
==== Front
Breast
Breast
The Breast : Official Journal of the European Society of Mastology
0960-9776
1532-3080
Elsevier

S0960-9776(24)00129-2
10.1016/j.breast.2024.103798
103798
Review
Effect of different exercise types on quality of life in patients with breast cancer: A network meta-analysis of randomized controlled trials
Li Liang
Wang Yutong
Cai Mingzhou
Fan Tonggang tonggangfan@126.com
⁎
College of Wushu, Shanghai University of Sport, Shanghai, China
⁎ Corresponding author. Shanghai University of Sport, Hengren Road, Yangpu District, Shanghai, 200438, China. tonggangfan@126.com
04 9 2024
12 2024
04 9 2024
78 1037987 6 2024
4 8 2024
3 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Background

Exercise is a rehabilitation strategy for patients with breast cancer; however, the optimal type of exercise remains uncertain. This study aimed to compare the effects of five exercise types on the quality of life of patients with breast cancer and provide a basis for their exercise rehabilitation.

Methods

As of May 2024, we searched four databases: Embase, PubMed, Web of Science, and Cochrane Library, and included randomized controlled trials that analyzed the effect of exercise on the quality of life of patients with breast cancer. A network meta-analysis was performed using a frequency-based framework.

Results

Forty-five papers involving 4092 participants were included. The five types of exercises included were all significant in the direct comparison with the control group, except yoga and mind–body exercises. Aerobic, resistance, and combination exercises were associated with quality of life. However, in indirect comparisons, only mind–body exercise versus resistance exercise had a significant effect. The effect of exercise on the quality of life(total health status) of patients with breast cancer was ranked based on surface under the cumulative ranking curve (SUCRA) values combined with effect sizes as follows: aerobic exercise (SUCRA = 84.1) > combined exercise (SUCRA = 78.8) > resistance exercise (SUCRA = 66.4) > yoga (SUCRA = 39.3) > mind-body exercise (SUCRA = 27.2) > usual care (SUCRA = 4.1).

Conclusions

Exercise can rehabilitate the quality of life of patients with breast cancer, and aerobic exercise may be the best type of exercise to improve their quality of life(total health status).

Highlights

• Exercise can rehabilitate the quality of life of patients with breast cancer.

• Aerobic exercise is the most effective exercise rehabilitation.

• Patients' choice on the appropriate type of exercise is based on their condition.

Keywords

Breast cancer
Aerobic exercise
Quality-of-life
Rehabilitation
Health
Abbreviations

SUCRA Surface under the cumulative ranking curve

PRIS-NMA Preferred Reporting Items for Systematic Reviews and Network Meta-analyses

NMA Network meta-analysis

EORTC QLQ-C30 European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire

SMD Standardized mean difference

CI Confidence interval
==== Body
pmc1 Introduction

Breast cancer is one of the most common malignant tumors in women, posing a severe threat to their physical and mental health and quality of life worldwide [1,2]. The incidence of breast cancer has steadily increased since the late 1970s. Globally, 2.3 million women were diagnosed with breast cancer, and 670,000 died in 2022. Breast cancer is the first or second leading cause of cancer-related deaths in women in 95 % of countries [3,4]. Breast cancer has become a significant public health problem in the current international community [5].

After surgical treatment, breast cancer patients' daily care and moderate exercise can improve their chemotherapy compliance [6,7]. Exercise plays a significant role in improving the quality of life of patients with breast cancer and is an essential measure of physical recovery [[8], [9], [10]]. Some studies have indicated that aerobics, resistance, yoga, and other exercises significantly improve the quality of life of patients with breast cancer [[11], [12], [13]]. However, many studies have focused on directly comparing the effects of exercise and usual care on the quality of life in patients with breast cancer [14,15]. Few studies have compared the effects of different forms of exercise in patients with breast cancer. Therefore, identifying the best exercise program for improving the quality of life of such patients is essential.

