease, including clinical trials for cancer, were
conducted using only male participants. A clinical trial is a medical research study often
conducted by a researcher, using human volunteers. These studies are federally regulated.
Because the purpose of a clinical trial is to ﬁnd the fastest and safest ways to ﬁnd
effective treatments and improve health, the results of male-only clinical trials were at
best, generalized to the female population (Murthy, Krumholtz, & Gross, 2004).

In 1993, Congress enacted the National Institutes of Health Revitalization Act
and encouraged equality in the representation of women and minority patients in clinical
trials (Murthy, et al., 2004). Since then, the number of women participating in clinical
trials and health initiatives has increased dramatically, but the use of data from these
studies is slow to be implemented in cancer treatment.

After heart disease, cancer is the second leading cause of death among women in
the United States (Glantz, Croyle, Chollette, & Pinn, 2003). Although the incidence of
cancer diagnosis increases for both men and women as they age, The Center for Disease
Control [CDC] (2000) suggests that women are at greater risk of a cancer diagnosis.

In addition to increased risk from cancer for women as they age, women also
experience cancer in a unique way. Spira and Kenemore (2001) suggest that a common

reaction to a cancer diagnosis for women is to feel out of control and helpless and at the

15

same time feel pressured to act and make decisions. Women may experience the
diagnosis as “a betrayal by her body” (p. 174), a crisis, and as putting her in danger.
Anxiety about her multiple roles and relationships, depression and psychosomatic
complaints may accompany the disease diagnosis. The authors also found that many
women are drawn to alternative types of cancer treatment and intervention because
frequently the signiﬁcance of relationships to enhance treatment compliance and
effectiveness are missed in the more traditional and medical cancer treatments. Faller,
Schilling, Otteni, & Lang (1995) found that women are drawn to alternative ways of
treatment in part because they are seeking other women friends in whom they can
conﬁde. The authors state, “They are searching for both concrete solutions for their
symptoms and for a context within which to integrate their new sense of self, not only as
a cancer patient, but also as a real and complex person who happens to have cancer” (p.
175)

The literature is unclear about whether women or men beneﬁt more with
improved quality of life when participating in physical exercise. However, the literature
does suggest that women tend to seek out relationships and often augment traditional
cancer therapy with individual therapy, group therapy, support groups, and educational
groups. Men may beneﬁt more from engagement in a physical intervention when
diagnosed with cancer and may experience a greater sense of improved quality of life
than women.

Cancer and Age
Based on recent changes in demographics, the number of people who are 65 and

older is expected to double over the next 40 years (Roux, Dingley, Lewis, & Grubbs,

16

2004). This fact promises to put additional stress on an already overwhelmed health care
system. The CDC (2000) reports that both men and women have increased incidence of a
cancer diagnosis as they age. People age 65 and older account for 62% of patients with
lung, colon, breast, or prostate cancer (Gross, Murthy, Li, Kaluzny, & Knnnholz, 2004;
Murthy et al., 2004; Roux, et al., 2004).

Although elderly patients account for more than two thirds of cancer patients,
they represent only 25%-30% of the clinical trial participants (Gross et al., 2004; Murthy
et al., 2004). While a mandate for increased enrollment of women and minorities in
clinical trials appeared in the National Institutes of Health Revitalization Act of 1993, a
call for the enrollment of the elderly was absent. Murthy et al. (2004) found that “elderly
patients, both minorities and whites, were strikingly underrepresented compared with
their younger counterparts” (p. 2725).

Murthy, et a1. (2004) state that men and women are equally likely to be
represented in a clinical trial if diagnosed with colorectal or lung cancer, but older men
are more likely to enroll than older women. Gross (2004) and colleagues analyzed data
on participants in the non-surgical clinical trials of the National Cancer Institute Clinical
Trial Cooperative Group. They examined the ethnic distribution data ﬁom breast,
colorectal, lung, and prostate cancer clinical trials from 2000 through 2002. The
researchers compared this data to data of participants enrolled from 1996 though 1998.
The conclusion demonstrated that “the elderly, both minorities and whites, were
strikingly underrepresented compared with their non-elderly counterparts” (p. 1063).
Gross asserts that these ﬁndings are concerning given the cancer rate among the elderly.

The literature is not clear about which population diagnosed with cancer, based on

17

age range, experiences a more improved quality of life after participation in physical
exercise. It seems likely that younger individuals diagnosed with cancer may experience
a greater improvement in quality of life from physical activity because of potentially
greater physical ﬂexibility.

Aging Women and Cancer

A brief review of aging women and cancer treatment is included in this review of
the literature because of the unexpected comments about this population found in the
research. While this speciﬁc population is not analyzed in this study, it is important to
note the challenges speciﬁc to study and inclusion of this demographic group in the
examination of cancer and quality of life.

The National Cancer Institute reveals that a disproportionate number of women
over 60 years of age are diagnosed with cancer. The mortality rate for cancer peaks for
women over 85 (Roux, et al., 2004), but aging women are not equally represented by
cancer research, and this is supported by studies (Murthy et al., 2004; Mutschler &
Alcon, 1997) that ﬁnd gender disparities are often a function of age. '

Although many research studies examine exercise in relationship to female breast
cancer patients (Mock, et al., 1994), relatively few research studies exist that examine the
variables of gender and age as they relate to cancer type and cancer treatment (Kieren, et
al., 1997; Murthy, et al., 2004; Pinto & Trunzo, 2004; Roux, et al., 2004; Rowland, et al.,
2000). The absence of more of these studies may be the direct result of access to health
care and other social forces such as sexism, ageism, and other discriminatory practices.
Roux and colleagues (2004) challenge health care providers to establish research studies

and improve clinical care for the increasing number of aging women, including an

18

enhancement of the cancer survivors’ quality of life. Dr. Vivian Pinn (Roux, et al., 2004)
states that tmderstanding how the biological factors of genetics, hormones, and staging,
interact with the social factors such as stress, economics, support, poverty, and
discrimination, is essential in understanding the health outcomes for aging women with
cancer.
Coping with Cancer

The literature regarding coping with a chronic illness indicates that the diagnosis
of cancer requires a wide range of coping options to deal with shifting functional
abilities, medical implications, various cancer treatments, and psychosocial reactions
(Clark, Bostwick, & Rummans, 2003; Livneh, 2000; Tatsurnura, Maskarinec, Shumay, &
Kakai, 2003). Livneh (2000) suggests that when individuals are confronted with
traumatic events such as a cancer diagnosis, they often resort to a wide array of coping
strategies. Some of the coping strategies are physical in nature, such as exercise, diet, and
vitamins. Some of the strategies are for the emotional trauma such as therapy, social
support, and religion. However, regardless of the type of cancer, people who have been
diagnosed with cancer often experience distress and make an attempt to cope (Clark, et
al., 2003; Livneh, 2000;).

Individuals may prefer coping through changes in their physical life-style.
Patterson (2003) surveyed more than 350 cancer patients in Washington to look at
changes in health-related behaviors for up to two years following cancer diagnosis. The
subjects were asked if they had made changes in diet, physical activity, or in their use of
vitamins or other supplements in an attempt to keep cancer from spreading or returning

The ﬁndings show that 50% started taking supplements, 40% made dietary changes, and

19

20% started a new activity. The results indicate that two thirds of the subjects made a
change in one area, one forth made a change in two areas and 10% made a change in all
three areas (Patterson, 2003). Patterson states, “The vast majority of patients reported that
these lifestyle changes improved their health and well-being” (p.167).

Strategies to cope emotionally are also used by people who have been diagnosed
with cancer. Clark et al. (2003) found that psychosocial interventions, such as individual
and group therapies that are structured by topic areas and issues are effective in reducing
cancer related stress. The authors state that the primary goal of the psychosocial therapies
should be to improve quality of life by decreasing stress and enhancing coping, rather
than to increase survival from the disease. However, Tatsumura et al. (2003) suggest that
the use of religion and spirituality is a way individuals cope and may prove helpful to
cancer patients in issues of “control, spiritual well-being, coping, depression, decision-
making, and possibly health outcomes” (p.65). Clearly, coping with cancer calls for
individuals to use a variety of coping skills. Interventions are commonly targeted to
improve physical or emotional well-being, variables associated with quality of life.
(Burnham & Wilcox, 2002).

Quality of Life
Overview

Survival of a cancer diagnosis may not be a cancer patient’s only concern. There
are also concerns about the quality of life for both the cancer survivors and for those who
are currently undergoing cancer treatment (Dow, 2003; MacVicar & Winningharn, 1986,
Rayson & Reno, 2003). Research shows that quality of life is often challenged both

physically and emotionally during the diagnosis and treatment of cancer (Kieren, et a1.

20

1997; MacVicar & Winningharn, 1986; Rayson & Reno, 2003). There has been an
increase of interest in quality of life for patients who are receiving cancer treatments and
interest in improving quality of life for cancer patients continues to increase (Cohen &
Herbert, 1996; Fitzpatrick, 1999; Gignac, et al., 2000; Litwin, 1999; Rayson & Reno,
2003)

Deﬁnition of Quality of Life

Quality of life is a measurement of the cancer patient’s experience. It is a
measurement that is useful in communicating patient perceptions to those involved in the
care of the patient because it captures the day-to-day impact of disease and treatment on
ﬁmctioning and perceived well-being. Research states (Frost, Bonomi, Estvving Ferrans,
Wong, & Hays, 2002) that while there is no clear deﬁnition of quality of life, it is
recognized as a “multi-dimensional concept that includes physical, psychological, and
social domains” (p. 489).

Research also suggests that deﬁning quality of life is a complex task and a
controversial topic (Angermeyer, Holzinger, & Kilian, 2001; Kieren, et al., 1997;
Muldoon, Barger, Flory, & Manuck, 1998). There is some confusion and skepticism
about how quality of life is measured, the accuracy of the measurement, and its
usefulness in medical research, but it is widely acknowledged as important (Muldoon, et
al., 1998).

There are many studies that attempt to understand and deﬁne the primary
determinants of quality of life. Information generated from a measurement of quality of
life implies that there is more than the physical body to consider in the treatment of a

cancer patient (Cohen & Leis, 2002; Courneya, 2001; Muldoon, et al., 1998). Patient

21

condition is both biological and psychosocial. Deﬁning the quality of life values for the
cancer patient, offers the patient an opportunity to communicate with health care
providers, and enables the patient and health care providers a way to communicate patient
well-being to the family (Muldoon, et al., 1998).

Assuming a relationship exists between a patient and their family within which
communication exists, communication may be complex. Patients may reluctantly depend
on family and friends, while attempting to hide or deny negative feelings and experiences
for fear of being a burden. Others fail to communicate anything about their experience,
allowing the family little opporttmity to understand what it means to experience cancer in
their life. When a family has insight into the overall patient well-being, they are better
prepared to act as a patient advocate. As decisions and concerns about appropriate care
are addressed, resolution takes place in an appropriate manner if the support persons are
aware of the quality of life values of the patient (Leichtentritt & Rettig, 2001). This
information also helps the physician understand and work with the patient and his/her
family.

Health care providers who understand quality of life issues are at an advantage
working with people with cancer. It is beneﬁcial to a health care provider to understand
these issues for several reasons. It aids in the detection of physical and emotional
problems that might otherwise go unrecognized, and it improves the delivery of care
(Detmar, Muller, Schomagel, Wever, & Aaronson, 2002). Medical clinicians most often
rely on the biomedical and the observable facets of cancer treatment and may be reluctant
to ask about subjective side-effects of cancer treatment (Kieren, et al., 1997). Quality of

life information offers clinicians an opportunity to integrate the changes in quality of life

22

with the disease process. This leads a clinician to dialogue with a patient regarding
treatment or therapy (Frost, et al., 2002).

In addition, information about quality of life may improve life for various
subgroups living with cancer within the general population. Deﬁnition of quality of life is
largely based on the values of the various populations. Population-speciﬁc treatments
may have a high probability of success in improving quality of life, and when identiﬁed,
they may be valued and supported by societal resources (Frost et al., 2002). Frost and
colleagues (2002) also suggest that society beneﬁts from a healthy and productive
population and that this goal is attained by maximizing the quality of life for as many
people as possible.

Research shows that many have tried to deﬁne quality of life (Courneya, 2001;
MacVicar and Winningham, 1986; Rummans, Bostwick, and Clark, 2000; Till, McNeil,
& Bush, 1984) The World Health Organization [WHO], deﬁnes quality of life as,
“psychological and social functioning as well as physical functioning and incorporates
positive aspects of well-being as well as negative aspects of disease and inﬁrmity” (Till,
et al., 1984). MacVicar and Winningham (1986) were early advocates for the study of
quality of life improvement for people living with cancer. They were convinced that “the
ability to maintain one’s pattern of life activities is an undisputed aspect of quality of
life” (p. 238). Courneya (2001) has extensively researched the area of quality of life,
cancer, and exercise and deﬁnes quality of life as “overall happiness and satisfaction with
life” (p.60). Rummans, et al. (2000) deﬁne quality of life as “ the physical, psychological,
social, and spiritual domains of health that are inﬂuenced by a person’s experience,

beliefs, expectations, and perceptions” (p.1305). While these deﬁnitions vary in detail,

23

they share the concept that quality of life is about the individual patient’s satisfaction
with life.

Personal values are a component of quality of life and they inﬂuence the
deﬁnition of quality of life. Values inﬂuence our perceptions, decisions and actions
(Leichtentritt & Rettig, 2001). How someone reports the effects of symptoms and
treatments for cancer varies from person to person, because of difference in their personal
values (Carr & Higginson, 2001; Frost, et al., 2002). Individuals hold values inﬂuenced
by culture, family, age, gender, race, economic status and a wide range of additional
social, biological, and psychological determinants (Holzner, 2004; Moniz & Gorin,
2003)

Despite the challenges in deﬁning quality of life, the results of quality of life
measurement are believed to provide valuable information about the subjective
experience of the cancer patient (Goodwin, Black, Bordeleau, & Ganz, 2003). Garratt,
Schmidt, Mackintosh, & Fitzpatrick (2002) suggest that clinical trials should
incorporate a patient’s perspective on outcome, and a health related quality of life
assessment can achieve this. Unlike conventional medical indicators that assess pain,
fatigue, and disability, quality of life indicators also report the patient’s perception of
physical, emotional and social well-being. In addition, quality of life can inﬂuence the
course of the disease. Because cancer treatment often begins with treatments such as
radiation, surgery, and chemotherapy, and commonly lasts for months, the physical and
emotional well-being of patients is important. Quality of life may support on-going
treatments or may challenge investment in treatment (Pinto & Trunzo, 2004; Rowland, et

al., 2000).

24

Assessing the quality of life experience promotes quality of life as a valuable
consideration within the treatment planning (Courneya, et al., 2000). Patients
experiencing multiple diseases, multiple reoccurrences of a cancer, depression, or other
physical and emotional barriers, may not experience quality in their lives and may choose
to cope by not seeking treatment (Livneh, 2000).

Improvement of Quality of Life

Interventions are necessary to maintain quality of life for people living with
cancer. Side-effects of cancer and cancer treatment are often overwhelming, and the most
common of these symptoms include fatigue, nausea, depression, and anxiety. Fatigue
remains one of the most universal of cancer symptoms, and it is experienced by 70 to
100% of all patients receiving radiation (Loveland Cook, Guerrerio, & Slater, 2004;
Schwartz, 1999). Research shows that poor quality of life can interfere with daily
functioning, leisure activities, personal well-being, relationships, and can inﬂuence
compliance with medical treatment. It can also interfere with daily living tasks and
compromise a patient’s independent living (Courneya & Friedenreich, 1999; Loveland
Cook, et al., 2004).

Various interventions to improve quality of life exist. Current research provides
many examples of psychosocial cancer support interventions (Davis, 2004; Meier, 2003;
Tuma, 2004; Zimpfer, 1992). Courneya et al. (2000) recognize the variety of
interventions that are available to cancer patients, including “cognitive-behavioral
therapies, informational and educational strategies, individual and group psychotherapies,
and other alternative treatrnen ” (p. 2). Current research reveals that psychosocial

interventions may beneﬁt some patients with psychological and emotional support, but

25

frequently fail to address the physical needs of the cancer patient.
Physical Well-Being

People have an individually unique relationship with their body. It is a signiﬁcant
representation of their identity and worth (Thomsen, 2002). The media in the United
States promotes attention to the body and gives consumers messages about how best to
attain the social goals for beauty, power, and virility. The media suggests the best ways to
attain these goals for speciﬁc ages, race, and gender (Betta, 1999; Englis, Solomon, &
Ashmore, 1994; Halliwell & Dittrnar, 2004).

The physical body responds to care and to neglect. A long continuum of body
care exists, from total disregard or abuse of the body to attention and pampering of the
body. Research shows that neglect of the body and abuse of known carcinogenic
materials can put a person at higher risk of cancer (Moniz & Gorin, 2003). Some research
suggests a link between physical inactivity and increased risk of cancer (Friedenreich &
Orenstein, 2002; Lee, 1995). Risk of cancer diagnosis exists for everyone, including
people who attend to their bodies.

