ANDREWS UNIVERSITY Department of Public Health
Signature Assignment-Physical Activity Promotion Plan
Presented in Partial Fulfillment of the Requirements for the class: FTES510-999 Fitness and Health Promotion
Spring 20__ Dr. Padma Tadi Uppala
Overview and rationale
Among the different types of cancer, breast cancer is the most prevalent type of cancer in
women worldwide, in both developed and developing countries. "Approximately 40,610 women
are expected to die of breast cancer in 2017 in the US. Mortality rates for 2011-2017 for breast
cancer rates for Non-Hispanic Whites was 21.2 and for Non-Hispanic Blacks was 29.8% per
100,000 women” (American Cancer Society, 2017). In Michigan, breast cancer is the most
diagnosed cancer and the second-leading cause of cancer deaths in women. According to Institute
for Health Metrics and Evaluation (2016), age-standardized breast cancer rate in 2014 was 27.2
per 100,000 women for Berrien County, above the state and national average rate. In 2011 the
prevalence of obesity in women from Berrien County exceeded the state average rate and only half
the female population meet physical activity (PA) recommendations. A large number of studies
show the relationship between obesity/sedentary lifestyle and increased risk of breast cancer.
According to research, exercise could help prevent cases and deaths caused from breast cancer.
With exercise, there is a decrease in estradiol and an increase in the binding globulin to sex
hormones, which causes reduction of inflammatory and increase of the anti-inflammatory
substances which may prevent the development of cancer (Silva, 2018).
Treatment for breast cancer, such as surgery (radical or conservative mastectomy),
chemotherapy, radiotherapy or hormone therapy, is associated with the impairment of the body,
causing physical consequences such as fatigue and pain, as well as changes in body image, psychic,
emotional and social declines (Ussher, Perz & Gilbert, 2012). In this sense, the need for
interventions that minimize such complications, coupled with a healthy lifestyle, especially in
relation to eating habits and physical activity levels, is emphasized (George et al., 2011).
Physical exercise is a useful tool to manage post-treatment complications of cancer,
because it generates an increase in cardiorespiratory fitness and flexibility, gains in self-image,
self-esteem, decrease in depression and anxiety, and improvement in sleep quality (Battaglini et
al., 2014). Physical activity has been shown to be beneficial for breast cancer survivors, women in
initial stage, and women with metastatic breast cancer (advanced stage). However, due to fear of
bone fracture and fatigue related to cancer or cancer treatment that affects normal functioning,
those with metastatic breast cancer have typically been excluded from exercise interventions (Yee,
2014).
A community-based exercise intervention with breast cancer survivors was shown to be
feasible and improve significantly physical, psychological and functional well-being (Knobf,
Thompson, Fennie & Erdos, 2014). In Canada, a 12-week exercise program known as the “Breast
cancer patients Engaging in Activity while Undergoing Treatment” (BEAUTY) was also feasible
and effective in improving quality of life, preventing declines in physical and psychosocial
outcomes (Leach, Danyluk, Nishimura & Culos-Reed, 2015). These studies support the need to
include PA programming as part of treatment for breast cancer patients.
Given the above, the objective of this physical activity plan is to describe a structured
program of aerobic walking and resistance physical exercises for women with breast cancer in the
stage of chemotherapeutic and/or radiotherapeutic treatment.
Resilience in Overcoming Cancer! – ROC!
The objective of the project is to provide women with breast cancer a 12-week structured physical
activity program, prioritizing the physical, social and psychological well-being of this population.
Target Population: Women older than 18 years and undergoing treatment for breast cancer and
have no metastatic disease in the Berrien County.
Sample size: n=40
SMART aims and objectives
• To develop the habit of physical activity of 150 minutes per week in participants
following the 12-week intervention.
• To improve and/or maintain physical fitness of its participants by 50% following
the 12-week intervention.
• To increase knowledge about the benefits of physical activity in relation to cancer
in participants by 90% following the 12-week intervention.
• To increase psychological wellbeing in participants by 75% following the 12-week
intervention.