Without evidence for direct head-to-head comparisons, a network meta-analysis (NMA) can use all available evidence through indirect and direct comparisons, which can rank different treatment options and provide a more valuable reference for clinical decision-making [16,17]. In this study, we aimed to compare the effects of five forms of exercise (aerobic exercise, resistance exercise, mind-body exercise, combination exercise, and yoga) on the quality of life of patients with breast cancer, determine the optimal form of exercise for them, and provide a reference for their exercise rehabilitation.

2 Materials and methods

This study adhered to the Preferred Reporting Items for Systematic Reviews and Network Meta-analyses (PRIS-NMA) guidelines [18], including background, list of entries, and caveats, and was registered on the PROSPERO platform (ID: CRD42024549500).

2.1 Search strategy

Embase, PubMed, Web of Science, and Cochrane Library databases were searched using a computer; the search period was from the creation of the database to May 10, 2024, and the search language was English only. During the literature search, a search strategy was developed according to “Participants, Intervention, Comparison, Outcome, and Study” (PICOS) principles to make the search terms more accurate and comprehensive: P, patients with breast cancer; I, exercise; C, routine care; O, quality of life; and S, randomized controlled trials.

The search was conducted using a combination of subject terms and free words, with specific search terms including: (“Breast Neoplasm” OR “Breast Tumors” OR “Neoplasms, Breast” OR “Breast Cancer” OR “Mammary Cancer” OR “Breast Malignant Neoplasm” OR “Breast Malignant Tumor” OR “Human Mammary Carcinoma” OR “Human Mammary Neoplasm” OR “Neoplasm, Human Mammary” OR “Mammary Neoplasm, Human” OR “Breast Carcinoma”) AND (“Aerobic Exercises” OR “Resistance Exercises” OR “Strength Training” OR “Mind-body Exercise” OR “Tai-ji” OR “Tai Chi” OR “Qi Gong” OR “Ch'i Kung” OR “pilates” OR “baduanjin” OR “Exercise” OR “yoga”). Manual searches supplemented this to obtain relevant literature by tracing references to systematic evaluations and literature reviews related to the subject terms when necessary.

2.2 Selection criteria

The inclusion criteria were: (a) the type of study was a randomized controlled trial; (b) the study participants were patients with breast cancer aged ≥18 years; (c) the control group received routine care or health education but did not undergo any exercise interventions; (d) the intervention group performed at least one of the five exercise types: aerobic exercise, resistance exercise, mind–body exercise (including tai chi, qigong, Baduanjin, and Pilates), combination exercise (aerobic exercise combined with resistance exercise), and yoga; (e) the outcome indicator was quality of life; and (f) the measures were the European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Functional Assessment of Cancer Therapy (FACT)-Breast, FACT-Anemia, FACT-General, and Short Form (36) Health Survey. All measurement tools included the Global Health score.

The exclusion criteria were: (a) literature without data, such as conferences, abstracts, letters, and reviews; (b) repeatedly published studies; (c) research flaws and poor quality; (d) studies with incomplete data or wherein the required data could not be obtained even after contacting the authors; (e) studies that included patients without breast or other cancers; and (f) studies for which the full text was not available.

2.3 Data collection

Two researchers (LL and YW) determined the final literature to be included by independently reading the titles and abstracts of the required literature. After excluding literature that did not meet the inclusion criteria, the full text of the uncertain literature was read. Two researchers cross-checked the results of the included studies. They discussed the literature that was in disagreement or difficult to determine for inclusion and consulted a third researcher to resolve the issue if necessary. Data were extracted and organized for analysis according to a pre-established information extraction form. The primary extracted information included (a) general study information: authors, title, date of publication, source of literature, and country; (b) study characteristics, including the general condition of the study population and mean age; (c) study outcomes, including intervention; (d) study methods: randomization method, use of blinding, intervention time, and length of follow-up; and (e) study outcomes: continuous variables, including mean, standard deviation, and sample size.