The perception of one’s physical well-being is damaged when an individual is
diagnosed with cancer. There is a multitude of research studies that document the primary
physical side-effects of cancer and cancer treatment as pain, weakness, fatigue, and
nausea (Mock, et al., 1997; Porock, Kristjanson, Tinnelly, Duke, & Blight, 2000; Ream
& Richardson, 1999; Winningham, Nail, Burke, Brophy, Cirnprich, Jones, Pickard-
Holley, et al., 1994;).

In addition, cancer treatments occasionally result in long-term pain (Caffo,

Amichetti, Ferro, Lucenti, et al., 2004) Types of curative or reconstructive surgery may

26

leave a person scarred or perhaps, with chronic pain. Some surgical procedures
potentially arnputate a part of the body (i.e., breast, liver, kidney, lung). Changes in
appearance of the body due to cancer, challenge the physical well-being and emotional
well-being of people (Rowland et al., 2000). Self-esteem may be weakened, and interest
and ability to perform sexually may be reduced or severely tested.

Caffo and colleagues (2004) studied 529 women who were free from cancer for
one to four years. The women underwent “axillary dissection” breast cancer surgery. The
authors examined the pain experienced by the women and found that regardless of the
speciﬁc kind of surgery, one third of the women experienced pain distress. This distress
had a signiﬁcantly negative effect on their quality of life. They also found that the
experience of pain represents a continuous memory for the patients, of both the treatment
and the disease. Pain is believed to be a sign of incumbent disease and leads to fear of
worsening or reoccurring cancer. Breast cancer patients who feel pain, even without
progressing disease, suffer considerable physical and emotional distress. As a result they
adjust badly in terms of quality of life (Caffo, et al., 2004).

The relationship between cancer, exercise and physical well-being is of great
interest to experts in the ﬁelds of sports, medicine, rehabilitation, and counseling. Recent
research explores the relationship between exercise and cancer patients and the physical
side effects and symptoms they experience due to their cancer (Dimeo, Rumberger, &
Keul, 1998; Mock, et al., 1997; Porock, et al., 2000; Ream & Richardson, 1999;
Schwartz, 1998; Winningham, et al., 1994;). An overview of the research by Courneya
(2003) examined exercise and cancer survivors. The author located and summarized

forty-seven published studies. Almost all studies showed the beneﬁcial effects of

27

exercise in cancer survivors living with a variety of cancer diagnoses. Speciﬁc to the
clinical trials of exercise during cancer treatment, the author examined a total of 24
studies; fourteen of these studies were speciﬁc to breast cancer survivors. All studies
were found to be of good quality, and included supervised exercise sessions, objective
ﬁtness indicators, and validated psychometric measures. However, limitations across all
of these studies included small samples, non-representative samples, and exercise
interventions that did not coincide with the medical treatment in its entirety. Despite the
limitations of these studies of cancer survivors and physical exercise, the conclusion of
the overview conducted by Courneya (2003) suggests that exercise may be an effective
intervention for enhancing quality of life in cancer survivors.

Emotional Well-Being

The diagnosis of cancer changes life. Cancer can lead to physical restrictions and
disabilities that may lead to depression and other psychosocial problems. Research
suggests that a reduction in a person’s emotional quality of life results in depression,
anxiety, stress, body-image concerns, decreased self-esteem, and loss of a sense of
control (Courneya, et al., 2000).

Beyond the question of survival, cancer patients are concerned with the day-to-
day living, about the ability to function, the dependency on others, or the fear of
becoming dependent. These feelings intensify the psychological reactions to cancer, as
well as cancer treatments (Davis, 2004; MacVicar & Winningham, 1986; Massie, 2004;
Roberts, Cox, Shannon, & Wells, 1994). Patients may experience anxiety, depression,
hopelessness and suffering (Glajchen, Blum & Calder, 1995).

Research suggests social work offers interventions to cancer patients attempting

28

to cope with emotional distress (Davis, 2004; Glajchen et al., 1995; Massie, 2004;
Roberts et al., 1994; Targ & Levine, 2002). Social work oncology is a specialized ﬁeld of
practice with effective and informed methods of working with cancer patients (Tolley,
1994). While common social work methods to improve emotional well-being are
frequently individual and group therapies, social workers also offer biopsychosocial
interventions that seek to bring relief. These include support to families, assistance in
communication, and referrals to appropriate resources. Social workers bring expertise to
oncological patients in direct service, education, advocacy, and research (Glajchen et al.,
1995).

One of the chief emotional symptoms of cancer and cancer treatment is
depression (Akechi, Nakano, Akizuki, & Okamura, 2003; Caffo, et al., 2004; NIH, 1996;
Ressel, 2003). Furthermore, NIH claims that, as cancer treatment becomes more
aggressive, depression and fatigue increase. The NIH challenges physicians to be aware
of these symptoms, to identify the patients most at risk, and design the best ways to
“deliver interventions across the continuum of care” (p. 243).

Depression produces many dysﬁmctional symptoms, including thoughts of
suicide, hopelessness, prolonged hospitalizations, less compliance with cancer treatment,
and worry from caregivers. The psychological symptom of depression requires
recognition in the treatment of cancer. Loveland Cook and colleagues (2004) state that
hospitalized cancer patients experience an estimated 25% likelihood of having depression
symptoms serious enough to be diagnosed with Major Depressive Disorder.

Problems with body image and sexuality also interfere with emotional well-being

Rowland and colleagues (2000) used a self-report questionnaire with 1,957 breast cancer

29

survivors, one to ﬁve years after their original cancer diagnosis. They collected data
regarding their quality of life, body image, and physical and sexual functioning. The
authors found that the psychosocial impact of cancer surgery “occurs largely in areas of
body image and feelings of attractiveness” (p.1422). Research supports the claims that
body image and sexuality concern women receiving surgery or other body changing
cancer treatments and these concerns inﬂuence their emotional well-being (Kieren, et al.,
1997; Pinto & Trunzo, 2004; Rowland, et al., 2000).

EmOtional well-being and physical well-being are closely connected. Often,
however, interventions to improve quality of life address either emotional well-being or
physical well—being. Research implies that exercise may be one intervention that
addresses a wide variety of quality of life concerns. This includes both physical and
emotional well-being issues for cancer patients (Courneya & Friedenreich, 1999; Watson
& Mock, 2003).

Exercise
Overview

Exercise has long been recognized as an effective way to improve and maintain
health (Addy, Wilson, Kirtland, Ainsworth, et al., 2004; Pate, Pratt, Blair, et al., 1995;
Spence & Lee, 2003). In addition, studies have suggested that there is a link between
physical activity and the prevention of cancer (Friedenreich & Orenstein, 2002; Lee,
1995). There are several plausible biological explanations for this increased health and
they include a change in hormone levels and growth factors, decreased obesity, and
possibly a change in immune function (Friedenreich & Orenstein, 2002). Improvements

in both physical and emotional states are associated with people who work at being

30

healthy and exercise (Schwartz, 1998). People interested in health are exercising in
greater numbers and exercise in a variety of places such as health clubs, gymnasiums,
community centers, neighborhoods, and in their homes. Exercise is prescribed for many
populations that include men and women, old and young.

Moreover, exercise is now considered appropriate for some people living with
chronic illnesses and is thought to be beneﬁcial in the prevention of some diseases
(Clark, 2003; Gregg, Cauley, Stone, Thompson, et al., 2003). The ACS (1997) recognizes
the beneﬁts of exercise and added regular exercise to the list of recommended cancer
prevention measures. There is signiﬁcant research suggesting exercise may act as a
preventive measure to cancer diagnosis (Gapstur & Gann, 2001; Gottieb, 2003;
Schnining Minneapolis, 2004).

In a review of the literature regarding cancer and exercise, it is clear the word
“exercise” describes a variety of activities (Burnham & Wilcox, 2002; Courneya &
Friedenreich, 1999; Dimeo, et al., 1998). The actual physical activity practiced by cancer
patients in the literature depends on the age, gender, cancer type or cancer stage, the
patients’ personal level of ﬁtness, and the patients’ exercise experience (Watson & Mock,
2003). Deﬁning the type of physical activity most able to deliver maximum beneﬁt and
avoid harm is an area of research needing further study. For the purpose of this
dissertation, references to the term “exercise” is inclusive of all of the types of physical
activity used by cancer patients in the various research studies.

Exercise and Cancer
Despite the continued success of new and improved treatment methods and

medicines, a diagnosis of cancer often produces damaging physical changes and

31

emotional distress (Courneya & F riedenreich, 1999, Burnham & Wilcox, 2002). As
discussed above, cancer and the side-effects of treatment interfere with the quality of life
for people living with cancer (Courneya, 2003).

In a literature review, Courneya and Friedenreich (1999) examined 18
intervention studies using exercise following cancer diagnosis. The results of the studies
consistently demonstrated that exercise had a positive effect on the quality of life of
cancer patients as measured by improvement in physical and functional well-being, and
psychological and emotional well-being. In addition, the studies extended the research
beyond breast cancer and early stage cancers and included quality of life indicators
beyond physical well-being. The studies are limited by the quasi-experimental designs.
The limitations of such designs include no control group, participant self-selection into
groups, and the use of no-treatment control groups, or no control group at all. Additional
limitations included failure to determine activity levels of participants prior to the study,
and the short 10-12 week exercise intervention (Courneya & Friedenreich, 1999).

Current research conﬁrms that over the past few years, the relationship between
illness and exercise is increasingly being acknowledged (Clark, 2003; Gregg, et al., 2003;
Scully, Kremer, Meade, Graham & Dudgeon, 1998). Speciﬁcally, research suggests that
exercise reduces the negative physical and emotional side-effects of cancer and cancer
treatment side-effects by elevating mood and building endurance and is effective in
improving quality of life (Durak & Lilly, 1998; Segal, Reid, Courneya, Malone,
Parliament, & Scott et al., 2003).

Nieman (1999) asserts that there are many physical beneﬁts to exercise: 1) resting

blood pressure is consistently reduced, 2) mood is effectively improved, and 3) strength

32

and ﬂexibility are promoted. In addition, research suggests that in addition to the physical
beneﬁts, the psychological beneﬁts of exercise are many and include beneﬁts such as
relaxation, increased social contact, promotion of self-care, and self-esteem (MacVicar &
Winningham, 1986; Schwartz, 1998). Pinto and Trunzo (2004) suggest that breast cancer
survivors who exercise can expect an increased sense of health and may improve their
body strength and tone and may feel better about their body image.

Exercise is frequently prescribed as a treatment for rehabilitation after completing
cancer treatment (Brown, 2004; Durak & Lilly, 1998). However, exercise is now being
examined as a treatment alongside of or adjunctive to the traditional cancer treatments,
such as chemotherapy, radiation, and surgery (Watson & Mock, 2003). Recent research
investigates the effect of exercise on the quality of life for people living with and
receiving treatment for cancer (Courneya & Friedenreich, 1999; Courneya, et al., 2000;
Courneya, 2001; Durak & Lilly, 1998, MacVicar, & Winningham, 1986; Segar, Katch,
Garcia, Haslanger, & Wilkens, 1998,). Physical activity, or body movement that
increases energy expenditure (Pangrazi, & Corbin, 1999) affects various body systems
positively, and favorably inﬂuences a wide range of disease stages (Oweis & Spinks,
2001; Shepard, 1995).

MacVicar and Winningham (1986) completed one of the ﬁrst studies examining
cancer and exercise. These authors found that patients who exercise during cancer
treatment, experienced positive improvements in mood. Courneya (2001) examined
eleven studies on the effect of an exercise intervention program during cancer treatment.
All eleven studies showed statistically signiﬁcant results favoring the hypothesis that

exercise during cancer treatment provides beneﬁcial effects on a wide variety of

33

outcomes that enhance the quality of life. Results of this meta-analysis suggest that
exercise during cancer treatment improves many biopsychosocial outcomes.

In a discussion of cancer, exercise, and quality of life, fatigue must be mentioned
because research states that fatigue is one of the most common and signiﬁcant side
effects of cancer treatments and it affects cancer patients both physically and
emotionally. Common scholarly thinking is that 70-100% of all cancer patients,
regardless of diagnosis, stage of disease, or type of cancer, are affected by fatigue
(Dimeo, et al., 1998; Porock, et al., 2000; Schwartz, 1999; Winningham, et al., 1994).
Fatigue inﬂuences a patient’s sense of overall well-being, independent living skills,
relationships with family and friends, and the ability for the patient to comply with
treatment (Porock et al., 2000).

Research indicates that deconditioning due to inactivity after a cancer diagnosis
may contribute to fatigue and add to a decrease in both physical and emotional well-being
(MacVicar & Winningham, 1986; Schwartz, 1999; Williamson, 1998; Winningham, et
al., 1994). Research suggests that physicians commonly advise cancer patients to limit
their activities but that not using, or “disuse” of every major system in the body creates
and promotes weakness and fatigue, both psychologically and physiologically (MacVicar
& Winningharn, 1986). Williamson (1998) examines the activity restriction model of
depressed affect. The author proposes that the extent to which routine activities are
restricted by a major life stressor plays a role in psychological adjustment. Major
disruptions in normal activities result in poorer mental health outcomes. Illness and
disability are life stressors, depression a possible reaction to this stressor, and the

signiﬁcance of activity restriction adds to the depression. Williamson states activity

34

restriction “plays an important role in the psychological adjustment, with major
disruptions in normal activities resulting in poorer mental health outcomes” (1998, p.
327).

Studies about exercise and cancer commonly include the factors of patient fatigue
caused by cancer treatments and a decrease in patients’ quality of life. Decreasing fatigue
and increasing quality of life are the goals of combining cancer and exercise. Research
studies show that symptoms of fatigue for cancer patients are frequently treated with a
prescription to rest (Coumeya, et al., 2000; Dirneo, et al., 2000; Porock, et al., 2000).
Patients in treatment for conditions such as heart disease, or surgeries, are encouraged,
with supervision, to almost immediately move about. This has not been the case with
cancer patients. MacVicar and Winningham (1986) state that being sedentary for a
prolonged time and the treatment side effects of cancer treatment can result in
“progressive physical debilitation marked by generalized weakness and rapid fatigue
upon exertion” (p. 235). There is some question as to whether this inactivity may lead to
deconditioning or an exacerbation of fatigue over the long term, and negatively affect the
emotional and physical well-being of cancer patients (Courneya, et al., 2000; Porock et
al., 2000). I

Studies suggest that exercise during cancer treatment may be physically and
emotionally beneﬁcial, and that cancer patients should be encouraged to exercise during
cancer treatment to maintain and improve functional ability (Courneya, 2001; Dimeo, et
al., 1997; Schwartz et al. 2001; Watson, 2002). These studies claim that exercise appears
to improve fatigue and functional ability. Watson (2002) states that interviews with

cancer patients and randomized clinical trials repeatedly demonstrate “a decrease in

35

cancer-related fatigue in patients receiving exercise as an intervention, whether in the
form of a community-walking program, treadmill program, or by hospital ergometer”
(p.16). Structured exercise programs for previously sedentary patients with cancer
demonstrate that exercise is safe and produces positive psychosocial effects (Mock et al.,
1997; Schwartz, 1998).

Researchers assert that with a diagnosis of cancer, every effort should be made to
maintain the highest level of physiological and psychological functioning during the
course of the illness (Courneya & Friedenreich, 1999; MacVicar & Winningham, 1986).
However, the type of exercise, and the level of exercise for speciﬁc cancer diagnoses,
remains unclear. Watson (2002) states that the mode, intensity, duration, and frequency
of physical activity for maximizing the therapeutic effect for cancer patients remains
undetermined. The ACS (2004) released guidelines on nutrition and physical exercise
during and after cancer treatment and stressed health care providers and cancer survivors
should consider the individual cancer survivor’s overall medical and health situation.
Neff (2004) responds to this report and states that it remains unclear if physical activity
has any effect on treatment efﬁcacy, but supports the ACS report and suggests that cancer
patients who were active remain active, and those who were sedentary, develop low-
intensity activities.

Although the literature cited above has suggested an important and positive role
for exercise for cancer patients in cancer treatment, few research studies were found that
examine samples with more than an average of 25 participants (Courneya &
Friedenreich, 1999). No research comparing the effect of exercise on the physical quality

of life to the effect of exercise on the emotional quality of life for cancer patients was

36

discovered. Moreover, there is no research exploring whether one determinant of quality
of life improves more than the other. The literature review revealed few studies that
examined the inﬂuence of gender, age range, type of cancer, and cancer treatment on the
improvement of physical and emotional quality of life.

This dissertation explores the relationship between a ten-week exercise program
for individuals in treatment for a cancer diagnosis and the quality of life indicators,
physical and emotional well-being. The study compares the change in physical well-
being and the change in emotional well-being after participation in the exercise. In
addition, the study examines the inﬂuence of variables (gender, age range, cancer type
and cancer treatment) on the change in physical well-being.

Summary

In Chapter II, the relevant literature was discussed in terms of three broad topics

areas. The topic areas were cancer, exercise, and quality of life. Relevant subtopics were

also presented. The methodology used in the study is presented in Chapter III.

37

CHAPTER III

Methodology

Epistemology

The branch of philosophy that is concerned with the origins and the development
of knowledge is epistemology (Hughes, 1999). Literally speaking, epistemology is the
theory of knowledge that seeks to distinguish true knowledge from false knowledge.
Intellectual discussions regarding what constitutes the state of knowledge have existed
for centuries. Historically, the trend of epistemology is the movement away from a
passive view of knowledge and progress toward a more adaptive and active view of
knowledge (Heylighen, 1993). The epistemological theories of today no longer resemble
the “absolute truths” once employed by Plato (Lee, 1979).

