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Pillay J, Guitard S, Rahman S, Saba S, Rahman A, Bialy L, Gehring N, Tan M, Melton A, Hartling L. Patient preferences for breast cancer screening: a systematic review update to inform recommendations by the Canadian Task Force on Preventive Health Care. Syst Rev 2024; 13:140. [PMID: 38807191 PMCID: PMC11134964 DOI: 10.1186/s13643-024-02539-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Different guideline panels, and individuals, may make different decisions based in part on their preferences. Preferences for or against an intervention are viewed as a consequence of the relative importance people place on the expected or experienced health outcomes it incurs. These findings can then be considered as patient input when balancing effect estimates on benefits and harms reported by empirical evidence on the clinical effectiveness of screening programs. This systematic review update examined the relative importance placed by patients on the potential benefits and harms of mammography-based breast cancer screening to inform an update to the 2018 Canadian Task Force on Preventive Health Care's guideline on screening. METHODS We screened all articles from our previous review (search December 2017) and updated our searches to June 19, 2023 in MEDLINE, PsycINFO, and CINAHL. We also screened grey literature, submissions by stakeholders, and reference lists. The target population was cisgender women and other adults assigned female at birth (including transgender men and nonbinary persons) aged ≥ 35 years and at average or moderately increased risk for breast cancer. Studies of patients with breast cancer were eligible for health-state utility data for relevant outcomes. We sought three types of data, directly through (i) disutilities of screening and curative treatment health states (measuring the impact of the outcome on one's health-related quality of life; utilities measured on a scale of 0 [death] to 1 [perfect health]), and (ii) other preference-based data, such as outcome trade-offs, and indirectly through (iii) the relative importance of benefits versus harms inferred from attitudes, intentions, and behaviors towards screening among patients provided with estimates of the magnitudes of benefit(s) and harms(s). For screening, we used machine learning as one of the reviewers after at least 50% of studies had been reviewed in duplicate by humans; full-text selection used independent review by two humans. Data extraction and risk of bias assessments used a single reviewer with verification. Our main analysis for utilities used data from utility-based health-related quality of life tools (e.g., EQ-5D) in patients; a disutility value of about 0.04 can be considered a minimally important value for the Canadian public. When suitable, we pooled utilities and explored heterogeneity. Disutilities were calculated for screening health states and between different treatment states. Non-utility data were grouped into categories, based on outcomes compared (e.g. for trade-off data), participant age, and our judgements of the net benefit of screening portrayed by the studies. Thereafter, we compared and contrasted findings while considering sample sizes, risk of bias, subgroup findings and data on knowledge scores, and created summary statements for each data set. Certainty assessments followed GRADE guidance for patient preferences and used consensus among at least two reviewers. FINDINGS Eighty-two studies (38 on utilities) were included. The estimated disutilities were 0.07 for a positive screening result (moderate certainty), 0.03-0.04 for a false positive (FP; "additional testing" resolved as negative for cancer) (low certainty), and 0.08 for untreated screen-detected cancer (moderate certainty) or (low certainty) an interval cancer. At ≤12 months, disutilities of mastectomy (vs. breast-conserving therapy), chemotherapy (vs. none) (low certainty), and radiation therapy (vs. none) (moderate certainty) were 0.02-0.03, 0.02-0.04, and little-to-none, respectively, though in each case findings were somewhat limited in their applicability. Over the longer term, there was moderate certainty for little-to-no disutility from mastectomy versus breast-conserving surgery/lumpectomy with radiation and from radiation. There was moderate certainty that a majority (>50%) and possibly a large majority (>75%) of women probably accept up to six cases of overdiagnosis to prevent one breast-cancer death; there was some uncertainty because of an indication that overdiagnosis was not fully understood by participants in some cases. Low certainty evidence suggested that a large majority may accept that screening may reduce breast-cancer but not all-cause mortality, at least when presented with relatively high rates of breast-cancer mortality reductions (n = 2; 2 and 5 fewer per 1000 screened), and at least a majority accept that to prevent one breast-cancer death at least a few hundred patients will receive a FP result and 10-15 will have a FP resolved through biopsy. An upper