2.4 Risk of bias

Two independent reviewers (LL and YW) assessed the risk of bias in the included studies using the Cochrane Risk of Bias Assessment Tool recommended by the Cochrane Collaboration. The risk-of-bias assessment guidelines are based on seven entries in six areas: selection (including randomized sequence generation and allocation concealment), implementation (including blinding of study participants and researchers), measurement (blinding of study outcomes), follow-up (completeness of outcome data), reporting (selective reporting of study results), and others (other sources of bias). The risk of bias was assessed using seven dimensions of the risk of bias assessment guidelines, which resulted in “low risk of bias,” “high risk of bias,” and “unclear” findings [19].

2.5 Statistical analysis

NMA was performed using Stata18 (STATACorp, College Station, TX, USA) software through a random-effects model based on a frequentist framework. Owing to the different scales of measures, effect sizes were combined using standardized mean differences (SMDs) and 95 % confidence intervals (CIs), and the data were tested using an inconsistency model. If P > 0.05, the data were analyzed using a consistency model. If an inconsistency was observed, non-transmission was possible, and potential modifiers affecting the intervention effect were examined. The effects of different exercise types on the quality of life of patients with breast cancer were assessed based on the surface under the cumulative ranking curve (SUCRA). A more significant SUCRA value indicated a better intervention effect. Funnel plots were used to assess the publication bias.

3 Results

3.1 Literature selection

Herein, 1275 articles were retrieved from four databases and other sources. Overall, 631 articles were initially screened, and 145 were excluded after further screening. Finally, after reading the complete texts and excluding non-English-language articles, non-randomized controlled trials, and studies with inconsistent participants and incomplete data, 45 randomized controlled trials were included in the NMA. The retrieval flowchart is shown in Fig. 1.Fig. 1 Literature retrieval process.

Fig. 1

3.2 Research characteristics

Forty-five randomized controlled studies from 18 countries worldwide were included in this study, with literature published between 2004 and 2024 and a total sample size of 4092 cases. The sample size was all patients with breast cancer aged ≥18 years, and most of the included studies were on COMPLETED surgery, radiotherapy, or chemotherapy. Thirteen studies reported aerobic exercise, nine reported resistance exercise, ten reported combination and mind–body exercise, and seven reported yoga, while the control group mostly performed USUAL medical care. The intervention period of the included studies varied from a minimum of 3 weeks to a maximum of 26 weeks, and the most frequently selected outcome indicator was the EORTC QLQ-C30. All included studies were published in English; therefore, all the included literature shared a similar basic profile and was comparable. The essential characteristics of the included studies are presented in Table 1.Table 1 Basic characteristics of the included literature.