The epistemology of a discipline is characterized by the way it conceptualizes
problems, provides the sources of evidence, and deﬁnes methods of analysis (Hahn,
1995). Scholars conduct research based on their professional assumptions about society
and the ways in which social reality is constructed. Knowledge of the researcher’s
methodological stance, then, is essential in understanding all aspects of the research, from
hypothesis generation to data analysis and conclusions.

Prior to the description and discussion of the actual study, it is important to

38

understand the perspective that led to the design and implementation of this work. This
study depicting the relationship between cancer and exercise, was guided by the
understanding that the epistemological concepts of health and illness are connected and
inﬂuenced by the biological, the psychological, and the social aspects of an individual.
The present research is based on the assumption that the biomedical model of health care
fails to address many signiﬁcant issues in the determination of health and illness.

The biomedical model is based on a scientiﬁc model that neglects the emotions
and social conditions of the individual. Engel (1977), a physician who challenged the
efﬁcacy of the biomedical model, asserted that the biomedical model reduces the
assessment, diagnosis, and treatment of illness to the biological. He states, “It [the
biomedical model] assumes disease to be fully accounted for by deviations from the norm
of measurable biological variables” (p. 130). The biomedical model is advantageous to
the concept of disease, because it ignores the role of health, sickness, and healing
(Greaves, 2002). The model provides little attention to understanding what makes life
worth living or what enhances quality of life. Instead, it demands that disease be dealt
with scientiﬁcally and objectively. The biomedical model separates the biological from
social behavior and events, and personal feelings and thoughts (Engel, 1977).

Research shows (Cousins, 1979; Engel, 1977; Hubbard, 1995) that medical
training often shapes doctors to think of medicine in a biomedical framework long before
they begin to interact with patients and patient families. The result of this form of medical
treatment is a public discontent with health care. The health care system is consistently
perceived as impersonal, uncaring, inﬂexible, and rushed (Engel, 1980). However, recent

modiﬁcations have occurred in medical training. During the past decade, the health care

39

profession has slowly emerged from the practice of the biomedical model to a more
holistic form of health care practice, a model that weaves together the biological, the
psychological, and the social aspects of life (Zittel, Lawerence, & Wodarski, 2002).

As the term suggests, the biopsychosocial theory incorporates the biological, the
psychological and the social determinants of life, and claims that all spheres are
necessary in consideration of health and illness (Moniz & Gorin, 2003). The model is
holistic and resists the attempt to separate spheres of ﬁmctioning. The biopsychosocial
theory identiﬁes and supports the function of quality of life as an important indicator in
measuring how individuals experience illness and disease (Claiborne & Vandenburglr,
2001; Weick, 1986; Zittel, et al., 2002). The biopsychosocial theory embraces the idea
that although disease is diagnosed, the individual may feel healthy, and conversely, an
individual may feel ill with no evidence of a biological diagnosis (Engel, 1977; Gilbert,
2002; Moniz & Gorin, 2003).

The infusion of the biopsychosocial theory into health care is a signiﬁcant step
away from the narrow focus of the biomedical model (Moniz & Gorin, 2003). Recent
scholarly literature reﬂects the increased use of the biopsychosocial theory of
intervention (Claiborne & Vandenburgh, 2001; Gilbar, 1996; Gilbert, 2002; Hoffman,
2000; Hubbard, 1995; Moniz & Gorin, 2003; van der Walde, Urgenson, Weltz, & Hanna,
2002; Zittel, et al., 2002). The biopsychosocial theory is implemented in the treatment of
many physical, social and emotional illnesses (Ross, 2000). The biopsychosocial model is
used to treat diseases like cancer by incorporating an interdisciplinary model to assure
that all biological, emotional and social aspects of the patient are receiving attention

(Gilbar, 1996; Sestini & Pakenham, 2000).

40

There are advantages in using the biopsychosocial theory. First, the diagnoses of
minority populations are treated more effectively using the biopsychosocial framework
(van der Walde, et al., 2002). The theory incorporates the many unique circumstances of
oppression, and stigmatization experienced by minority populations in society as well as
within the health care system (Moniz & Gorin, 2003). Second, the biopsychosocial theory
is successfully incorporated into the treatment of diseases with particularly challenging
interventions such as treatment planning for alcoholism (van der Walde, et. al, 2002). For
example, women who are addicted to alcohol experience biopsychosocial realities that
are signiﬁcantly different from those of men. Women experience gender-based
experiences such as “social stigma, double standards, differing expectations for men and
women, and the fact that women are an oppressed group in numerous cultures” (van der
Walde, et. al, 2002, p. 148). Understanding these differences is an important step in the
design of an accurate and beneﬁcial treatment plan. The biopsychosocial model also
assists in understanding the connections between the biological, psychological, and social
components in suicide (Hoffman, 2000) and to explain the neurological, psychological,
and person-environment links for people living with Alzheimer’s disease (Caron &
Goetz, 1998).

Finally, Morantz-Sanchez (2000) recognizes that the biopsychosocial theory
offers movement toward emotional and social inclusion in the medical treatment of
women. She writes that recent feminist scholarship attributes the biopsychosocial theory
for progressive movement that “has begun to emphasize forms of negotiation and modes
of bargaining, as the doctor and patient assess the illness experience and transform it into

the diagnosis of disease, an agreed-upon course of action, and a particular mode of

41

treatment” (p. 294).

The biopsychosocial model stands in stark contrast to the reductionist philosophy
of the biomedical theory of health care (Weick, 1986). The biopsychosocial theory offers
scholars an opportunity to fuse emotional health with physical health for patients, and
examines the changes in feelings and physical conditions in the patients’ overall
experience of quality of life (Claiborne & Vandenburgh, 2001).

As discussed previously, research reveals that exercise has a positive effect on a
broad range of quality of life indicators for people living with cancer (Courneya, Mackey,
& Jones, 2000; Lee, 1995). Courneya, et al. (2000) suggests that exercise for cancer
patients is as beneﬁcial physically as it is psychologically when it adds to patient levels
of conﬁdence. Exercise may elevate mood, stimulate appetite, and increase the cancer
patient’s positive experience with quality of life (N ieman, 1999; Shepard, 1995). Exercise
is a potentially beneﬁcial adjunctive therapy, treating the physical and emotional well-
being of people living with cancer.

This study is guided by the perception that the relationship between cancer and
exercise and the concepts of health and illness are linked. The connection is based on the
biological, the psychological, and the social facets of the cancer patient. For purposes of
this inquiry, the psychological and the biological perceptions of well-being of cancer
patients are targeted to determine if these perceptions improve after participation in an
exercise program. Data were collected from cancer patients regarding their perceptions of
quality of life before and after participating in the ten-week cancer “Wellﬁt” program.
The biological (physical well-being) and psychological (emotional well-being) results are

explored. Furthermore, the study investigates whether greater change occurs in physical

42

well-being or greater change occurs in emotional well-being after exercise participation
and if the variable changing the most is inﬂuenced by gender, age range, cancer type, or
cancer treatment.

Description of the Program

In the present study, quantitative methodology is used to understand the
relationship between exercise and the cancer patients’ quality of life. This relationship is
based on their self-report of physical well-being and emotional well-being.

This study is based on the results of data collected by research staff from Mercy
Health Services members: St. Mary’s Cancer Center, The Michigan Athletic Club
[MAC], and East Hills Athletic Club [EHC]. The original study, named the “Cancer
Wellﬁt Program”, was conducted between August, 2002 and April, 2003. The Cancer
Wellﬁt Program received ﬁrnding from a private foundation to implement a ten-week
exercise program for cancer patients and their support person.

The exercise program for cancer patients was developed from a belief that the
resources of the Mercy Health Services could offer more support to people living with
cancer. Mercy Health Services includes St. Mary’s Hospital, St. Mary’s Cancer Center,
many ambulatory care clinics, and two health clubs. Both health clubs enjoy a good
reputation in the community, where middle to upper middle class populations utilize the
clubs as a convenient and luxurious environment to physically “work out.” Both health
clubs offer many opportunities for members to exercise in a variety of ways; using a gym,
exercise rooms, weight rooms, tennis courts, racket-ball courts, an indoor running track,
and a swimming pool. Mercy Services was convinced that these facilities could provide

the opportunity to offer beneﬁcial health services to individuals living with chronic

43

illnesses.

The Director of Research of the Cancer Center at St. Mary’s Hospital believed
that a partnership between the Cancer Center and the two health clubs would be
beneﬁcial for people living with cancer and an appropriate use of the health clubs. The
director was convinced that the health clubs could be an asset to oncologists as a
treatment option for people who were emotionally and physically struggling with cancer.
The director at the cancer center and his research assistant (this author) designed the data
collection techniques, chose the standardized tests, created the consent forms, and
received approval ﬁ'om St. Mary’s Human Subject Review Committee (Mercy Health
Services). In August of 2002, the Mercy Health Services Cancer Center’s “Cancer Wellﬁt
Program” began.

The “Cancer Wellﬁt” program implemented by Mercy Health Services Cancer
Center is a recognized program for people living with cancer. It was ﬁrst implemented in
1990 in Santa Barbara, California (Appendix L). This program uses a four-component
approach for exercise (Durak, 2001). The ﬁrst component concentrates on progressive
resistance “strength training” as the primary training regime. Patients select stations that
ﬁt their initial ﬁtness level and medical concerns, and progress to higher weight levels
and additional stations as pain free ﬁtness levels and strength improves. The second
component concentrates on aerobic training using machines, step classes, and group
walking. The important aspect about training in a community health club environment is
that patients can select from a variety of classes that are speciﬁcally designed for them.
They can also use aerobic machines so they can improve their aerobic capacity during

their initial 10 weeks of supervised exercise.

44

The third component of the Wellﬁt program is range of motion and ﬂexibility.
This component concentrates on working out scar tissue deﬁcits, and balancing out
general musculature. The ﬁnal component is mind/body ﬁtness. This component consists
of breathing, relaxation, one or two yoga classes within the 10 weeks, and some
meditation programs (Durak & Lilly, 1997). All of these components are part of the
health club programming at the two health clubs, and are offered to cancer participants
along with water exercise, and other club programs (Appendix D).

Many health clubs and clinics in the United States are examining the Cancer
Wellﬁt program as the model to emulate. The Wellﬁt program is now used in Southern
California, Colorado, and Illinois. Wellﬁt has trained hundreds of cancer survivors, and
outcomes of the trainings have been published regarding the participants’ increase in
strength (over 45%), aerobic capacity (30%), and multitude of quality of life
improvements (in general, over 29%) (Durak & Lilly, 1997). The results of training and
exercise continue after treatment of cancer. Research found that after 5 years in
remission, over 90% of participants continue to exercise either self-paced or in a club.
Their level of vigor is over 80% and almost all use some type of complimentary therapy
to enhance their recovery progress (Durak & Lilly, 1997). Since its creation, the Wellﬁt
program has grown, offering the cancer and exercise program in over 25 different
locations throughout the United States. As part of the orientation to the Wellﬁt program,
the personal trainers from the two health clubs in Grand Rapids visited the original site of
Cancer Wellﬁt in Santa Barbara. They participated in training sessions and observed the
Wellﬁt program in action.

Mercy Health Services introduced the Cancer Wellﬁt Program to the Grand

45

Rapids community as a research study for people living with cancer, and invited any
adult being treated for cancer within the last six months to participate. Patients learned
about and gained access to the program application process through a variety of
information sources. News of the program traveled by way of physicians, nurses, social
workers, and other medical professionals. Promotion of the program also occurred
through TV news clips, two newspaper articles, the health club newsletter, and a brochure
mailed to all the Grand Rapids oncologists’ ofﬁces.

Subjects and Sampling

Subjects for this study were also recruited from the local community hospitals,
referred by nineteen different doctors and cancer treatment professionals, and through the
subject’s self-referral. Brochures were delivered to physician offices describing the
program and explaining the referral process.

All interested patients were routed through a consent process at Saint Mary’s
Cancer Center. The Cancer Center Director of Research carefully controlled subject
suitability, as described below, for the program, ensured physician knowledge and
endorsement of patient participation, and explained the exercise program and research
beneﬁts, risks, and obligations to the appropriate subjects. The patient signed a consent
form for treatment (Appendix B). Subjects signed and received a copy of the informed
consent form in full compliance with the procedures approved by the institutional review
board at St. Mary’s Mercy Services, Grand Rapids, Michigan.

Not all patients referred to the Cancer Wellﬁt study were included in the program.
To ensure the safety of each participant, exclusionary criteria were developed in

consultation with the Director of Oncology at the St. Mary’s Cancer Center. The criteria

46

for exclusion from the Cancer Wellﬁt research program included: diabetic patients, class
III cardiac patients, patients physically incapable of exercise due to advanced disease,
lung irradiation, late stage cancer patients, patients under the age of 18, and patients who
did not obtain physician endorsement. In addition, patients who admitted to back pain or
pain in their bones or joints, sudden dizziness or dypsnea were excluded. Patients
experiencing extreme muscle weakness and patients experiencing severe nausea were
also counseled out of the study. Data were not collected on the patients counseled out of
the Wellﬁt program.

Subjects who did not complete both the F ACIT pretest and posttest were not
excluded from the Cancer Wellﬁt program but were excluded from the statistical
analysis. The physical trainers participating in the program distributed and when
complete, collected the FACIT pretest at the ﬁrst group meeting and the FACIT posttest
at the last meeting. Thirteen subjects did not complete both the pre and post testing
components of the FACIT. Completion of the tests may not have occurred for a variety of
reasons including, drop-out from the Wellﬁt program, absence on the day the test was
given, or an incomplete pre or posttest escaped the attention of the trainer.

The ﬁnal sample included 62 individuals living with cancer. The participants were
26 men and 36 women, between the ages of 21 and 79, with a mean age of 54.5. The
participants were living with 10 different cancer types: breast (24), colon (1), lung (2),
ovarian (3), brain (2), melanoma (l), testicular (2), lymphoma (5), leukemia (2), prostate
(10), and other types (10). All patients were in cancer treatment, anticipating cancer
treatment, or had been in treatment within six months prior to beginning the Cancer

Wellﬁt exercise program. The participant’s cancer treatments included: surgery (2),

47

chemotherapy (14), radiation (17), combination of 2 or more therapies (13), other (7), and
nine subjects did not answer the question.

The Wellﬁt program was offered without cost to program participants due to a
grant from the Doran Foundation and in-kind membership gifts from East Hills and
Michigan Athletic Clubs. The only cost incurred by participants was for transportation to
and from the health clubs.

Design and Procedures

The subjects were assigned to one of nine exercise groups based on the numerical
capacity of the next exercise group offered. The assignment to a group was not random,
and assignment often depended on the presence or absence of health complications of the
subjects. For example, once a patient was admitted into the program, they occasionally
experienced a severe response to a cancer treatment and requested a later start date with a
later group. Ethically, this request superceded the need to assign patients to an exercise
group based on an opening in the next exercise group, or any attempt at random
assignment.

The groups were made up of six toll individuals. Each exercise group
participated in a ten-week group that was directed by two or three professional exercise
trainers. The Fitness and Personal Training Director of the health clubs was responsible
for the quality and delivery of the Wellﬁt exercise program. The qualiﬁcations of the
Director include: certiﬁcation by the American College of Sports Medicine as a Health
Fitness Instructor, certiﬁcation by the American Council on Exercise, as a Clinical
Exercise Specialist, and a Lifestyle and Weight Management Consultant.

The groups met on various times and days of the week to accommodate work

48

schedules. The program sessions were held at an athletic club with each group remaining
intact with the same group of participants and the same group of trainers. The trainers
followed a previously organized training and education schedule. The schedule was
shared with the participants in the program as an informational handout (Appendix D).

The exercises consistently used by the trainers were divided into two main areas,
resistance training exercises and abdominal exercises. The resistance training exercises
were: 1) the Cybex leg press, 2) the Cybex chest press, 3) the Cybex seated row or lateral
pulldown, 4) the Cybex shoulder press, 5) the Cybex leg curl, 6) the cable tricep
pushdown, and 7) the dumbbell bicep curl. The abdominal exercises included: 1)
isometric contractions, 2) crunches or forward crunches, 3) pelvic tilt, 4) alternative
supine leg lowering (with progress to reverse crunch), 5) the proned hover, and 6)
bridges.

The aerobic-exercise program was performed on treadmills, stationary bicycles,
and stair-climbing machines. The participants were also trained on the weight machines
and the free-weights. In addition to the small group supervision sessions with the Wellﬁt
program, participants were offered free services throughout the health clubs for the entire
lO—week program.