limit for an acceptable number of FPs was not evaluated. When using data from studies assessing attitudes, intentions, and screening behaviors, across all age groups but most evident for women in their 40s, preferences reduced as the net benefit presented by study authors decreased in magnitude. In a relatively low net-benefit scenario, a majority of patients in their 40s may not weigh the benefits as greater than the harms from screening whereas for women in their 50s a large majority may prefer screening (low certainty evidence for both ages). There was moderate certainty that a large majority of women 50 years of age and 50 to 69 years of age, who have usually experienced screening, weigh the benefits as greater than the harms from screening in a high net-benefit scenario. A large majority of patients aged 70-71 years who have recently screened probably think the benefits outweigh the harms of continuing to screen. A majority of women in their mid-70s to early 80s may prefer to continue screening. CONCLUSIONS Evidence across a range of data sources on how informed patients value the potential outcomes from breast-cancer screening will be useful during decision-making for recommendations. The evidence suggests that all of the outcomes examined have importance to women of any age, that there is at least some and possibly substantial (among those in their 40s) variability across and within age groups about the acceptable magnitude of effects across outcomes, and that provision of easily understandable information on the likelihood of the outcomes may be necessary to enable informed decision making. Although studies came from a wide range of countries, there were limited data from Canada and about whether findings applied well across an ethnographically and socioeconomically diverse population. SYSTEMATIC REVIEW REGISTRATION Protocol available at Open Science Framework https://osf.io/xngsu/ .
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Affiliation(s)
- Jennifer Pillay
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Samantha Guitard
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sholeh Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Sabrina Saba
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ashiqur Rahman
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Nicole Gehring
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Maria Tan
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Alex Melton
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Faculty of Medicine and Dentistry, University of Alberta, 11405 87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
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Li Y, Gao L, Chao Y, Lan T, Zhang J, Li R, Zhang Z, Li S, Lian J, Wang Z, Chen X. Various interventions for cancer-related fatigue in patients with breast cancer: a systematic review and network meta-analysis. Front Oncol 2024; 14:1341927. [PMID: 38406816 PMCID: PMC10885696 DOI: 10.3389/fonc.2024.1341927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/17/2024] [Indexed: 02/27/2024] Open
Abstract
Purpose To investigate the effects of various intervention approaches on cancer-related fatigue (CRF) in patients with breast cancer. Method Computer searches were conducted on PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wanfang databases from their establishment to June 2023. Selection was made using inclusion and exclusion criteria, and 77 articles were included to compare the effects of 12 interventions on patients with breast cancer. Results Seventy-seven studies with 12 various interventions were examined. The network findings indicated that cognitive behavioral therapy (CBT) (SMD, -1.56; 95%CI, -3.08~-0.04), Chinese traditional exercises (CTE) (SMD, -0.85; 95%CI, -1.34~-0.36), aerobic exercise (AE) (SMD, -0.77; 95%CI, -1.09~-0.45), multimodal exercise (ME) (SMD, -0.75; 95%CI, -1.26~-0.25), music interventions (MI) (SMD, -0.74; 95%CI, -1.45~-0.03), and yoga (YG) (SMD, -0.44; 95%CI, -0.83 to -0.06) can reduce CRF more than the control group (CG). For relaxation exercises (RE) (MD, -6.69; 95%CI, -9.81~-3.57), MI (MD, -5.45; 95%CI, -7.98~-2.92), AE (MD, -4.34; 95%CI, -5.90~-2.78), ME (MD, -3.47; 95%CI, -4.95~-1.99), YG (MD, -2.07; 95%CI, -3.56~-0.57), and mindfulness training (MD, -1.68; 95%CI, -2.91~-0.46), PSQI improvement was superior to CG. In addition, for CTE (MD, 11.39; 95%CI, 4.11-18.66), YG (MD, 11.28; 95%CI, 1.63-20.93), and AE (MD, 9.34; 95%CI, 0.26~18.42), Functional Assessment of Cancer Therapy-Breast improvement was superior to CG. Conclusion Cognitive behavioral therapy (CBT) is the most effective measure for alleviating CRF in patients with breast cancer and Relaxation exercises (RE) is the most effective measure for improving sleep quality. In addition, Chinese traditional exercises (CTE) is the best measure for enhancing quality of life. Additional randomized controlled trials (RCTs) are expected to further investigate the efficacy and mechanisms of these interventions. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023471574.