Logic Model
Promotion
This will be a community wide campaign that is offered to women ages 18 and older who are
currently being treated for breast cancer and have no metastatic disease.
• Flyers/ brochures will be distributed at:
§ Marie Yeager Cancer Center
§ Cancer Care Lakeland Health
§ Berrien County Cancer Service
• Small posters on community boards in the local area
• Flyers at all local Oncologist’s offices
• A 12-week exercise program with an educational support group component. Additionally,
it will be followed by a 12-week maintenance program.
§ Planned strength-training program with a personal trainer
§ Educational component at the Marie Yeager Cancer Center
Intervention
This will be a 12-week exercise program with an educational component. The educational support
group will be held on a weekly basis for the first 12 weeks. A rehabilitation cancer specialist will
help educate patients on physical activity during treatment. Participants will be encouraged to
share ideas and support each other. There will also be a 12-week follow-up maintenance program.
Initially participants will need to get clearance from their doctor to participate in the program.
Once in the program they will be given a picture identification card to show to all participating
exercise facilities to gain free entrance. Currently all local YMCA’s and CrossFit gyms are
participants. Each gym has a breast cancer patient personal trainer that has been trained by the
Marie Yeager Cancer Center on exercise prescriptions for cancer populations. The participant will
have one free training session with the personal trainer to create a strength training program. After
the first 12-weeks they will have another free meeting with the personal trainer to make any
adjustments to their plan. We have included strength training because it can help with bone mineral
density, lymphedema, and can help with “weight loss in patients undergoing treatment” (Baumann,
et al., 2013).
The 2008 Physical Activity Guidelines require 150 minutes per week of “moderate-intensity
aerobic exercise” (Harold W. Kohl & Murray, 2012). Our program is promoting 3 days of weight
training and 2 days of aerobic walking or aerobic exercise class for 30 minutes each session. This
would provide the 150 minutes that are recommended. The intensity can be determined by the
Talk Test.
Schedule
Exercise Type Low Energy Medium Energy High Energy Aerobic 3×10 minute sessions 2 x 15-minute sessions 30-minute session Strength 1-2 sets of 8-10 reps. 1-3 sets of 8-10 reps. 2-3 sets of 8-10 reps. Flexibility 5-7 days per week 5-7 days per week 5-7 days per week
(H.J. Leach, Danylu, & Culos–Reed, 2014)
Sample Schedule
Monday Tuesday Wednesday
Thursday Friday Saturday Sunday
Pilates Strength Total Body
Pool aerobics 30 minutes
Strength Total Body
30-minute aerobic walk
Rest Strength Total Body
Educational Support Group
Flexibility Stretching 5-10 min.
Flexibility Stretching 5-10 min.
Flexibility Stretching 5-10 min.
Flexibility Stretching 5-10 min.
Flexibility Stretching 5-10 min.
Participants can choose from many types of classes depending on what the participating
gym has to offer. Some of the different classes could include yoga, flexibility classes, step aerobics,
Zumba. Once a strength training program has been established participants can use a phone app or
hardcopy worksheet to log their weight and repetitions for each workout.
Leadership
• Co-directors of the program are Hazel Fuentes and Ana Howard
• Dr. Buck- Program Medical Doctor and an Oncologist
• Marie Yeager Cancer Center- Program Coordinator
• Program Coordinator Administrative Assistant
• Marie Yeager Cancer Center- Educator and Counselor
• Personal trainers from different gyms who will be working with the clients
Funding
Funding will be acquired through several different sources. The program will apply for grants from
Honor Credit Union, Michigan Department of Health and Human Services, and the Susan G.
Koman Foundation. We are asking participating gyms to donate a six-month to one-year
membership or provide a membership at a lower rate. We will be working with CETI the Cancer
Exercise Training Institute to certify our personal trainers. The Cancer Exercise Specialist
Certification is a value of $399 therefore we are asking personal trainers to donate their time in
exchange for the certification. Our desire is to provide this program free of cost to participants.