Data were collected by the Wellﬁt trainers prior to beginning the ﬁrst session of
the ten-week exercise program and during the last session of the program. Color-coded
packets were designed to ensure all the questionnaires were given to each participant and
that the pretest and posttest information was accounted for. The questionnaires and other
subject information were assigned to a subject ﬁle. The subject ﬁles were all assigned

unique numbers based on four-digits. The ﬁrst two digits were for the chronological

49

W .
‘ . El.

number of the group, while the next two numbers were for the participant number. The
ﬁle number assigned to the participant and dispensed by the Wellﬁt trainers was based in
alphabetical order, and the list of participant names and numbers was kept separate from
the data ﬁles and from the research team to assure conﬁdentiality. The research assistant
collected the data from the athletic clubs and stored the paper data in ﬁles in a locked
room in the Research Center. The research assistant transferred all data into the statistical
program, Statistical Program for Social Sciences (SPSS) computer software.
Instrumentation

Before and after a ten-week exercise program, the subjects completed four
surveys: 1) Proﬁle of Mood States [POMS], 2) Functional Assessment of Chronic Illness
Therapy with the Fatigue subscale [FACIT-F], 3) Social Inventory, and 4) Exercise
Questionnaire. In addition, the club trainers conducted a preliminary physical strength
baseline. The decision was made, for purposes of this study, to examine the results of tthe
FACIT-F, version 4. The study did not examine the results of the POMS, the Social
Inventory, or the Exercise Questionnaire.

The FACIT questionnaire is a collection of health-related quality of life
questionnaires and it has been under development since 1987. This questionnaire has
several advantages for measuring quality of life. First, the items in the questionnaire were
developed with both patient and expert input. This collaborative effort improves the goal
of including patient relevant factors in quality of life. Second, there are several hundred
publications detailing its performance as well as many formal validation studies
(Overcash, Extermanrr, Parr, Perry, & Balducci, 2003; Webster, Odom, Petermarr, Lent,

& Cella, 1999; Winstead-Fry & Schultz, 1997). Third, there is availability of cross-illness

50

comparative scores, and ﬁnally, there is a body of research that illustrates clinically
signiﬁcant differences and changes in scores in FACIT scales that aids in study sample
size determination and interpretation of study results (Webster, Cella, & Yost, 2003).

The FACIT-F is a standardized questionnaire used to collect and analyze relevant
quality of life data and is divided into ﬁve primary quality-of-life domains; physical well-
being, social/family well-being, emotional well-being, functional well-being, and
additional concerns (fatigue) (Webster, et al., 2003). The present study gives attention
only to the sub-scores of the “physical well-being” and “emotional well-being” domains
of quality of life.

The FACIT-F questionnaire is designed to be appropriate for measurement of
quality-of-life for patients with any form of cancer (Webster, et al., 2003). The FACIT-F
is a combination of the CORE questionnaire called the Functional Assessment of Cancer
Therapy-General (FACT-G) of 27-items, with the addition of 13 questions regarding the
assessment of fatigue on the quality of life. Extensions of this questionnaire have also
been used and validated with other forms of chronic illness, such as Acquired Immuno-
deﬁciency Virus [AIDS], Parkinson’s disease, multiple sclerosis, and rheumatoid
arthritis.

The FACIT-F can be administered by self-report with paper or computer, or by
interview (face-to-face or telephone). For this study, the FACIT-F was administered to
subjects using pencils with the printed questionnaire. The pretest was administered during
the ﬁrst day of the ﬁrst week of the Wellﬁt program and the posttest was administered
during the second day of the tenth and ﬁnal week. The 6-11 subjects in each group

completed the questionnaires in a large conference room located in the health center. The

51

F ACIT-F assessment is written at the 4th grade reading level and is designed to take less
than ﬁfteen nrinutes to complete (Webster, et al., 2003). The Wellﬁt trainers handed out
the FACIT-F assessments to each subject and collected them when the subjects had
ﬁnished. After each lO-week Wellﬁt program, the research assistant collected the data
completed by the group and the results were entered into the Statistical Program for
Social Sciences computer program.

The FACIT-F questionnaire has ﬁve sections and in each section there is a list of
statements to which the subject can respond by circling one of the following answers in a
5-point Likert-type scale: 1 = Not at all, 2 = A little bit, 3 = Somewhat, 4 = Quite a bit, or
5 = Very much. The physical well-being section has 7 items, the social/family well-being
has 7 items, the emotional well-being section has 6 items, the functional well-being
section has 7 items and the fatigue section has 13 items. Each item is stated as a fact
regarding the cancer patients’ quality of life and they respond to that statement by
circling a response that is the closest to matching their feeling about the statement. For
instance, in the physical well-being section, the ﬁrst statement is “I have a lack of
energy”. The total questionnaire is 3 pages in length. i

The F ACIT-F subheadings, or the total of all subheadings, are scored so that a
higher score indicates improvement in quality of life. The scores on negatively-phrased
statements are reversed, and all items within the subheading are then added for a
subheading ﬁnal score. The subheading scores of physical well-being, emotional well-
being, social/family well-being, functional well-being and the additional score of fatigue
are added together for a total FACIT-F score (Webster, et al., 2003). Missing scores were

created by using the average of the other answers in the scale. Subheading scales can be

52

created for missing data as long is there are no more than 50% of the data missing.

FACIT-F subheading scores reveal even minimal differences in quality of life.
Minimal differences in quality of life that are worth noting by a cancer patient, offer
clinicians an opportunity to adjust treatment (Brady, et al., 1997; Webster, et al., 2003).

Seventy-ﬁve subjects completed the pre-tests, but only 62 subjects completed the
posttests. The 13 subjects who did not complete both the pretest and the posttest were
excluded from the analysis.

Validity and Reliability

The goal of using quantitative methodology was to gain a statistical analysis of
the subjects’ report of difference in physical and emotional well-being before and after
participating in the Cancer Wellﬁt exercise program. The F ACIT-F is a standardized tool
developed to measure quality of life. The literature recognizes this questionnaire to have
good reliability and past use of the FACIT-F reports the reliability to coefﬁecient alpha
range = .69-.82 (Cella, 1997).

Using SPSS, the Cronbach alpha reliability range was used to determine the alpha
range for the subscales “physical well-being”, “emotional well-being”, and the total
FACIT score. The results of the Cronbach alpha reliability based on the F ACIT-F total
score with 40 items is .7015. This reliability score is within the reliability range cited in
the literature. The results of the “physical well-being” subsection of the F ACIT-F
questionnaire are alpha = .6437 and the “emotional well-being” subsection with 6 items
reveals an alpha = .6761.

Again, as with the physical well-being subsection reliability test, the alpha falls

somewhat lower that the reliability range cited in the literature because of the brevity of

53

the test.

Given the length of the questionnaire subsections used in this study to examine
the physical and emotional well-being aspects of quality of life, the reliability range of
these questions is acceptable. In addition, the results of this study are generalizable to
other cancer and exercise studies if the Cancer Wellﬁt program, or a similar program, is
used for the exercise component and if the other sample resembles the one that received
the Cancer Wellﬁt program for this study in terms of gender, age range, cancer type, and
cancer treatment. Because there are a number of similar programs meeting these two
criteria, it is likely that there will be some generalizability from this study.

Assumptions of the Study

The research methodology was based on certain assumptions that if violated,
would affect the validity of the study. It was assumed, and there was no reason to doubt,
that the respondents were sufﬁciently knowledgeable to respond accurately to the
standardized tests and to honestly respond about their experience, perceptions, and
feelings. It was assumed that the survey items were clear enough for the subjects to
‘ answer the research questions. Finally, it was assumed that the ﬁndings of this study
would be useful to the social work profession and to other disciplines such as sociology,
kineseology, and physical rehabilitation.

Summary

Chapter III contained a discussion of the study’s epistemology and
methodology, subjects and sampling, procedures, instrumentation, data analysis, and
assumptions. The results of the study are presented in Chapter IV, including the

characteristics of the subjects, general ﬁndings, and results based on the research

54

hypotheses.

55

CHAPTER IV

RESULTS

Overview

Sixty-two subjects participated in the “Cancer Wellﬁt” research project,
conducted under the auspices of St. Mary’s Health Services Cancer Center in Grand
Rapids, Michigan. The participants were assigned to nine exercise groups that met in one
of two hospital owned health clubs for a ten-week supervised program. The groups
participated in the ten-week programs over the course of one year, April 2002 through
April, 2003. F our of the nine exercise groups met at one health club and ﬁve exercise
groups met at the second health club. Originally, seventy-ﬁve participants enrolled in the
study, but due to incomplete pre and post-test results, the results of the thirteen subjects
were excluded, as described in Chapter III.

The thirteen participants excluded from the study included men (7) and women
(6) between the ages of 35 and 74. These subjects were diagnosed with breast (4), lung
(1), ovarian (l), melanoma (l), testicular (l), pancreatic (1), prostate (2), and other (2)
cancers. They were in a variety of treatments for cancer: namely, surgery (2)
chemotherapy (4), radiation (3) and a combination of treatment types (4). The excluded
participants identiﬁed a variety of treatment goals including palliative care (3 ), curative

(6), adjunctive (l) and other (3). The data did not suggest unique demographic

56

characteristics in the excluded subjects. The remaining sixty-two subjects form the
sample for this study.
Characteristics of the Study Sample
The study sample contained 36 women (58.1%) and 26 men (41.9%) and was

composed of participants representing a wide age range.

Age Range

 

 

 

Percent
N

90,9 ‘36: 90‘ '36: 70 76‘ 6‘0‘ 6‘0: 6‘0 63:0 )0, 1"
7

7 0
is, .13, .13, Jae J’s .k .11 *0 13, +0 .13,
is 6% is 9e in ‘96 ‘94 5’s 9's 9% °e °a~
0/ 0/ O O/ 96 0/0
Age Range

Figure 1. Percentage of Participants Based on Age Range.

The subjects (see Figure l) ranged from twenty to eighty years in age (N = 62,
M=54). It was expected that the subjects in the study would be middle-aged and older
given the increase risk of a cancer diagnosis as a person ages. In fact, twelve of the 62

subjects (19%) were 70 or older. It was not expected that the high percentage of the

57

subjects in this age range would volunteer to be in an exercise program during their

cancer treatment.

The sample was composed of individuals (N=62) receiving cancer treatment for

nine different cancer types (see Figure 2).

cancer type
50

 

Percent

 

 

 

breast lung
colorectal ovarian

brain testicular leukemia other
melanoma lymphoma prostate

cancer type

Figure 2. Percentage of Participants Based on Cancer Type.

The types of cancer included breast (24, 38.7%), colorectal (l, 1.6%), lung, (2,
3.2%), ovarian (3, 4.8%), brain (2, 3.2%), melanoma (l, 1.6%), testicular (2, 3.2%),
lymphoma (5, 8.1%), leukemia, (2, 3.2%), and prostrate (10, 16.1%). Ten subjects

(16.1%) indicated that they had a diagnosis of a form of cancer not listed.

All participants were required to be in cancer treatment during the Wellﬁt

program. This was a rmique feature of the study because often exercise as an intervention

58

for cancer patients is examined as part of cancer treatment rehabilitation. The subjects

indicated they were recipients of a variety of cancer treatments (see Figure 3).

type of treatment
30

 

20

 

 

 

Percent

no answer surgery chemo radiation combination other

type of treatment

Figure 3. Percentage of Participants Based on Type of Cancer Treatment.

Nine participants (14.5%) responded to the question about type of cancer
treatment with “no answer”. The short answer question “Current treatment” (Appendix
J) could have been confusing or misleading for those anticipating or just completing
active treatment. The other responses to the cancer treatment item included surgery (2,
3.2%), chemotherapy (14, 22.6%), radiation (1 7, 27.4%), a combination of therapies (13,
21%) and other treatments not listed (7, 11.3%).

Participants in the study (N=62) were referred to or volunteered to participate in

the Wellﬁt program for a variety of reasons. While it was suspected that the goal for

59

participation was curative in nature, participants responded to the item asking about the

goal of cancer treatment with a variety of answers (see Figure 4).

goal of cancer treatment
70

 

eoj
504
40.
30+
204

101

 

 

Percent

 

 

 

no answer palliative curative adjuvant other

goal of eancertreatment

Figure 4. Percentage of Participants Based on Goal of Cancer Treatment.

Sixteen participants (25.8%) responded to the question about their goal for cancer
treatment with “no answer.” This relatively high response may indicate emotional
discomfort with this question or it could indicate the cancer patients’ uncertainty about
the goal of treatment for their cancer diagnosis. Seven (11.3%) of the participants
indicated that the goal of their cancer treatment was palliative and 37 (59.7%) responded
that their goal for cancer treatment was curative. Other participants (2, 3.2%) stated the
treatment goal was to support other forms of treatment. The strong response indicating

the cancer treatment goal as curative was not surprising. It was expected that participation

60

in cancer treatments would be offered to and described to cancer patients primarily as a
way to oppose the presence of cancer in their bodies.

The two primary criteria for enrollment in the Cancer Wellﬁt program were 1) the
participants’ diagnosis of cancer and 2) their participation in a form of cancer treatment.
Cancer treatment was deﬁned as treatment prescribed by their “cancer doctor.” The
treatment was to be received during the Cancer Wellﬁt exercise program, scheduled to
begin during the Cancer Wellﬁt program, or treatment within the six months prior to the
beginning of assignments to the Cancer Wellﬁt program group session.

The subjects were required to sign a physician release of information (Appendix
G) allowing the Cancer Wellﬁt staff to notify and consult with the subject’s physician.
The physician was asked to sign a form acknowledging their comprehension of Cancer
Wellﬁt program and their support for the subject’s participation.

The Cancer Wellﬁt program was facilitated by St. Mary’s Cancer Center and
there was a concern that research subjects would only be referred to the program only by
oncologists or other physicians associated with St. Mary’s Cancer Center. This was not
the case. Subjects participating in the program were patients of nineteen physicians in the
West Michigan area. The Medical Director and Chief Oncologist of the Cancer Center
was the only physician working as an employee of St. Mary’s Cancer Center and his
referrals accounted for many of the referrals (23%) and he referred the most participants
when compared to other physicians. However, 77% of the referrals came from physicians
working primarily outside of the St. Mary’s Cancer Center.

The impression is that the Cancer Wellﬁt brochures, a health club newsletter

communication, a newspaper article, and community media were effective and inﬂuenced

61

people living with cancer to seek out the Cancer Wellﬁt program. In addition, it appears
that a number of physicians were inﬂuenced by their awareness of the program and

referred their patients to the program.

General Findings

Findings will be presented by discussing each research hypothesis in terms of the
quantitative ﬁndings. The statistical results of the quantitative ﬁndings reveal two of the
four hypotheses to have statistical signiﬁcance. One additional hypothesis demonstrates a
trend. Analyses were conducted to provide descriptive information (means, standard
deviation) and insure that data met assumptions to perform regression analyses. The
rejection level used in statistical analysis was .05.

Results Presented by Research Hypothesis
Physical Well-Being

Hypothesis one examined data collected using the “physical well-being” quality
of life domain as measured by the FACIT — F. Values within this subsection of the
F ACIT - F included the following responses: 0 (Not at all), 1 (A little bit), 2 (Somewhat),
3 (Quite a bit), and 4 (Very much). The physical well-being subsection contains seven
statements with a total possible sum score of 28. The higher score indicates improvement
in physical well-being. The questionnaire asked each subject to indicate the level of truth
about each of the following statements: 1) I have a lot of energy, 2) I have nausea, 3)
Because of my physical condition I have trouble meeting the needs of my family, 4) I
have pain, 5) I am bothered by side effects, 6) I feel ill, and 7) I am forced to spend time

in bed.

62

Hypothesis 1
There will be a statistically signiﬁcant improvement in the posttest average scores
of physical well-being reported by cancer patients who are in active treatment for
a variety of cancer diagnoses and participate in a lO-week exercise program when
compared to the pretest average scores. (Higher mean score on the “physical well-
being” subscale as measured by the Functional Assessment of Cancer Therapy -
Fatigue [FACIT-F] will be associated with improved physical well-being).
Results 1
The data did not reveal any evidence against normal distribution. The statistical
analysis employed the paired samples t-test was used to determine if the mean posttest

results of physical well-being of the sample demonstrated a statistically significant

difference from the mean pretest results of physical well-being.

pre FACIT physical well-being

 

8

 

 

Frequency

11.00 12.00 15.00 17.00 19.00 21.00 23.00 25.00 26.00 28.00
11.70 13.00 16.00 18.00 20.00 22.00 24.00 25.70 27.00

pre FACIT physical well-being

Figure 5. Frequency of Physical Well-Being Pretest Scores.

63

Descriptive statistics revealed the pretest scores (M = 21.2, SD = 4.1) and the
actual total values ranging from 11-28. The frequency table (see Figure 5) indicates that
38 of the subjects (59%) responded with a score falling between 22 and 28 on the FACIT

pretest physical well-being questionnaire.

post FACIT physical well-being

 

12

10-

Frequency

 

 

 

9.30 12.00 16.00 18.00 21.00 23.00 25.00 27.00
11.00 15.00 17.00 19.00 22.00 24.00 26.00 28.00

post FACIT physical well-being

Figure 6. Frequency of Physical Well-Being Posttest Scores.

The means and standard deviations for the posttest scores were (M = 22.7, SD =
4.7) and the actual total values ranged from 9.30 to 28. The frequency table (see Figure 6)
indicates that 43 of the subjects (67%) responded with a score falling between 22 and 28
on the FACIT posttest physical well-being questionnaire.

The range of the posttest physical well-being scores is larger and includes a lower
score for one subject. However, the mean score of posttest results (22.7) are almost 1.5

points higher than the pretest scores (21.2).

Findings based on the difference in means between the mean pre and posttest
results of the FACIT-F, physical well-being subsection, suggest that participants reported
improved physical well-being after participation in the Cancer Wellﬁt exercise
intervention. The quantitative results demonstrate a statistically signiﬁcant improvement
in participant physical well-being after participation in the Cancer Wellﬁt program (see
Table 1).