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Affiliation(s)
- Ying Li
- College of Sports Science, Jishou University, Jishou, Hunan, China
| | - Lei Gao
- School of Nursing, Dalian University, Dalian, Liaoning, China
| | - Yaqing Chao
- Ophthalmology Department, Xuzhou First People’s Hospital, Xuzhou, Jiangsu, China
| | - Tianhao Lan
- School of Stomatology, Dalian University, Dalian, Liaoning, China
| | - Jie Zhang
- College of Sports Science, Jishou University, Jishou, Hunan, China
| | - Ruoqi Li
- The Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Zerui Zhang
- Medical School, Weifang University of Science and Technology, Weifang, Shandong, China
| | - Shuming Li
- College of Sports Science, Jishou University, Jishou, Hunan, China
| | - Jing Lian
- Department of Pathology, Cancer Hospital Affiliated to Shanxi Province Cancer Hospital, Taiyuan, Shanxi, China
| | - Zhaofeng Wang
- College of Physical Education, Beibu Gulf University, Qinzhou, Guangxi, China
| | - Xiaoan Chen
- College of Sports Science, Jishou University, Jishou, Hunan, China
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Kim SH, Jo HY. Factors Associated with Poor Quality of Life in Breast Cancer Survivors: A 3-Year Follow-Up Study. Cancers (Basel) 2023; 15:5809. [PMID: 38136354 PMCID: PMC10741455 DOI: 10.3390/cancers15245809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
The purpose of this study was to identify subgroups of quality of life (QOL) changes in breast cancer survivors (BCSs), and to determine factors associated with subgroups of consistently low or deteriorated QOL. We enrolled 101 women recently diagnosed with breast cancer in South Korea and asked them to complete a questionnaire at baseline (within 1 month of diagnosis), 1 year later (Year 1), 2 years later (Year 2), and 3 years later (Year 3). We assessed QOL using the global QOL subscale from the EORTC QLQ-C30. We defined low QOL as a global QOL score 10 points below the mean score of the general population. Based on low QOL as defined in this study, we identified subgroups of QOL changes over 3 years. We identified four subgroups of QOL changes: improved (47.4%), stable (30%), continuously low (8.8%), and deteriorated (13.8%), and considered the last two categories (22.6%) poor QOL. Logistic regression analyses demonstrated that significant determinants of poor QOL were insomnia at Year 1, fatigue and anxiety at Year 2, and fatigue, depression, and comorbidity at Year 3. In conclusion, persistent symptoms of insomnia, fatigue, anxiety, depression, and comorbidity are potential risk factors for poor QOL in BCSs.