Evaluations
A formative evaluation will be included. Questions will be asked concerning the overall
proposal of the project. How much can exercise help in alleviating symptoms from treatments?
How often are participants willing to exercise? How inactive are patients going through treatment?
What are the barriers for participating in the program? Who will train the personal trainers on
cancer exercise prescription? How can we encourage participants to exercise? “Is there a leader in
the target population who can assist with outreach?” (Harold W. Kohl & Murray, 2012).
A process evaluation focuses on how well the program is functioning. Therefore,
attendance will be monitored. An assessment of delivery alternatives will be included (Harold W.
Kohl & Murray, 2012). The program will divide the group and in one group the Oncologist will
prescribe exercise as part of the treatment and in the other group it will just be suggested by the
Oncologist. Participants will be surveyed on the program every two weeks during the education
class. If attendance is low what program changes can take place that would be helpful? Do
participants feel competent enough with their strength training program or is more personal
training involvement needed? Which gyms are seeing better results in participants and why? What
is working in the program and what is failing?
Outcome evaluations will include the following assessments. Fatigue will be measured by
the Fatigue Symptom Inventory (FSI) which was devised for cancer populations. “Higher scores
on the FSI indicate greater fatigue” (Rajotte, et al., 2012). Quality of life was evaluated by using
the second version of SF-36. “This measure includes eight scales: Physical Functioning, Role-
Physical, Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional, and Mental
Health” (Rajotte, et al., 2012). Furthermore, both the mental and physical summary are determined
by the different scales.
Pre and post assessments will be done on participants to ascertain if cancer treatment
symptoms are better after engaging in the program. Participants will evaluate their satisfaction
with the program. Personal trainers will measure resting heart rate, weight, and waist to hip ratio.
They will also assess mobility with a goniometer test, strength with a handgrip dynamometry and
1 rep maximum. Muscular endurance will be tested by the sit-ups and push-ups test. Cardio
assessments such as the YMCA 3- minute Step test will also be used (Harold W. Kohl & Murray,
2012). All of these assessments will be done before and after the program.
A cost-effectiveness evaluation will occur at the end of the program. Did participants miss
less work days due to exercise? Did participants respond better to the treatment therefore having
fewer medical complications? The costs of running the program, employees' incomes, assessment
costs, and personal training fees. Did the participants find that it was a cost-effective use of their
time? (Harold W. Kohl & Murray, 2012).
Public Health Practice Strategies and Policy
Research has shown that physical activity both during and after treatment can be helpful
with the side effects of treatment, mental health, fatigue, and the reoccurrence of cancer (Mendes,
2014), (Breast Cancer, 2017), (C. Kent Osborne, 2018). This is why partnerships and advocacy
are so important in encouraging physical exercise not only among the healthy but those who have
breast cancer. The American Cancer Society, the National Breast Cancer Foundation, American
Breast Cancer foundation, CDC, and medical community should form partnerships to advocate for
policies that help implement an exercise program as part of treatment. It is important that the
medical community include exercise as part of the standard of care after diagnosis. Medical
training may have to be revised to incorporate this new method of practice. The guidelines are
present, but patients need to be reminded of the importance of physical activity. The standard of
care should include a referral to a physical therapist with a cancer specialist (National
Comprehensive Cancer Network, 2019). Policies need to be put into place so that it becomes a
routine procedure.
It is important to examine the research on breast cancer and exercise and then present the
scientific evidence to insurance companies with the hope that they are influenced to reimburse
gym memberships. It is essential that policy makers are made aware of the research. A multi-
faceted approach including the medical community, media, cancer advocates, insurance
companies, and political realm needs to be created. It is important to make the public aware through
media, foundations, and American Cancer Society of the significance that exercise can have on
cancer. Perseverance will be needed as this issue will need to be presented consistently over a long
period of time (Harold W. Kohl & Murray, 2012). The importance of physical activity on cancer
is largely substantiated in research therefore, programs like ROC can be an invaluable resource for
those with cancer.