Table 1. Paired Sample T-Test Statistics based on Pre and Posttest Results Measuring
Physical Well-Being.

Paired samples t-test statistics physical well-being

 

 

 

 

 

 

 

 

 

 

 

 

 

Std. Error
Mean N Std. Deviation Mean
Pair 1 post FACIT
physical well- 22.7145 62 4.69851 .59671
being
pre FACIT
physical well- 21.2323 62 4.10964 .52192
beinL
Paired sampls test physical well-being
Paired Differences
. . run—m; d‘ ‘ '
2 'r physrcd wall-bang 1.4822 4.5246 2.579 61 .012

 

 

 

 

 

 

 

 

The statistical test, as shown in Table 1, revealed a difference in the mean of 1.48,
and standard deviation of 4.52 (p = .012). The results support the hypothesis.

The improvement in physical well-being was expected and supports the results of
current research. The results support studies that suggest that people live with a variety of
different cancers with less nausea, weakness, pain, and fatigue and are better able to live

with the ravaging effects of fatigue and nausea when they engage in physical activity

65

(MacVicar & Winningham, 1986). However, threats to internal validity of the results
exist and will be discussed in Chapter V.
Emotional Well-Being

The data were collected using the “emotional well-being” quality of life domain
as measured by the FACIT — F. Values within this subsection of the FACIT — F included
the following responses; 0 (Not at all), 1 (A little bit), 2 (Somewhat), 3 (Quite a bit), and
4 (Very much). The emotional well-being subsection contains seven statements with a
total possible sum score of 28. The higher soore indicates improvement. The
questionnaire asked each subject to indicate the level of truth of each of the following six
statements: 1) I feel sad, 2) I am satisﬁed with how I am coping with my illness, 3) I am
losing hope in the ﬁght against my disease, 4) I feel nervous, 5) I worry about dying, and
6) I worry that my condition will get worse.
Hypothesis 2

There will be a statistically signiﬁcant difference in the posttest average

scores of emotional well-being reported by cancer patients who are in active

treatment for a variety of cancer diagnoses and participate in a 10-week exercise

program when compared to the pretest average scores. (Higher mean score on the

“emotional well-being” subscale as measured by the Functional Assessment of

Chronic Illness Therapy — Fatigue [FACIT-F] will be associated with improved

emotional well-being).
Results 2

The data did not reveal any evidence against normal distribution. The statistical
test employed was the paired samples t-test. It was used to determine if the sample mean

posttest results of emotional well-being demonstrated a statistically signiﬁcant difference

from the mean pretest results of emotional well-being (see Figure 7).

66

pre FACIT emotional well-being

 

14

12*

10*

81

 

 

 

Frequency
N

8.00 12.00 14.00 16.00 18.00 20.00 22.00 23.00 26.00
10.00 13.00 15.00 17.00 19.00 21.00 22.80 24.00

pre FACIT emotional well-being

Figure 7. Frequency of Emotional Well-Being Pretest Scores.

Descriptive statistics (see Figure 7) revealed the mean pretest scores (M = 19.5,
SD = 3.68) and the actual response values ranged from 8 -26. Figure 7 indicates that 38
of the subjects (59%) responded with a score falling between 22 and 28 on the FACIT
pretest emotional well-being questionnaire.

Descriptive statistics (see Figure 8) revealed the mean emotional well-being
posttest scores (M = 20.48 SD = 3.18) and the actual total values ranged from 5 to 24.
Figure 8 shows that 54 of the subjects (84%) responded with a score falling between 20
and 28 on the FACIT posttest emotional well-being questionnaire. This signiﬁes a shift to

higher FACIT scores.

67

post FACIT emotional well-being

 

 

 

Frequency
M

5.00 14.00 17.00 19.00 21.00 23.00
11.00 16.00 18.00 20.00 22.00 24.00

post FACIT emotional well-being

Figure 8. Frequency of Emotional Well-Being Posttest Scores.

The range of posttest emotional well-being scores is larger and includes a lower
score for one subject (5). However, the mean of the posttest result (20.5) is approximately
1 point higher than the pretest result (19.5).

Findings, based on the difference in means between the pre and posttest results of
the FACIT-F, emotional well-being subsection, suggest that subjects reported statistically
signiﬁcant improvement in their emotional well-being after participation in the Cancer
Well-ﬁt exercise intervention (see Table 2). The statistical test results, as shown in Table
2, revealed a difference in mean of 1.00, and a difference in standard deviation of 3.40 (p

= .023).

68

 

 

Table 2. Paired Sample T-Test Statistics Based on Pre and Posttest Results Measuring
Emotional Well-Being.

Paired samples t-test statistics emotional well-being

 

 

 

 

 

 

 

 

 

 

 

 

Mean N Std. Deviation
Pair 1 post FACIT
emoﬁonal well- 20.4839 62 3.17646
being
pre FACIT
emotional well- 19.4806 62 3.67561
being
Paired sanples test ermtional “ell-being
Pa'red themces
, inn—m I 9‘
Par 1 W mil-ham 1.0032 3.1% 2325 61 £23

 

 

 

 

 

 

 

 

The improvement in emotional well-being was expected based on research
studies. The results supported studies that demonstrate that people with emotional distress
associated with cancer experience improved emotional well-being when involved in
increased physical activity. The results are subject to the threats to internal validity make
it impossible to determine if the improvement was due solely to the exercise intervention.
Issues relating to internal validity will be discussed further in Chapter V.

Diﬁérence between Physical Well-Being and Emotional Well-Being

Results from the t-tests for hypotheses 1 and 2 demonstrated participants reported
statistically signiﬁcant improvement in both physical and emotional well-being. The
research question in hypothesis three seeks to determine if there is a statistically
signiﬁcant difference in the improvement change between physical and emotional well-

being.

69

Hypothesis 3
There will be a statistically signiﬁcant difference in improvement in the sample
mean of physical well-being when compared to the sample mean of emotional
well-being reported by cancer patients who are in active treatment for a variety of
cancer diagnoses and participate in a 10-week exercise program.
Results 3
The side-by-side boxplot (see Figure 9) demonstrates that the means of
physical and emotional well-being are very close. The boxplot also demonstrates the

presence of outliers and an extreme outlier.

 

 

 

 

 

 

 

 

 

 

 

15.00 .4 837
2
10.00 -- 30 _
_o_ i"
5.00 —
0.00 -~ I I I I
-500 _. _— __
oil
-1000 — 210
43
-1500 a *
l l
armband mm

Figure 9. Difference Between the Means in Improved Physical Well-Being and Improved
Emotional Well-Being.

To ascertain the difference in improvement, a paired sample t-test measuring the
difference between group means was employed. The results conclude there was not a
statistically signiﬁcant difference of improvement between physical and emotional well-

being.

70

Table 3. T-Test for Improved Physical Well-Being and Improved Emotional Well-Being.

 

 

 

 

 

 

 

 

Paired Sample Statistics
_ Mean N Std. Deviation
Pair 1 Improve
emotion 1.0032 62 3.39826
Improve
| ical 1.4823 62 4.52467
Paired Samples

 

 

 

 

 

 

 

T.__d I d‘ M
an em renal-physicall -.681 61 .499

 

The results indicated the statistical change for physical well-being (M = 1.48, SD
= 4.52) and emotional well-being (M = 1.0032, SD = 3.40). The statistical test reveals t =
-.681, p = .499 (two-tailed). These results indicated there is no statistically signiﬁcant
difference in change reported between physical and emotional well-being.

To determine if one area of well-being had improved more than the other, the
Cohen’s measure of effect size was applied. The Cohen’s Effect-size statistical test
indicated that the improvement in physical well-being had a slightly larger effect size.
The effect size assumes that one variable has an effect on another variable. One of the
main effect statistics is the difference in means between two variables. It is calculated by
dividing change in mean by standard deviation. The results express the difference in
means as a fraction of the standard deviation. For instance, a change in one standard
deviation is a moderate effect and anything less than 0.2 standard deviation is very small

(Hopkins, 2000). The result of this test indicates that the effect size of improvement in

71

emotional well-being was d = 0.295. The effect size of improvement in physical well-
being was d = 0.328. While the difference in mean improvement was not statistically
signiﬁcant, the effect size of improvement in physical well-being is slightly greater.
Influence of Variables on Improvement in Physical Well-Being
The variables of age, gender, cancer type, and cancer treatment of the sixty-two
subjects were explored to determine if they were signiﬁcant in inﬂuence on improvement
in physical well-being.
Hypothesis 4
There will be a statistically signiﬁcant relationship between the variables 1)
gender, 2) age range, 3) cancer type, and 4) cancer treatment and improvement in
physical well-being reported by cancer patients who are in active treatment for a
variety of cancer diagnoses and participate in a lO-week exercise program. The
literature does not specify an identiﬁable direction of change.
Results 4.1: Gender
The distribution of the gender variable was examined by application of the side-

by-side box plot (see Figure 10). Figure 10 shows that the distribution is somewhat

skewed: therefore, the Mann-Whitney statistical test was used to compare means.

72

 

15.004 37

 

 

 

 

 

 

 

 

 

 

 

 

O
O
2’ 10.00— _ __
13 “l
7:
E 5.00— ,
2: 0.00— M l J
3 __
S
a -5.00—-
E
34
4000-4 0
realm m‘ane

Gender

Figure 10. Difference in the Means of Improved Physical Well-Being Between Female

and Male Participants.

The ﬁndings of the Mann-Whitney Test (see Table 4) indicated that men (N = 26)

had a mean rank of 34.48 and women (N = 36) had a mean rank of 29.35. (p = .265) and

sum of ranks = 1056.50.

Table 4. Difference in Improvement Between Genders.

Mann-Whitney Test

 

 

 

 

 

 

 

 

 

Ranks
I gender N Moan Rank Sum of Rank:
WW?” male 26 34.48 896.50
Wm” female 36 29.35 1056.50
Total 62
Test Shtlstlcsh)
Improved
physical
Mann-Whitney U 390,500
ercoxon W 1056.500
Z -1.1 14
Asymp. Sig. (2-tailed) .265

 

 

 

 

a Grouping Variable: gender

73

 

The results suggested that while there is a small difference in improved physical
well-being based on gender, gender is not a signiﬁcant variable in improvement (U =
390.50, T = 1056.50) The test results revealed 2 = —1.114 (p = .265). There is no
statistically signiﬁcant difference between the mean change in physical well-being and
gender. There was an expectation that there would be a difference in the perception of

improved physical well-being being between men and women, but this hypothesis was '

not supported.
Results 4.2: Age Range

The variable age range was examined for inﬂuence on the improvement. of
physical well-being using simple linear regression. The scatterplot (see Figure 11)
examined sample distribution and indicated a negative correlation between change in

physical well-being and age range and shows that as the subjects increase in age,

improvement in physical well-being is slower.

 

 

 

 

 

15.004
. o
O
10.00-
00 O 0
'5'? o o
i 5.00- O 8 o o O
3
E
‘3 0.005 o
gt 0 o o o o o
- -5.00— 0
R Linear:
° o .014
40.001 0
I I I I I l I
0.00 2.00 4.00 6.00 8.00 10.00 12.00
AgeRange

Figure 11. Scatterplot of Improved Physical Well-Being and Age Range.

74

The statistical test of linear regression, as displayed in Table 8, was applied to
determine if age range was a predictor of change in improved physical well—being.

The regression summary (see Table 5) revealed p = .364 (t = -.914). The results
suggest age range is not a predictor of improvement in physical well-being aﬁer
participation in a physical exercise program. These results are surprising because it was
expected that there would be a signiﬁcant difference in the perception of well-being

based on age range aﬁer participation in the Wellﬁt program.

Table 5. Regression Summary of Age Range.

Model Summary

 

 

I 1 Adjusted Std. Error of
Model R R Square R Square the Estimate
[1 [ .1178 .014 -.003 4.53077 J

 

 

 

 

a. Predictors: (Constant). Age R3099

 

 

 

 

 

 

 

Coefﬁcient!“
Unstandardized
Coefﬁcients
Model 8 Std. Error t 819‘ . 1
1 (53nstant) 2.837 1.590 1.785 . 79
Age Range -.181 .198 -.914 .364

 

 

 

a. Dependent Variable: difphysi

The results indicated a weak correlation between age range and improvement in
physical well-being (R square = .014) and no statistically signiﬁcant relationship. The

results do not defend the hypothesis.

75

Results 4.3: Cancer Type

The relationship between the type of cancer and the improvement in physical
well-being was examined. Cancer types identiﬁed in the data included, breast, colorectal,
lung, ovarian. brain, melanoma, testicular, lymphoma, leukemia, prostate, and other
cancer.

The side-by-side box plot (see Figure 12) examined the distribution of the mean
of physical well-being change. The mean appears similar for many types of cancer,
particularly breast, ovarian, testicular, lymphoma, and prostate. Figure 12 also indicates
that the mean for subjects living with leukemia improved in physical well-being more
than the average diagnostic categories and the mean for subjects living with brain cancer

improved in physical well-being less than most diagnostic categories.

 

 

 

 

 

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Figure 12. Side-by-Side Boxplot of Improved Physical Well-Being and Type of Cancer.

76

The statistical test, one-way analysis of variance [AN OVA], was conducted to
determine ifthe means of cancer types signiﬁcantly varied from each other in their
relationship to changed physical well-being. Due to single responses, colorectal and
melanoma cancer were not included in the analysis, so the remaining nine cancer
diagnoses are included in the statistical test.

Variations in sample size (see Table 6) for cancer types indicate some cancer
groups had better representation than other groups, for example the breast cancer sample
N - 24, and in contrast, lung cancer sample N = 2. Results of the analysis showed that
mean difference in improvement in physical well-being varied based on the type of
cancer diagnosis. The least improvement in physical well-being was reported by subjects
with brain cancer (M = -3.85). The most improvement in physical well-being was

reported by subjects with leukemia (M = 9.00).

Table 6. AN OVA Test Results on Improved Physical Well-Being by Type of Cancer.

 

 

 

 

 

 

 

cancer type Mean N Std. Deviation
breast 1.1667 24 4.96655
colorectal 2.0000 1 .
lung 7.5000 2 .70711
ovarian .0000 3 3.00000
brain -3.8500 2 8.69741
melanoma 6.0000 1 .
testicular .5000 2 .70711
lymphoma -.2000 5 3.83406
leukemia 9.0000 2 5.65685
proolale 1.4000 10 2.87518
other 1.6600 10 3.84713
Total 1.4823 62 4.52467

 

77

The test statistics, (see Table 7) of the AN OVA revealed no statistically
signiﬁcant relationship of cancer type to improved physical well-being, but did indicate a
possible trend. The results between groups (df = 8 and MS = 33.418) and the results

within groups (df= 51 and MS = 18.831) revealed F = 1.775 and p = .104.

Table 7. AN OVA Test Statistics of Improved Physical Well-Being by Type of Cancer.

 

 

ANOVA
improved physical well-being
Sum of .
guaree df Mean Square F _ Sig.
267.34 8 33.41 1.775 .104
Within Groups 960.38 51 18.83
Total 127.73 59

 

 

 

 

 

 

 

 

The Kruskal-Wallis nonparametric statistical test (see Table 8) was conducted to
test if the population distribution for cancer types were similar by comparing the sum of

ranks. The results also indicated no statistically signiﬁcant relationship (df = 8, p value =
.3 1 1).

Table 8. Kruskal Wallis Test Statistics of Improved Physical Well-Being by Type of
Cancer.

 

 

Kruskal Wallis
Improved
. physical
Chi-Square 9,337
of 8
Asymp- Si9. .311

 

 

 

 

The results of the statistical testing suggested there may be a trend toward a
relationship between cancer type and a change in physical well-being. The result of the

type of cancer diagnosis inﬂuencing physical well-being would not surprising. For

78

instance, people diagnosed with brain cancer may be at risk for aggressive treatment to an
area of the body that has signiﬁcant inﬂuence over physical and emotional well-being. A
cancer diagnosis such as brain cancer may be accompanied by high-risk treatments or a
poor prognosis for recovery. In comparison, people diagnosed with one of the variety of
leukemia diagnoses may be faced with a more optimistic prognosis. The more optimistic
prognosis based on type of cancer may inﬂuence a change in physical well-being or
perhaps a better functioning level. However, the results do not indicate a signiﬁcant
relationship between type of cancer and improved well-being. The hypothesis was not
supported.
Results 4. 4: Type of Cancer Treatment

The type of cancer treatment was also examined to discover if it inﬂuenced
sample report of improved physical well-being. The types of treatment examined
included no answer, surgery, chemotherapy, radiation, a combination of treatments, and
other treatments. The results of a side-by-side scatterplot, as shown in Figure 13,
examined the sample distribution of mean difference between cancer treatments and

improved physical well-being.

79

 

 

 

 

 

 

 

 

 

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Typeofcancertreatrnent

Figure 13. Side-by-Side Boxplot of Improved Physical Well-Being by Type of Cancer
Treatment.

The results of Figure 13 showed the mean differences between types of cancer
treatments to appear very similar, however, the results also indicated extreme outliers
from the mean.

Table 9. ANOVA Test Statistics of Improved Physical Well-Being and Type of Cancer
Treatment.