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Affiliation(s)
- Soo-Hyun Kim
- Department of Nursing, Inha University, Incheon 22212, Republic of Korea;
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Tran TXM, Jung SY, Lee EG, Cho H, Kim NY, Shim S, Kim HY, Kang D, Cho J, Lee E, Chang Y, Cho H. Health-related quality of life in long-term early-stage breast cancer survivors compared to general population in Korea. J Cancer Surviv 2023:10.1007/s11764-023-01482-2. [PMID: 37999857 DOI: 10.1007/s11764-023-01482-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/06/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE This study assessed health-related quality of life (HRQoL) of long-term breast cancer (BC) survivors diagnosed at early stages and compare with cancer-free, age-matched women. METHODS The study population included BC survivors diagnosed with ductal carcinoma in situ (DCIS) or breast cancer stages I-II, who had undergone lumpectomy/mastectomy, with time since diagnosis ranging from 9 to 16 years. Survey was conducted at two tertiary hospitals in 2020. Data for cancer-free female controls was randomly drawn from a population-based survey and age-, education-matched with 1 case: 3 controls ratio. Self-reported HRQoL was assessed using EQ-5D with five dimentions. EQ-5D utility index score was calculated. Difference in EQ-5D score was evaluated using the Tobit regression model with adjustment for other covariates. RESULTS Of 273 survivors. 88% and 12% underwent mastectomy and lumpectomy, respectively. The mean (standard deviation, SD) age at survey was 57.3 (8.5) years old. BC survivors reported significantly more problems performing daily activities (11% vs. 5%, p < 0.001), pain/discomfort (46% vs. 23%, p < 0.001), and anxious/depressed feelings (44% vs. 8%, p < 0.001) relative to the controls. Difference in EQ-5D score between BC survivors and the general population was higher in older age groups. The overall EQ-5D score of BC survivors was statistically lower than that of the control subjects (adjusted [Formula: see text]=0.117, p < 0.001). CONCLUSION Long-term BC survivors who survived beyond ten years post-diagnosis experience more pain, anxiety, and distress, leading to an overall poorer HRQoL. IMPLICATIONS FOR CANCER SURVIVORS This study suggest the importance of follow-up care, particularly focusing on pain, anxiety, and distress management to enhance the HRQoL of long-term BC survivors.
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Affiliation(s)
- Thi Xuan Mai Tran
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, 10408, Republic of Korea
| | - So-Youn Jung
- Center for Breast Cancer, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Eun-Gyeong Lee
- Center for Breast Cancer, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Heeyoun Cho
- Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, 323 Ilsan-Ro, Ilsandong-Gu, Goyang-Si, Goyang, Gyeonggi-Do, 10408, Republic of Korea
| | - Na Yeon Kim
- Cancer Education Center, Samsung Comprehensive Cancer Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Sungkeun Shim
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Ho Young Kim
- Cancer Education Center, Samsung Comprehensive Cancer Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, 06351, Republic of Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, 06351, Republic of Korea
| | - Eunsook Lee
- Center for Breast Cancer, National Cancer Center, Goyang, 10408, Republic of Korea
- Department of Cancer Biomedical Science, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, 10408, Republic of Korea
| | - Yoonjung Chang
- Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, 323 Ilsan-Ro, Ilsandong-Gu, Goyang-Si, Goyang, Gyeonggi-Do, 10408, Republic of Korea.
- Department of Cancer AI and Digital Health, Graduate School of Cancer Science and Policy, National Cancer Center, 323 Ilsan-Ro, Ilsandong-Gu, Goyang-Si, Goyang, Gyeonggi-Do, 10408, Republic of Korea.
| | - Hyunsoon Cho
- Department of Cancer AI and Digital Health, Graduate School of Cancer Science and Policy, National Cancer Center, 323 Ilsan-Ro, Ilsandong-Gu, Goyang-Si, Goyang, Gyeonggi-Do, 10408, Republic of Korea.
- Integrated Biostatistics Branch, Division of Cancer Data Science, Research Institute, National Cancer Center, Goyang, Republic of Korea.