References:
American Cancer Society. Breast Cancer Facts & Figures 2017-2018 Atlanta: American Cancer Society, Inc. 2017.Retrieved from: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf
Battaglini, C. L., Mills, R. C., Phillips, B. L., Lee, J. T., Story, C. E., Nascimento, M. G., & Hackney, A. C. (2014). Twenty-five years of research on the effects of exercise training in breast cancer survivors: a systematic review of the literature. World journal of clinical oncology, 5(2), 177. Baumann, F. T., Bloch, W., Weissen, A., Brockhaus, M., Beulertz, J., Zimmer, P., … & Zopf, E. M. (2013). Physical activity in breast cancer patients during medical treatment and in the aftercare-a review. Breast care, 8(5), 330-334. Breast Cancer. (2017, February 18). Exercise During and After Treatment. Retrieved from Breast Cancer: https://www.breastcancer.org/tips/exercise/treatment. C. Kent Osborne, M. (2018). Exercise during adjuvant breast cancer treatment may improve cardiovascular function. San Antionio Breast Cancer Symposium (pp. https://www.healio.com/hematology-oncology/breast-cancer/news/online/%7B00d1324d-0749-4ee3-9724-3b7200a9a5a3%7D/exercise-during-adjuvant-breast-cancer-treatment-may-improve-cardiovascular-function). Healio. George, S. M., Irwin, M. L., Smith, A. W., Neuhouser, M. L., Reedy, J., McTiernan, A., … & Moore, S. C. (2011). Postdiagnosis diet quality, the combination of diet quality and recreational physical activity, and prognosis after early-stage breast cancer. Cancer Causes & Control, 22(4), 589-598. Harold W. Kohl, I., & Murray, T. D. (2012). Foundations of Physical Activity and Public Health. Champaign, IL: Human Kinetics. Institute for Health Metrics and Evaluation [IHME]. (2016). US County Profile: Berrien County, Michigan. Seattle, WA: IHME Knobf, M. T., Thompson, A. S., Fennie, K., & Erdos, D. (2014). The effect of a community-based exercise intervention on symptoms and quality of life. Cancer nursing, 37(2), E43-50.
Leach, H. J., Danyluk, J. M., & Culos–Reed, S. N. (2014). Design and implementation of a community-based exercise program for breast cancer patients. Current Oncology, 21(5), 267.
Leach, H. J., Danyluk, J. M., Nishimura, K. C., & Culos-Reed, S. N. (2015). Evaluation of a community-based exercise program for breast cancer patients undergoing treatment. Cancer nursing, 38(6), 417-425.
Mendes, E. (2014, October 22). The Power of Exercise in Breast Cancer Survivors. Retrieved from American Cancer Society: https://www.cancer.org/latest-news/the-power-of-exercise-in-breast-cancer-survivors.html National Comprehensive Cancer Network. (2019). Exercising During Cancer Treatment. Retrieved from National Comprehensive Cancer Network: https://www.nccn.org/patients/resources/life_with_cancer/exercise.aspx Rajotte, E. J., Jean, C. Y., Baker, K. S., Gregerson, L., Leiserowitz, A., & Syrjala, K. L. (2012). Community-based exercise program effectiveness and safety for cancer survivors. Journal of Cancer Survivorship, 6(2), 219-228. Silva, D. A. S., Tremblay, M. S., de Souza, M. D. F. M., Guerra, M. R., Mooney, M., Naghavi, M., & Malta, D. C. (2018). Mortality and years of life lost due to breast cancer attributable to physical inactivity in the Brazilian female population (1990–2015). Scientific reports, 8(1), 11141. Ussher, J. M., Perz, J., & Gilbert, E. (2012). Changes to sexual well-being and intimacy after breast cancer. Cancer nursing, 35(6), 456-465.
Yee, J., Davis, G. M., Beith, J. M., Wilcken, N., Currow, D., Emery, J., … & Segelov, E. (2014). Physical activity and fitness in women with metastatic breast cancer. Journal of Cancer Survivorship, 8(4), 647-656.
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