 

 

ANOVA
difphysi
Sum of
Squares df Mean Square F Sig.
Wm” 58.032 5 11.606 .546 .741
Within Groups 1190.798 56 21.264
Total 1248.830 61

 

 

 

 

 

 

 

 

The statistical test ANOVA (see Table 9) was performed to determine if type of

cancer treatment inﬂuenced improved physical well-being. The results of the AN OVA

80

indicated p = .741. In addition, due to the extreme outliers ﬁom the mean, the

nonparametric statistical test, the Kruskal Wallis (see Table 10) was employed.

Table 10. Kruskal Wallis Test Statistics of Improved Physical Well-Being and Type of
Cancer Treatment.

Kruskal-Wallis Test

 

 

Test Statistics(a,b)
difphysi
ChiSquare 2.774
of 5
Asymp. Sie- .735

 

 

 

 

a Kmskal Wallis Test
b Grouping Variable: type of cancer treatment

Both the AN OVA and the Kruskal Wallis test (see Table 10) results revealed (df
= 5, p value = .735) that the type of cancer treatment was not statistically signiﬁcant in
relationship to improvement in their physical well-being. It was expected that the type of
cancer treatment a participant was engaged in would effect the perception of improved
physical well-being, particularly given the often tenacious side-eﬁects that can result
from treatment. However, this was not the case and the hypothesis was not supported.

Summary

The results of this study indicated that people in treatment for cancer and
participating in a ten-week exercise program reported statistically signiﬁcant
improvement in both their physical and emotional well-being. The difference in
improvement in physical versus emotional was not statistically significant.

Improvement in physical well-being was examined to explore whether or not the

variables gender, age range, cancer type, and type of cancer treatment inﬂuenced the

81

improvement. The statistical tests reveal that these independent variables did not have a
statistically signiﬁcance effect in the improvement of participants in physical well-being.
However, the type of cancer diagnosis appears to indicate a trend toward a relationship in

the improvement of physical well-being.

82

CHAPTER V

DISCUSSION AND IMPLICATIONS

Overview

Cancer and cancer treatment contribute to a number of negative side-effects that
inﬂuence physical and emotional well-being of people in cancer treatment and diminish
their experience of quality living. Individuals in cancer treatment experience symptoms
that decrease physical function, alter body composition, decrease strength and physical
ability, increase fatigue and emotional distress, and contribute to an overall decrease in
quality of life (Burnham, 2000).

This exploratory study examined the physical and emotional well-being of people
living with and being treated for cancer. Speciﬁcally, the researcher examined the pretest
and posttest results of physical well-being and emotional well-being, after participation in
a ten-week exercise program, as measured by the Functional Assessment of Chronic
Illness Therapy - Fatigue (FACIT-F) for 62 individuals diagnosed with cancer.

This study provides support to the growing body of literature that reports that
during cancer treatment physical activity is beneﬁcial to the quality of life for cancer
patients. Prior to this study, no research was discovered that examined the difference in
pre and posttest scores between the F ACIT- F subsections entitled physical well-being

and emotional well-being. In addition, few studies were located that examined the

83

inﬂuence of gender, age range, cancer type, and cancer treatment on the improvement of
physical well-being.

The quantitative ﬁndings of four hypotheses were examined in this study. The
results of the statistical analyses of hypotheses one and two found the results to be
statistically signiﬁcant. The quantitative ﬁndings of hypothesis three and four were not
statistically signiﬁcant, however, hypothesis 4.3 did suggest a trend.

The ﬁndings show there were statistically signiﬁcant improvements in both
physical and emotional well-being of the participants. In addition, the results revealed
that the difference in improvement between physical and emotional well-being was not
statistically significant. However, using the Cohen’s Effect-size statistical test indicated
that the improvement in physical well-being had a slightly larger effect size and that
therefore the improvement in physical well-being was examined for inﬂuence by the
independent variables, gender, age range, cancer type, and type of cancer treatment.

The variables gender, age range, cancer type, and type of cancer treatment were
explored to see if these variables inﬂuenced an improvement in physical well-being, but
no signiﬁcant relationships were discovered. However, there was a trend toward a
signiﬁcant relationship between improved physical well-being and the type of cancer.

The discussion and implications of this dissertation are presented below. This
chapter includes a summary and discussion of the study’s major ﬁndings, the limitations
of the study, the implications for practice, and policy, recommendations for future study

and concluding remarks.

84

Major Findings
Improvement in Physical Well-Being

Research claims that to achieve a healthy US. population, there must be an
increase in exercise (Brisson & Tudor-Locke, 2004; Morrow, Krzewinski-Malone,
Jackson, Bungum, & F itzGerald, 2004; Vuori, 1995). Exercise is recognized as an
effective prevention method for disease, like diabetes and obesity, and an effective
method in improving the condition of people living with chronic illnesses such as heart
disease. In addition, research asserts that physical activity, when performed on a regular
basis, need not be strenuous to achieve health beneﬁts (N ies & Kershaw, 2002; Vuori,
1995)

For individuals living with chronic illnesses like cancer, this news about exercise
offers hope for physical beneﬁts ﬁ'om exercise because vigorous exercise may not be
well tolerated by people surviving cancer treatment. Moderate physical activity may be
an effective way to improve cancer patients’ quality of life and the lower intensity level
of the exercise program may allow cancer patients to adapt more easily to exercise
programs and so participate more frequently. This study suggests consistent and moderate
levels of exercise, as offered through exercise programs, like “Cancer Wellﬁt,” may
assist cancer patients to experience an improved quality of life through improved physical
and emotional well-being.

The side-effects of cancer and cancer treatments plague individuals and may
result in times of prolonged inactivity. However, it seems clear that this inactivity may
contribute to a decline in physical functioning and fatigue (MacVicar & Winningham,

1986) and that increased low to moderate physical activity, may lead to an increase in

85

physical capacity and functioning. Increased functioning by participation in the Cancer
Wellﬁt program may have been a contributing factor in the patients’ reports of improved
physical well-being and research. Courneya, 2003, suggests that an increase in physical
well-being may lead to an improvement in quality of life.

Although improvement in physical well-being was signiﬁcant after participation
in the Cancer Wellﬁt program, causality cannot be asserted because this study did not
successfully control for the multiplicity of variables inﬂuencing the study participants
during their participation in the ten-week Wellﬁt program. Potentially, participants were
inﬂuenced by a variety of experiences during this study that may have contributed to their
perception of improved physical well-being such as the encouragement and praise of a
support person, a change in diet or appetite, or previous positive experiences with
exercise. In addition, some participants may have had less disabling side—effects from
their speciﬁc cancer diagnosis and type of cancer treatment, allowing them to participate
more fully in the planned exercise sessions of Wellﬁt. Feeling better would also enable
some participants to exercise more on their own between scheduled exercise sessions.
This study, however, provides support for past research ﬁndings (Durak & Lilly, 1998;
Segal, et al., 2003) that suggest a strong relationship between increased physical activity
and improved physical well-being.

Improvement in Emotional Well-being

Emotional well-being improved signiﬁcantly for the participants over the course
of the Cancer Wellﬁt exercise program. Subjects reported improvement in emotional
well-being, a state that is often assaulted by the common emotional side effects of cancer

treatment, fatigue, depression, anxiety, conﬁrsion, body image concerns, and a sense of

86

loss of control over normal activities (Burnham, 2000). The activity associated with the
exercise program appears to have inﬂuenced the improvement of emotional well-being
for the cancer patients participating in the program.

The results of this study support the growing body of research (Courneya &

F riedenreich, 1999; Nies & Kershaw, 2002; Pinto & Trunzo, 2004; Watson & Mock,
2003) that suggests physical activity is inﬂuential for improved emotional well-being.
This area of study is not as well developed as the area examining the relationship
between physical activity and improvement in physical well-being. However, the
evidence is growing that there are emotional benefits for cancer patients involved in low
to moderate physical activity.

A main focus of cancer rehabilitation has been the effort to improve quality of life
and there are currently many interventions available for social workers to assist cancer
patients to cope with the emotional distress related to disease and treatment (Graydon,
1994). Many of the interventions are psychological in nature and include education,
support and therapy groups. The goal of these interventions is to increase quality of life
by decreasing distress and enhancing the coping strategies of cancer patients (Clark, et
al., 2003). Interventions like the Cancer Wellﬁt Program examined in this study, suggest
that this type of exercise program for people in treatment for cancer, may also be a
successful alternative or adjunct treatment to improve the quality of their lives.

Diﬂkrence in Improvement Between Physical and Emotional Well-being

In this study, there was no statistically signiﬁcant difference between the

improvement reported in physical well-being and the improvement reported in emotional

well-being. However, while the differences are not statistically signiﬁcant, the results

87

may be signiﬁcant when examined through the lens of prescribing exercise as an adjunct
therapy for cancer patients while in treatment.

Results of this study have noteworthy implications for health care professionals
and for social workers treating patients with cancer. In addition to the traditional methods
of emotional support currently utilized by social workers, physical activity should also be
considered as an effective support intervention. The results of this study suggest that
crucial indicators of quality of life, physical and emotional well-being, both signiﬁcantly
improved after participation in physical activity.

The complexity of how humans cope and manage to ﬁnd hope makes it difficult
to ascertain the speciﬁcs of the relationship between the perception of improved quality
of life and physical activity. However, improving quality of life may be inﬂuenced by an
increased sense of hopefulness, the perception of personally altering one’s cancer, the
self-directed treatment and care of one’s body, and a change in the sense of isolation with
the cancer (Davis, 2004). It is possible that variables such as the distraction, the potential
social support, and the maintenance of social roles (father, mother, wife, etc.),
independence in the physical activity, or by acting as a “time out” from appointments and
medical treatments may be reﬂected in this improvement in quality of life. The results of
this study support the literature that suggests that physical activity may improve quality
of life in the spheres of both physical and emotional well-being. Courneya et al. (2000)
found that an exercise program for people with cancer “builds conﬁdence, develops new
skills, incorporates social interaction, and takes place in an environment that engages
body and spirit” (p. 54). For individuals able to participate, physical activity is an

important complementary intervention for the experience of emotional distress. People

88

living with cancer may improve in physical and emotional quality of life by increased
participation in low intensity physical activity.

Health care social workers have a unique position in their work with multi-
disciplinary teams in the treatment of cancer. They represent the consistent voice seeking
to balance attention to the treatment of the both physical and emotional health of the
individual with cancer. Exercise and forms of physical activity represent a method to
address both of these domains inﬂuencing quality of life. Further research into the
relationship between increased physical activity and improved emotional well-being
represents a multi-disciplinary frontier in which social workers must be present. Social
workers must offer leadership and assistance in the development and evaluation of
programs that address quality of life issues through physical exercise.

Social workers should consider physical activity as an intervention because there
are beneﬁts from physical activity to cancer patients beyond the improvement in physical
and emotional well-being. For instance, physical exercise is natural in that it does not
require more medication. In addition, the intervention is safe, particularly when
participants experience support ﬁ'om their physicians and when the physical activity
goals are developed within the context of participants’ physical ability. Not one of the 62
participants in the Wellfit exercise program experienced an injury due to participation in
the exercise program. This low level of risk is supported by other studies (Courneya,
2003)

In addition, physical exercise places people living with cancer in a visible position
in society. For example, while the Wellﬁt program was in process, participants with

visible signs of their cancer or cancer treatment came to the health clubs. They

89

participated in exercise with no hair, surgery scars, or while sitting in a wheelchair. They
were present and visible in the weight room, the pool, the shower room, and the aerobic
health room. The inclusion of the ailing within our population ﬁts well with social work
values and ethics. Instead of populations perceived as different being “shunned” or
invisible, exposure to our universal humanity helps break down stigrnatization by society
and reduces shame. Isolation by individuals living with disease frequently separates
community from the reality lived by many societal members. Concrete images humanize
the ﬁequently terrifying concept of cancer for people who live in fear of their own
diagnosis someday.

Inﬂuence of the Independent Variables on Improved Physical Well-Being

This study also sought to discover if the independent variables gender, age range,
cancer type or type of cancer treatment inﬂuenced the improved physical well-being of
participants. The ﬁrst variable the study examined was gender. The results suggest that
men and women did not signiﬁcantly vary in their perception that physical well-being
improved after their participation in Cancer Wellﬁt and the results do not indicate that
one gender experienced a significant improvement in physical well-being more than the
other gender.

This ﬁnding was unexpected because of societal norms for gender. The societal
expectation is that men will perceive improvement in physical well-being signiﬁcantly
more than women if both genders participate in physical activity. This expectation is
based on the antiquated stereotype for proper gender behavior that exists in the United
States. Sports have been and still are considered a male domain (Koivula, 1999). The

gender norm includes the assumption that women prefer therapeutic talk to physical

90

activity and engage in relationships to deal with stress. Studies (Tegerson & King, 2002)
suggest that individuals participate in exercise for different reasons and that the reasons
are related to gender. Tergerson and King (2002) found that women tend to exercise “to
stay is shape”, while men exercise “to become strong.” The expectation was that men
would more eagerly take part in a physical intervention based on their personal
experience with physical activity as a way to strengthen the body and to deal with stress
and report greater improvement in physical well-being than women. The ﬁndings of this
study suggest that both men and women with cancer who were able to engage in physical
activity experienced improvement in physical and emotional well-being during their
cancer treatment. The study also suggests that when doctors, and trainers, and social
workers encourage and support physical activity as a method to feel better physically,
both women and men achieve beneﬁts. The Cancer Wellﬁt program combined physical
activity with conﬁrming and empowering relationships between participants, trainers, and
staff. The impact of these relationships results in trainers thinking about additional
services for people other than athletes or people in relatively “good” health. In addition,
individuals with disease experience the warmth, respect, and personal regard from
trainers. This positive attention encourages participants in their exercise program.
Doctors and other health care providers should therefore include both genders
when recommending low intensity physical activity during cancer course of treatment.
Social workers know that empowerment is associated with expectations that one can
achieve higher levels of self-efﬁcacy. Empowerment is key to health promotion and
disease prevention. In addition, there is considerable support for the idea that social

support plays a major role in prevention and health promotion (Cowles, 2003). It is

91

understood that social support can come from a variety of sources, but the Wellﬁt
exercise group offered social support and contributed to both men and women
experiencing improvement in quality of life. Further study is necessary to understand the
inﬂuential role of social support and the attention of the care providers in improved
quality of life for people living with cancer.

Next, the study examined the inﬂuence of the variable of age range on the
perception of improved physical well-being. The ﬁndings suggest that there was no
relationship between subjects based on age range and improvement in physical well-
being. No speciﬁc age range experienced a more signiﬁcant statistical improvement in
their physical well-being after participation in the Cancer Wellﬁt than any other age
range.

It was expected that older participants would perceive less improvement in
physical well-being than the younger participants. This expectation was based on age
stereotypes that perceive younger participants as more physically ﬁt upon beginning the
program and more experienced with exercise as a health intervention than the older
participants. However, the study suggests that despite age, when the beliefs and
expectations are related to the capability of successﬁrlly executing necessary courses of
action to satisfy the situational demand, people will participate willingly in an exercise
program. Bandura (1986) emphasizes that self-efﬁcacy can inﬂuence health-related
behavior, including physical activity. Individuals with high self-efﬁcacy expectations
tend to approach more challenging tasks, put forth more effort, and persist longer in the

face of barriers (Mculey, Katula, Mihalko, Blissmer, et al., 1999). Research suggests that

92

self—efficacy is a key predictor of whether older adults, as well as other age groups, will
adopt and maintain physical activity (Netz & Raviv, 2004).

The results suggest that all adult cancer patients, regardless of age range, who
were able to engage in physical activity experienced improvement in physical well-being
during their cancer treatment. Disease may be a powerful equalizer in regard to age.
While further research is necessary in this area of study, ﬁndings suggest that physical
activity, tailored to the level of ability, supports successful participation in exercise
programs and may inﬂuence perceived improvement in physical well-being. Doctors and
other health care providers should include adults of all ages with cancer when
recommending physical activity during the course of cancer treatment.

Next, the study examined the inﬂuence of the variable of cancer type. The results
of this analysis suggested that the type of cancer diagnosis may mildly inﬂuence the
perception of improved physical well-being for a person participating in an exercise
program. Speciﬁcally, the results were based on the examination of the types of cancer
examined in this study, breast colorectal, lung, brain, melanoma, testicular, lymphoma,
leukemia, prostate, and the category “other”. Due to insufﬁcient data (only one
participant with the speciﬁc cancer diagnosis) colorectal and melanoma were not
included in the statistical analysis. The ﬁndings suggest that brain cancer patients were
somewhat less likely to experience signiﬁcant improvement in physical well-being than
other cancers. In addition, subjects with a diagnosis of leukemia were somewhat more
likely to experience improvement in physical well-being.

The results suggest that certain types of cancer inﬂuence the impact of physical

activity as a successful intervention for improved physical well-being more than others.

93

Perhaps the more invasive cancers or the stage of a cancer interferes with signiﬁcant
quality of life issues and is a barrier to effective interaction with physical activity. For
example, during the Wellﬁt program, a participant came to the health club who was
diagnosed with brain cancer. During the course of the program, her health and strength
and ultimately her prognosis worsened. The participant had a support person to assist
with her wheelchair and she continued to participate in very low intensity physical
activity. It seems unlikely that this individual would report an improvement in physical
well-being at the end of the ten-week program.