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Liu YC, Hung TT, Konara Mudiyanselage SP, Wang CJ, Lin MF. Beneficial Exercises for Cancer-Related Fatigue among Women with Breast Cancer: A Systematic Review and Network Meta-Analysis. Cancers (Basel) 2022; 15:cancers15010151. [PMID: 36612147 PMCID: PMC9817866 DOI: 10.3390/cancers15010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022] Open
Abstract
CONTEXT Cancer-related fatigue (CRF) is the most common cause of physical powerlessness in women with breast cancer (BC). The practice of continuous effective exercise is beneficial with respect to reducing CRF. OBJECTIVE To explore exercise efficacy and respective ranks with respect to reducing CRF in women with BC within the inter-treatment and post-treatment periods. METHODS Throughout this systematic review and network meta-analysis, articles published from 2000 to March 2022 were included. Article searches were conducted on the MEDLINE, Embase, CINAHL, and CENTRAL databases. Adult women with BC and different exercise programs were compared with those involved in regular care as a control during or after treatment. In addition, randomized controlled trials (RCT) were also included. A risk-of-bias assessment, with the revised Cochrane risk-of-bias tool regarding RCT and probability-based ranking, was established based on the surface under the cumulative rank (SUCRA) method via network meta-analysis. RESULTS a total of 5747 women with BC followed seven exercise interventions. Yoga (SMD = -0.54, 95% CI [-0.86, -0.22]) was ranked first (94.5%), with significant effects in respect of mitigating CRF, followed by resistance exercise (66.2%), and aerobic resistance (63.3%), while Qigong ranked last (22.2%) among the 36 RCT in inter-treatment. Aerobic resistance exercise (SMD = -0.52, 95% CI [-0.98, -0.07]) induced significant effects in respect of mitigating CRF in the 38 RCTs in the post-treatment period. Yoga, aerobic yoga, and aerobic resistance exercise ranked as the top three (75.5%, 75.0%, and 72.4%, respectively), whereas relaxation ranked last (38.8%) in the post-treatment period. CONCLUSION Yoga, aerobic resistance, and aerobic yoga are recommended for the purposes of inter- and post-treatment exercise to reduce CRF in women with BC by enhancing their physical resilience and long-term quality of life.
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Affiliation(s)
- Yu-Chen Liu
- School of Nursing, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Tsai-Tzu Hung
- Nursing Department, National Cheng Kung University Hospital, Tainan 70101, Taiwan
| | | | - Chi-Jane Wang
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Mei-Feng Lin
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5035); Fax: +886-6-237-7550
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Effect of a telehealth-based exercise intervention on the physical activity of patients with breast cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022; 9:100117. [PMID: 36276881 PMCID: PMC9583041 DOI: 10.1016/j.apjon.2022.100117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/05/2022] [Indexed: 12/01/2022] Open
Abstract
Telehealth-based exercise intervention as a non-pharmacological intervention has gradually emerged in breast cancer (BC), which shows feasibility and high levels of patient satisfaction. This systematic review aims to identify the effect of telehealth-based exercise interventions on the physical activity (PA) of patients with BC. We searched CENTRAL, CINAHL, PsycINFO, EMBASE, PubMed, Web of Science, ClinicalTrials.gov, CNKI, Wanfang, VIP, and SinoMed. Study selection and quality appraisal were performed independently by two reviewers. The review protocol was registered in PROSPERO (CRD42022326484). Nine studies, which included 1127 patients with BC, were identified. Compared with usual care, the telehealth-based exercise intervention had a significantly positive effect on PA (Standardized mean difference (SMD) = 0.26, 95% confidence interval (CI) 0.09 to 0.43, P = 0.003), aerobic capacity (SMD = 0.20, 95% CI 0.03 to 0.38, P = 0.02), upper body function (Mean difference (MD) = −4.56, 95% CI −7.66 to −1.47, P = 0.004), upper muscle strength (SMD = 0.26, 95% CI 0.09 to 0.42, P = 0.002), lower muscle strength (SMD = −0.95, 95% CI −1.27 to −0.62, P < 0.00001), abdominal muscle strength (MD = 23.85, 95% CI 13.84 to 33.86, P < 0.000,01), fatigue (SMD = 0.56, 95% CI 0.13 to 1.00, P = 0.01), and quality of life (SMD = 0.26, 95% CI 0.04 to 0.49, P = 0.02). Conversely, anthropometric and body composition and pain did not differ significantly between the two groups. Telehealth-based exercise intervention improved PA, physical performance, fatigue, and quality of life of patients with BC compared with routine care, which should be promoted clinically as a comprehensive treatment for BC.
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