On the other hand, at least 1 participant reported to a trainer that the Wellﬁt
program had dramatically inﬂuenced his improved physical well-being and that “good
reports” from the doctor were evidence of the physical improvement. In both examples, it
seems likely that a powerful inﬂuence on the perception of physical well-being was the
type of cancer, or perhaps the stage of the cancer, and not the Wellﬁt program alone.

The effect of a type of cancer diagnosis on the improvement in physical well-
being needs to be studied based on subjects with a shared type of cancer diagnosis and
current research supports this claim (Courneya, 2001). Doctors and health care providers
may ﬁnd cancer patients with certain types of cancer are less able to beneﬁt from an
exercise program during their cancer treatment, but perhaps there is still some advantage
to participation. The ﬁndings call for increased research in the area of study pertaining to
speciﬁc types of cancer, physical activity and quality of life.

Finally, this study examined the inﬂuence of the variable, type of cancer
treatment, on the report of improved physical well-being. The ﬁndings suggest that based

on type of cancer treatment, there was no statistically signiﬁcant difference in improved

94

physical well-being between types of treatment. Subjects did not signiﬁcantly vary in
their report that physical well-being improved after their participation in Cancer Wellﬁt.
This ﬁnding promotes the idea that despite type of cancer treatment, adult cancer patients
who were able to engage in physical activity experienced improvement in physical well-
being during their cancer treatment. Doctors and other health care providers should
consider being inclusive of cancer patients receiving a variety of cancer treatments when
recommending physical activity during the course of treatment. Further research is
necessary in the study of the inﬂuence of type of cancer treatment, increased physical

exercise and improved physical well-being.

Implications
Practice Implications
The results of improved emotional well-being after participation in physical
activity has significant implications for social workers. The design of interventions for
many social workers in primary health care settings are in direct service roles and are
likely to include provision of counseling and linkage to community services (Cowles,
2003). Support groups are frequently viewed as an active way to engage patients to take
an active role in their health care. Support groups for people sharing a common physical
disease are not uncommon. This is a traditional intervention for social workers practicing
in clinical oncology. However, the results of this study imply that a physical intervention,
such as an exercise program, may offer patients an additional active role in their health

care.

95

Cowles (2003) suggests that the mental, physical, and social health of an
individual affect each other. For instance, depression may cause biochemical changes that
impair the immune system and increase susceptibility to disease. Depression related to
social isolation can contribute to the inability to concentrate and to increased injury or
accident. On the other hand, disease can produce strong adverse emotional reactions due
to actual or perceived threat to a normal social role. Because of the interaction of
biopsychosocial spheres, high quality health care requires simultaneous examination and
treatment of the whole person and this examination must include the physical symptoms,
emotional states, social and physical environment conditions, cultural inﬂuences, and
cognitive interpretations (Cowles, 2003). Social workers are trained in the examination
and assessment of human behavior within a social environment. The implementation of
holistic assessments is a critical role best done by professionals with this training. A
biopsychosocial assessment potentially steers an accurate and healthful intervention plan.

The Wellﬁt program appears to be a productive method of treatment for the
emotional side-effects due to cancer treatment, in part, because of the balance of attention
to the psychological, the biological and the social needs of the patient. The programmatic
blend of individually tailored and supervised exercise with the talking, listening, and
group support, served to beneﬁt the biopsychosocial needs of the participants.

An important element of group interventions is the inﬂuence of the care-givers or
support persons. This phenomenon is called the “attention effect” and is frequently
experienced by people experiencing dependency due to illness (Ross & Mirowski, 2002).
Research suggests that social support consistent with what the individual needs has been

empirically shown to buffer the stress impact of some diseases and life experiences

96

(Hoffman, 2000). Attention, as offered in traditional counseling groups or within exercise
groups, may assist in the alleviation of cancer related stress. Exercise groups, like any
kind of support groups, are conducted and supervised by various professionals and as one
might expect, personalities and personal philosophies vary greatly. Although the
inﬂuence of the trainer on the subjects was not examined in this study, it seems likely that
the trainer, and other social support providers inﬂuenced the participants’ perception of
improved physical and emotional well-being. For instance, an empathic and attentive
trainer could possibly create participant feelings of being cared for, supported, and
encouraged, and thus feeling an overall improvement in their well-being.

The role of the supportive relationship between the professional trainer and other
health care professionals and the cancer patient may inﬂuence the patient’s perception of
improved quality of life. Also, the addition of physical activity may complement
traditional interventions and offers participants a sense of independence, self-efﬁcacy,
and mutual aid. The exercise groups offer participants with cancer concrete examples of
others coping with cancer both physically and emotionally. While differences exist
between individual coping styles based on the variable gender, age range, race and
ethnicity, cancer diagnosis and type of cancer treatment, there may be commonalities in
the human experience with disease that lends a sense of mutuality.

Finally, the results suggest a need for social workers to be active in the formation
of interdisciplinary groups as an approach to cancer treatment. Multidisciplinary groups
are a common way for social workers to practice, but interdisciplinary groups are unique.
Cowles describes an interdisciplinary group as having four distinctive features. The

features include (1) small group size, (2) the operation of small-group dynamics or

97

bonding, (3) shared decision-making, and (4) more frequent, regular, and direct face-to-
face communication. The rationale for interdisciplinary groups in the treatment of cancer
is that multiple systems of knowledge and skill serve to maximize efﬁcacy and
effectiveness. The result is both a treatment that works well and costs less. Patients being
treated for cancer will beneﬁt from the increased partnership with experts ﬁ'om all
spheres including the biological, the social, and the emotional.

This study suggests that creative and successful interventions created to improve
patient quality of life are possible with teamwork. The national health care trend toward
chronic disease case management, the need for greater coordination and cooperation
across professional services and informal social supports is vital to know and understand
because it is the future of health care. Social workers can offer a variety of skills in the
leadership of interdisciplinary teams because social workers are trained to assess
individuals using a biopsychosocial model. They are knowledgeable about social policy
and programs, understand and practice evidence based theories and methods and are
prepared to design and implement the evaluation and research process.

Policy Implications

Health care in the United States is in turmoil. It is the most expensive care in the
world and the examination of current health care strategies is vital. Clearly, the US.
health care system is at a crossroads (Cowles, 2003). While cost effectiveness of health
care interventions is frequently recognized as a vital issue, the United States health
system continues to prefer treatment instead of prevention (Dobelstein, 2003). Questions
about delivery of services and alternative treatments drive national discussions about how

effective treatment can be delivered in the least expensive manner possible. Exercise

98

programs for populations with chronic illness may be an effective and efﬁcient
alternative treatment.

The results of this study suggest that the role of exercise and increased physical
activity in the treatment of the physical and emotional effects of cancer and cancer
treatment may assist in improvement of, or perhaps prevention of the side-effects
associated with cancer. This study took place in a community health center and was
funded through a private grant. However, many hospitals and communities have access to
community centers or health centers. Exercise as a prescribed intervention could be
ﬁmded or covered by health insurance as an alternative to or as an in-home treatment.
Low intensity physical activity is an intervention that can be practiced by patients in
cancer treatment in home, church, school, or community center settings. As with other
forms of group therapy, the cost for provision of services is lessened by the participation
of multiple members.

Emerging trends in health care delivery shift care ﬁ'om the hospital in-patient
setting to the community as the center of health care delivery, increase emphasis on the
health care market and cost control, increase emphasis on the measurement of outcomes
related to health care interventions and increased patient participation in health care
decisions (Cowles, 2003). In addition, there is a trend toward gradually transforming
once terminal health problems into more chronic long-term care issues. These trends,
along with the growing expectation that families and individuals will have to do more of
the care-giving of the sick, strengthen the need for innovative programs like cancer

exercise groups. As experienced case-managers, social workers have an integral role to

99

play in both the development and maintenance of physical and emotionally supportive
health care programs.

Health care policy and government funding for the inclusion of exercise as an
inﬂuential tool in the treatment of physical and emotional side-effects of cancer, the
diagnosis and treatment, gives patients and cancer treatment specialists an inexpensive
and effective alternative. Physicians and human service workers, such as social workers
and psychologists in conjunction with physical trainers, may prescribe physical activity
as an opportunity for cancer patients to be physically and emotionally involved in their
cancer treatment in a way not offered by such treatments as radiation and
chemotherapies.

The National Association of Social Workers (NASW) NEWS has reported on a
number of recent studies from the National Institutes of Health and National Academies
with the common theme of “the need for emphasis, not just on medical interventions, but
on the social, cultural, economic, family and community factors in prevention and
treatment of health conditions” (O’Neill, 2001 , p. 3). As a response to this need and
because of the values and ethics of the social work profession, social workers ought to
consider what is really needed for lasting change and improvement in our health care
system. Cowles (2003) offers a number of goals for social workers which include, (1) the
elevation of the health status of populations, (2) the reduction of social inequality, (3)
increased ﬁmding and programs for health promotion and disease prevention, (4)
improved quality and accessibility of publicly supported care services, (5) promotion in
social work of more research of an experimental design nature to develop a solid body of

effective social work interventions in health care, and (6) further development of a body

100

of knowledge about the social and environmental determinants of disease and about
effective interventions to promote health and prevent disease at a population level.

The work ahead for social work is immense and must be multi-pronged. To
engage in these tasks, graduate schools must offer health care education and the
education must be extensive in terms of the number and range of classes. Classes in
health care must be contemporary, relevant and reﬂect the reality of today’s health care
system. Population speciﬁc education targeting the disenfranchised and people living
with chronic illness and stigma would infuse social workers with important knowledge
for health care program assessment, development and evaluation. Social workers must
prepare for the realities of the complex nature of health insurance and national health care
policy. Social work graduate schools must create and maintain ﬁeld education
experiences for social work students in health care settings. The settings should include
both ambulatory care settings and in-patient facilities. Most importantly, social workers
must continue to learn how to perform evaluation and research on health care
interventions. This dissertation is an example of how pre- and post-intervention testing
adds to the body of practice knowledge.

Limitations of the Study

There are several limitations to this study that are essential to note. The
limitations are clustered in terms of study design and confounding factors.

First, the credibility of an outcome study depends, in a great degree, on the
sample size (Montcalm & Royse, 2002). The sample of participants in this study was 62
and this size sample increases the validity of the testing in comparison to other published

studies where sample sizes were smaller (Courneya & Friedenreich, 1999). However, the

101

sample, when examined by a range of cancer types, excluded certain cancer types from
meaningful representation because of small group size such as melanoma (N = 1) and
offered other cancer types such as breast cancer (N = 24) larger representation.

An additional study design limitation was sampling error. First, the sample for
this study was not random. The study relied on the participation of people often
exhibiting signiﬁcant side-effects from cancer and treatments. The ﬁrst concern was the
health needs of the subjects. Subjects ﬁ'equently requested assignment to a speciﬁc
exercise group because of a more convenient or reasonable start date. This allowance
offered subjects an opportunity to schedule around tough medical therapies or extended
visits to or from family and ﬁiends. It interfered with the original plan to assign
participants to the next available group based on the date they signed up to participate in
Wellﬁt. This adjustment may have altered results by surviving participants when they felt
better, more rested, or were assured of social support of loved ones.

In addition, the sample was referred from physician offices in West Michigan.
This fact limited the sample of cancer patients geographically, but perhaps also
economically. The offices referring patients to the research study all practice from ofﬁces
that accept minimally or do not accept Medicaid or other forms of public assistance and
insurance as the primary method of payment. This means that patients being treated for
cancer in neighborhood clinics or those unable to afford any cancer treatment are not
included in the sample. The ekclusion of clinics and other environments may have
affected the economic, racial and ethnic composition of the sample.

The present study does not examine the variable of race and this exclusion calls

for comment. The absence of racial diversity in the sample was a signiﬁcant, although not

102

 

a totally unexpected, limitation. Of the 75 participants initially enrolled in the study, only
two noted being of a race other than Caucasian. This variable, because of the lack of
racial diversity among the subjects, was not selected for further study at this time.
However, the fact representation from racial/ethnic minorities was so small is worth
noting, and should be considered along with socioeconomic class in future studies.

Research suggests (Murthy, et al., 2004) that minorities are faced with barriers to
clinical trials and other forms of health initiatives. First, minorities are subject to ongoing
patterns of discrimination and this results in a distrust of the health care system. Second,
given the history of unethical and exploitive clinical studies including minority members
in the past, minorities are likely to have signiﬁcant concerns about exploitation,
dishonesty, and the motivation of the researchers. Third, minority patients may be offered
access and information regarding clinical trials and health initiatives less oﬁen than
Caucasians. In addition, socioeconomic factors may be a barrier to participation, perhaps
lacking access to health care in general. Social and cultural barriers may play a role in
enrolhnent in health studies. Language, culture, and customs may interfere with social
comfort in health study participation (Murthy, et al., 2004).

Populations who are not represented in clinical trials, but are treated using the
results of clinical trials are at risk of harm. “It has been promulgated that ‘appropriate’
representation of speciﬁc patient subpopulations is necessary to further understanding of
race/ethnicity based diﬂerences in presentation, prognosis, and response to therapy”
(Murthy, 2004, p. 2726). The lack of racial diversity in this study interferes with the

applicability of the results to more than Caucasians.

103

Moreover, the dissertation studied the results of one treatment group. The ﬁndings
regarding the physical intervention would be stronger if they were compared to a second
non-intervention group. The exploration of a comparison between two groups would
better identify the inﬂuence of the Cancer Wellﬁt program as a determinant in
improvement of physical well-being. This, however raises a potential ethical dilemma in
that one group would not receive an intervention that was hypothesized to be helpful in
their treatment.

The short ten-week time period of the Cancer Wellﬁt program was also a

limitation. Additional confounding factors in this study were related to the different types

 

of cancer and types of cancer treatments the subjects were experiencing. Various cancers
and their accompanying treatments inﬂuence the body in different ways. Perhaps, the
more tenacious the cancer, the higher the cancer stage, and the more vigorous the cancer
treatment, the more challenging it is for a cancer patient to experience an improvement in
physical and emotional well-being. The variation in the severity of the cancer was not
controlled for in this study.

Lastly, as with all intervention research, there are potential threats to internal
validity. Because this was not a controlled laboratory study, there may have been other
variables, in addition to exercise, that inﬂuenced the subject’s perception of improved
physical and emotional well-being. For example, the time and vigor of exercise of the
subjects independent of the study was not controlled for in the statistical analysis.
Differences in physical activity during the exercise program could have occurred due to
individuals’ experience using exercise as an intervention in their pre-cancer lives or due

to natural individual variations of activity in daily living.

104

Recommendations

First, research into increasing the frequency of an exercise program being used as
an intervention due to cancer diagnosis ﬁts well with the call from the public for
complementary and alternative interventions in addition to, or in place of, medical
interventions. It is well established and highly researched that physical activity results in
a wide range of health beneﬁts (Oweis & Spinks, 2001).

Second, the cancer and exercise intervention research agenda ﬁts well with the
social push to control health care costs. An exercise program is a potentially low-cost
intervention for both physical and emotional well-being. Social workers must continue to
do research on the effect of low to moderate exercise on the physical and emotional well-
being of people being treated for cancer.

Third, the study of exercise as an intervention would beneﬁt by continued
examination of this intervention in the treatment of other chronic illnesses. As citizens in
the United States experience an increase in life expectancy, many live longer, and many
live with and potentially die ﬁ'om a chronic illness. Exercise programs may be useful in
inﬂuencing improvement of physical and emotional well-being for more of the many
chronic illnesses.

In addition, it is unknown whether or not any differences in ﬁtness outcomes
would have been evident had the exercise treatment continued beyond the ten-week
duration of this study. More studies are needed to evaluate the effectiveness of a similar
exercise program over a longer period of time and with a larger population of cancer

survivors.

105

Finally, participants in exercise programs living with cancer may experience an
increase in hope when they are supported in their efforts to survive their disease.
Research into the relationship between empowerment and increased physical activity may
suggest that this intervention offers a unique way for cancer patients to personally
participate in their cancer treatment. Exercise may be a unique way for a person with
cancer to be involved in their treatment in a way that is not possible with the more
common interventions of chemotherapy, radiotherapy, and surgeries. Further research is
necessary to examine the relationship between independent variables of gender, age
range, types of cancer and cancer treatments and the experience of improved physical
well-being and increased physical activity. Results may indicate that a safe, natural, and
self-directed intervention to improve quality of life is within the grasp of the people
living with cancer.

Conclusion

Physical and emotional symptoms of distress are present in cancer patients due to
their diagnosis and treatment. This distress is present in the lives of thousands of people
living in the United States. The symptoms of cancer and cancer treatment affect both the
individual with the cancer as well as the family and community caring for and supporting
them.

This study has presented and examined the results of an exercise program
developed and administered to 62 people living with cancer. For most of the subjects, this
study offered a unique way for them to practice self-efficacy through participation in

their treatment and helped improve their perception of physical and emotional well-being

106

Overall, the ﬁndings of this study support the claim made by previous researchers
that the physical and emotional disruption of well-being injures quality of life.
Improvement in quality of life for people living with cancer may be inﬂuenced by their
participation in an exercise program. Furthermore, it suggests that cancer patients may
perceive similar improvement in both physical and emotional well-being. The results
suggest that both men and women, adults from all age ranges, with a variety of cancers,
receiving a variety of cancer treatments, may all beneﬁt similarly ﬁ'orn increased physical

activity and experience an improved quality of life.

107

 

APPENDICIES

108

 

APPENDIX A

LANCE ARMSTRONG FOUNDATION GRANT

109

FOR IMMEDIATE RELEASE

Contacts:

Bianca E. Rodriguez

Director of Communications and Outreach
Lance Armstrong Foundation

(512) 236-8820 x103

LANCE ARMSTRONG FOUNDATION AWARDS COMMUNITY SERVICE
GRANT TO MICHIGAN NON-PROFIT TO ENCOURAGE CANCER
SURVIVORS TO GET FIT

AUSTIN, Texas — July 16, 2003 - The Lance Armstrong Foundation (LAF) recently selected

the Cancer Center at Saint Mary’s Mercy Medical Center in Grand Rapids, Mich., as a partner for
its 2003 Community Program. A grant from the LAF will further St. Mary’s work to help cancer
survivors with, through, and beyond cancer by promoting health and ﬁtness.

The grant from the LAF will enable the continuation and expansion of Cancer Wellﬁt, a free, 10
week program. The only structured exercise program of its kind in the community, Cancer Wellﬁt
focuses on individualized progressive strength training and aerobic and ﬂexibility exercises and
promotes an environment of mutual support and encouragement among participants. The program
offers 20 supervised exercise sessions for adult cancer patients and their primary supporters, who
play an important role in encouraging and motivating their lived ones to engage in an exercise
program.

“This project will provide a structured exercise program for those with cancer, and for a
supporter they designate. Exercise has demonstrated value for many with cancer in terms of
strength, stamina, and mood. We believe that by also providing exercise opportunities to key
supporters, their quality of life will improve and they will be more effective supporters as they
walk through the cancer experience with those they love,” said Mark Eastburg, director of

research and psycho-oncology.

110

As part of its 2003 Community Program, the LAF partnered with a variety of
organizations that provide programs that are positively impacting the quality of life today for
those living with, through, and beyond cancer. The LAF awarded more that $605,000 in grants to
43 community non-proﬁt organizations across the country, representing 22 states and
Washington, D.C. The LAF seeks to fund innovative projects, such as these, that promote the
optimal physical, psychological, and social recovery and care of cancer survivors and their loved
ones. Through their unique work these organizations address the following survivorship issues:

adolescent/young issues, physical activity and survivorship education.

About the Lance Armstrong Foundation

 

Founded in 1997 by cancer survivor and champion cyclist Lance Armstrong, the lance
Armstrong Foundation exists to enhance the quality of life for those living with, through, and
beyond cancer. The LAF seeks to promote the optimal physical, psychological and social
recovery and care of cancer survivors and their loved ones. The LAF focuses its activities on
survivor resources and support, community survivorship programs, national advocacy initiatives,

and scientiﬁc and clinical research grants. For more information, call the LAF at 512-236-8820.

About the Cancer Center at Saint Mary’s Mercy Medical Center

At The Cancer Center at Saint Mary’s, it’s our mission to provide state-of-the-art,
effective, and personal care for cancer patients, their families, and their community. We work as a
team of competent and compassionate practitioners committed to the treatment of cancer’s effect

on mind, body, and spirit. For more information call the Cancer Center at 616-752-5222.

###

111

APPENDIX B

PATIENT INFORMATION AND CONSENT FORM

 

112

Patient Information and Consent Form

Title: An Exercise Program for Cancer Patient and their Primary
Supporters to Improve Quality of Life

Sponsor: St. Mary’s Mercy Medical Center
Grand Rapids Clinical Oncology Program

Investigator: Dr. T. Gribbin m.

This consent form may contain words that you do not understand. Please ask
your doctor or the study staff to explain any words or information that you
may not understand.

 

Bac round I

You are being asked to take part in a research study. The purpose of this study is to
examine the effect of exercise on the physical and emotional health of a person diagnosed
with cancer and their support person.

Before you decide whether or not to take part in this study, we would like to explain
several things to you. This form will:

- explain the purpose of this study

- explain how this study may help you

- tell you how this study will be done

- tell you about any risks that may be involved in taking part of this study
- tell you what will be expected of you during this study

Purpose of this Study

The purpose of this study is to improve the health and lives of the citizens of Michigan.
We want to do this by improving the physical and emotional health of people who have
been diagnosed with cancer and their support person.

We want to improve the physical and emotional health of people diagnosed with cancer
and their support person by offering a lO-week exercise program. The physical problems
cancer patients may experience include fatigue and nausea. The emotional problems
cancer patients and their support persons may experience include depression and social
isolation. These emotional and physical problems, when combined, may lead to a less
enjoyable quality of life. We want to ﬁnd a way to reduce these problems. There will be
about 70 patients in the study.

113

Estimate of Time Involvement

You will be asked to answer questions in four short surveys before the exercise program
and after the exercise program. The surveys will be lists of questions that have several
answers for you to chose from. You will select the answer that seems right for you. There
are no right or wrong answers to the questions. The answers to the questions will help us
ﬁnd out how people with cancer and their support person feel emotionally and physically
before the exercise program and after the exercise program. You will also complete a
brief physical assessment.

The exercise program will be designed and monitored by certiﬁed trainers at one of two
health clubs in Grand Rapids, Michigan. The trainer will carefully work with you to
develop an exercise plan that matchers your ability. You will be asked to participate in an
exercise class 3 times a week.

The surveys will take about 30 minutes at the beginning and at the end of the study. The
exercise will take at least 60 minutes once a week.

Your Rights

This consent form gives you information about this research study. You will be able to
discuss the study with the study staff before you will be asked to sign the consent form. If
you agree to do the study, then you will sign the consent form. You will receive a signed
copy of the consent form to keep for your records. If you do not want to join the study,
you do not sign the consent form.

You need to know that:

- Your taking part in this study is voluntary

- You may decide not to take part in this study. You may also decide that you
no longer want to take part in this study after it has begun. You may stop the
study at any time without losing the beneﬁts of your medical care.

- If you do want to take part in this study, you may refuse to answer any
questions you do not want to answer without penalty. You may also refuse to
participate in any exercise or physical activity at any time without penalty.

- You will be told about any changes in the study. If changes occur, you may be
asked to sign a new consent form.

Confidentialig

Your medical records and any records generated in this study will be conﬁdential to the
extent permitted by law. You will be identiﬁed by a code. Personal information about
your records will not be released without your written permission and will be kept ina
locked and secure environment. You will not be personally identiﬁed in any publication
about this study.

114

Eligibility

You must meet certain standards to take part in this study. You must speak English or
Spanish to participate and you must be able to consent to be in this study. Your physician
must consent to your partidipation in this study. You will not be able to participate if you
have any physical conditions that might put you at any risk.

Risks and Discomforts

We do not anticipate any more risks for you during this study thanyou would experiences
if you were involved in any supervised exercise program. If you should experience pain,
bleeding, nausea, shortness of breath, or persistent soreness, please report this to your
physician or physical trainer.

Payment for Medical Care and Iniugy Related to This Study

Physical injury related to this study is not expected, but possible without any fault of you,
the study staff, the clinic, hospital, or health club. If you are injured as a result of your
participation in this research project, Saint Mary’s Mercy Medical Center will provide
emergency medical care if necessary. If the injury is not caused by the negligence of
Saint Mary’s Mercy Medical Center, you are personally responsible for the expense of
this emergency care and any other medical expenses that happen as a result of this injury.

ngal Rights

The above section does not take away your right to seek legal assistance.

Benefits of This Study

We hope to gain facts about the effect of exercise on the physical and emotional quality
of life for people who have cancer and their support person and by identifying these facts,
improve their life.

Additional Information

You will be asked for your consent if you complete any of the surveys before or after the
exercise program. You will also be asked for your consent to participate in the Wellﬁt
exercise program. If you do not want to participate in the surveys or in the exercise
program, then do not sign the consent form to complete a survey or to participate in the
exercise program.

Your decision to take part in this research study is completely voluntary. There will not
be any penalty or loss of beneﬁts to you if you decide not to take part. In addition, you

115

 

may withdraw from the study at any time. If you decide to withdraw from the research
study, there will be no penalty or loss of beneﬁts to you.

Costs to You

There is no cost to you for this study.

Questions or Research Related Problems

For questions about research and your rights as a patient in this study, contact:
Sister Myra Bergman at the IRB (Telephone - 616-752-6567).

Statement of Consent

I consent to take part in this research study. My taking part is completely voluntary. I
may decide not to allow myself to take part or to withdraw myself form the study at any
time without penalty or loss of beneﬁts to which I am entitled. This study may be stopped
without my consent by the doctor conducting the study, or by study staff.

I have opportunity to ask the study staff questions about this study and have received
satisfactory answers to all my questions in a language I can understand. I will have the
opportunity to have all my future questions answered in a satisfactory way in a language I
can understand. I will be given a signed copy of the consent form. I understand the
conditions and procedures and I know what the possible risks and beneﬁts are from
taking part in this research study. I do not give up my legal rights by signing this form. I
give my voluntary informed consent to take part in this research study.

116

The Wellfit Exercise Program

My initial and signature below indicates release of St. Mary’s Mercy Medical Center and
any of their agents, directors, subsidiaries, officers, employees, or instructors ﬁ'om and all
claims, costs, liabilities, expenses, judgments, including legal fees and court costs I may
have against the same for injuries, of any nature whatsoever, sustained by me as a result
of my participation in the Exercise and Wellness Program for cancer Patients in which I
am enrolling.

I also acknowledge the following:

1.

My physician will be consulted before my participation in this study. He/She will
clear me for exercise medically, and his/her permission will be obtained to
perform the routines I this study.

I agree to limit my participation to the level of activity that is tolerable to my
physical condition and medical situation at that time. i

I understand that I am waiving and releasing St. Mary’s Mercy Medical Center
and their agents, directors, subsidiaries, ofﬁcers, employees, or instructors from
any legal fees and court costs arising out of participation in this program. I further
agree to indemnify and hold harmless ﬁ'om any and all claims the sponsoring
facility.

This represents that I am participating in this program for the purpose of
improving my overall health, and not with the intent to teach this program on my
own or for a similar organization. I further represent that I am not presently
employed or associated with another company or organization that conducts
programs similar to this program. I understand that all materials and exercise
routines are the exclusive property of Medical Health and Fitness, and I will not
make use of the information and/or instructions except for personal use.

I understand that I would not be accepted on this study without the execution of
this waiver and release.

I acknowledge that I have read and understand this waiver and release.

117

APPENDIX C

PHYSICAN RELEASE OF INFORMATION

 

118

Physician Release of Information

This information allows us to obtain permission ﬁom your physician to participate in the
Cancer Well/it Progam, and allows us to obtain information that will be used as part of
the program evaluation (if you have agreed to participate in the stuabz).

By my signature, I authorize the release and exchange of any medical or other
information necessary for my treatment and/or involvement in the Exercise and Cancer
Study implemented by St. Mary’s Mercy Medical Cancer Center and East Hills/Michigan
Athletic Clubs.

 

 

P
Patient’s Name (type or print) Patient’s Signature Date :
Your address: l
Home Phone Work Phone

 

 

 

Other medical conditions you have (besides cancer):

 

Your Age: Your Race/Ethnic background:

 

My Oncologist’s name is:

 

My Primary Care Physician’s name is:

 

Address:

 

Phone Number:

 

Supporter Name/Phone Number:

 

Relationship to You (circle one): Spouse Child Sibling Friend

 

Witness’ Name (type or print) Witness’ Signature Date

119

APPENDIX D

CANCER WELLFIT TRAINING AND EDUCATION SCHEDULE

120

-3

b I:

u-m‘x .(‘TT'Zw—xmﬂt .

t:

 

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

WELLF IT

TRAINING AND EDUCATION SCHEDULE

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

Meet in conference room

Complete standardized testing

Introduction of instructors, the program, and participants
Tour of the facility

(2 trainers and 1 director)

Testing - heart rate, blood pressure, height weight, waist
and hip measurements, Harvard step test, and the prone
hover (4 trainers and 2 directors)

Meet with trainers for one-hour exercise session
Handout on the beneﬁts of cardiovascular exercise

Cardio setup/biomechanical assessment, group core
(2 trainers and l director)

Cardio setup/biomechanical assessment and/or strength
setup, group core (2 trainers and 1 director)

Meet with trainer for one-hour exercise session

Handout on beneﬁts of strength training, info on increasing
weight and repetitions

Strength set up group (to include leg press, chest press, &
rowing)

Strength/group core (2 trainers and 1 director)

Meet with trainer for one-hour exercise session

Handout on the beneﬁts of nutrition, info on importance of
Nutrients

Strength/group core (2 trainers)

Nutrition (1 dietitian)

Meet with trainer for one-hour exercise session

Handout on the importance of core strength with examples
for home

Strength/group core (2 trainers)

Strength/ group core (2 trainers)
Handout on stress reduction/relaxation techniques

Strength/ group core (2 trainers)

121

Week 7

Week 8

Week 9

Week 10

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

(Day 1)

(Day 2)

Strength/ group core (2 trainers)
Handout on mind/body medicine and info on yoga/pilates

Strength/group core (2 trainers

Yoga/Pilates specialty class (1 GF instructor)
Handout on home strengthening program

Strength/ group core (2 trainers)
Strength/ group core (2 trainers)

Handout on home stretching program
Meet with trainer for one-hour session

Strength/group core (2 trainers)

Strength/group core (2 trainers)
Handout on putting it all together and journaling goals

Strength testing for leg press, chest press, rowing, & hover
step test (2 trainers and 2 directors)

Assessment of heart rate, blood pressure, height, weight,
hip measurements, and the Harvard step test
Standardized testing

(2 trainers and 2 directors)

122

APPENDIX E

MSU HUMAN SUBJECTS REVIEW APPROVAL

123

MICHIGAN STATE

UNIVERSITY

 

October 17, 2003

TO: Rena HAROLD
232 Baker Hall

RE: IRB# 03-817 CATEGORY: EXEMPT 1-4

APPROVAL DATE: OctOber 16. 2003
EXPIRATION DATE:September16, 2004

TITLE: AN EXERCISE PROGRAM FOR CANCER PATIENTS AND THEIR PRIMARY
SUPPORTERS TO IMPROVE QUALITY OF LIFE

The University Committee on Research Involving Human Subjects' (UCRIHS) review of this

project is complete and I am pleased to advise that the rights and welfare of the-human

subjects appear to be adequately protected and methods to obtain informed consent are

appropriate. Therefore, the UCRIHS approved this project.

RENEWALS: UCRIHS approval is valid until the expiration date listed above. Projects
continuing beyond this date must be renewed with the renewal form. A maximum of four such
expedited renewals are possible. Investigators wishing to continue a project beyond that time
need to submit a 5—year application for a complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human subjeCts, prior
to initiation of the change. If this is done at the time of renewal, please include a revision form
with the renewal. To revise an approved protocol at any other time during the year, send your
written request with an attached revision cover sheet to the UCRIHS Chair, requesting revised
approval and referencing the project's IRB# and title. Include in your request a description of
the change and any revised instruments, consent forms or advertisements that are applicable.
PROBLEMS/CHANGES: Should either of the following arise during the course of the work,
notify UCRIHS promptly: 1) problems (unexpected side effects, complaints, etc.) involving
human subjects or 2) changes in the research environment or new information indicating
greater risk to the human subjects than existed when the protocol was previously reviewed and
approved.

If we can be of further assistance, please contact us at (517) 355-2180 or via email:
UCRIHS@msu.edu. Please note that all UCRIHS forms are located on the web:
http://www.humanresearch.msu.edu

Sincerely,

742/422

Peter Vasilenko, Ph.D.
UCRIHS Chair

124

APPENDIX F

CANCER WELLFIT PHYSICIAN NOTIFICATION

'LLL .

125

Wellﬁt Exercise Program for Cancer Patients
Physician Notiﬁcation for Participation

Dear Dr.

 

Your patient , has asked to enroll in the Cancer Wellﬁt
Exercise Program offered by the Cancer Center at St. Mary’s in conjunction with East
Hills/Michigan Athletic Clubs. Recent studies have shown that many people with cancer
experience physical and emotional beneﬁts from participating in a structured exercise

program.

Cancer Wellﬁt is a recreational exercise program speciﬁcally designed for cancer
patients. The program has been used successfully for several years with hundreds of
cancer patients in Santa Barbara, California. It emphasizes strength, ﬂexibility, and
aerobic training, individually tailored to the patient’s capacity.

Before proceeding, we wanted to make sure that there were no medical concerns that you
would have regarding your patients’ participation. We would appreciate your help by
answering the following questions.

Cancer Diagnosis Stage
Current Treatment
_Surgery _ Radiation Therapy _ Chemotherapy _ Other

Goal of Cancer Treatment
_ Adjuvant _ Curative _ Palliative

Do you have any concerns regarding this patient’s participation in Cancer Wellfit?

 

Some patients enrolled in the program have agreed to participate in a study that will track
their response to the program. Check here is you would like to be sent the results of the
study when it is complete. Yes, please send me a copy of the results

 

 

Physician Signature Date

Please FAX or return this form to Rebecca Philbrook at The Cancer Center at St. Mary’s,
616-752-5260

126

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