Table 1Study	Country	Sample Size (T/C)	Age (Mean ± SD)	Intervention Group	Control Group	Duration (weeks)	Outcome	condition	
Swisher 2015 [20]	USA	13/10	53.8 ± 10/53.6 ± 12	moderate intensity of aerobic exercises	usual medical care	12week	FACT-B	After active treatment	
Shobeiri 2016 [21]	Iran	27/26	42.70 ± 9.6/43.50 ± 8.6	moderate intensity of aerobic exercises	usual medical care	10week	EORTC QLQ-C30	completed surgery and chemotherapy or radiotherapy	
Murtezani 2014 [22]	Serbia	30/32	53 ± 11/51 ± 11	moderate intensity of aerobic exercises	maintain their sedentary lifestyle	10week	FACT-B	completed surgery, radiotherapy, and/or chemotherapy	
Lin 2022 [23]	China	48/48/49/47	Total(51.61 ± 30.71)	1G:aerobic exercises
2G:Resistance exercise	usual medical care	24week	FACT-B	postoperative	
Ligibel 2016 [24]	USA	47/51	49.3 ± 9.6/50.7 ± 9.4	Supervised and home-based aerobic exercise	routine care	16week	EORTC QLQ-C30	not amenable to surgical resection	
Lahart 2016 [25]	Uk	37/33	52.4 ± 10.3/54.7 ± 8.3	moderate intensity of aerobic exercises	usual care	24week	FACT-B	post-surgery	
Daley 2007 [26]	Uk	34/38	51.6 ± 8.8/51.1 ± 8.6	moderate intensity of aerobic exercises	continued with their lives as usual	8week	FACT-B	post-surgery	
Courneya 2011 [27]	Canada	160/160	50–70	moderate-to-vigorous intensity aerobic exercise	usual care	12week	SF-36	postoperative	
Courneya 2008 [28]	Canada	78/82/82	≥18	1G:aerobic exercises
2G:Resistance exercise	not to exercise training	17week	FACT-An	initiating adjuvant chemotherapy	
Charati 2022 [29]	Iran	35/35	≥18	aerobic exercises	usual care	5week	EORTC QLQ-C30	After chemotherapy	
Adams-C 2023 [30]	USA	15/15	63.3 ± 3.2/64.5 ± 3.2	moderate-intensity aerobic exercise	usual care	8week	FACT-B	Radiotherapy treatment	
Adams 2016 [31]	Canada	109/91/51	48.8(25–78)	1G:aerobic exercises
2G:Resistance exercise	avoid any new exercise training	17week	FACT-An	Chemotherapy treatment	
Steindorf 2014 [32]	Germany	77/78	55.2 ± 9.5/56.4 ± 8.7	Resistance exercise	muscle relaxation	14week	EORTC QLQ-C30	Chemotherapy treatment	
Soriano 2023 [33]	Spain	32/28	52.6 ± 8.8/52 ± 9.4	Resistance exercise	undertake ≥10,000 steps per day	12week	FACT-B	After treatment with chemotherapy or radiotherapy	
Schmidt 2015 [34]	Germany	49/46	52.2 ± 9.9/53.3 ± 10.2	Resistance exercise	loosening all muscles	12week	EORTC QLQ-C30	adjuvant chemotherapy	
Hagstrom 2016 [35]	Australia	19/15	51.2 ± 8.5/52.7 ± 9.4	Resistance exercise	usual
medical care	16week	FACT-G	completed surgery,
radiotherapy and/or chemotherapy	
Courneya 2007 [36]	Canada	78/82/82	49(25–78)	1G:aerobic exercises
2G:Resistance exercise	not to initiate an
exercise program	17week	FACT-An	beginning first-line adjuvant
chemotherapy	
Cešeiko 2019 [37]	Latvia	27/28	48.2 ± 6.7/49 ± 8	Resistance exercise	standard care	12week	EORTC QLQ-C30	completed surgery,
radiotherapy and/or chemotherapy	
Travier 2015 [38]	Netherlands	87/77	49.7 ± 8.2/49.5 ± 7.9	aerobic and strength exercise	usual care	18week	EORTC QLQ-C30	During chemotherapy	
Paulo 2019 [39]	Brazil	18/18	63.2 ± 7.1/66.6 ± 9.6	aerobic and strength exercise	relaxation exercises	10week	FACT-B	stage I to III breast cancer	
Milne 2007 [40]	Australia	28/29	55.2 ± 8.4/55.1 ± 8	aerobic and strength exercise	not given any specific
exercise	24week	FACT-B	stage
I–II breast cancer	
Mijwel 2018 [41]	Sweden	74/60	54.4 ± 10.3/52.6 ± 10.2	resistance and high-intensity interval aerobic exercise	usual care	16week	EORTC QLQ-C30	planned to receive adjuvant chemotherapy	
Herrero 2006 [42]	Spain	10/10	54.4 ± 10.3/52.6 ± 10.2	resistance and aerobic training	usual care	8week	EORTC QLQ-C30	After radiation therapy or after chemotherapy	
Dieli 2018 [43]	USA	46/45	Total(53.5 ± 10.4)	(aerobic and resistance) exercise	usual care	12week	FACT-B	postsurgery radiotherapy and chemotherapy	
De 2016 [44]	Italy	10/10	50.2 ± 9.7/46 ± 2.8	(aerobic and resistance) exercise	ollowed their usual lifestyle	24week	FACT-G	postsurgery radiotherapy and chemotherapy	
Carayol 2019 [45]	France	71/64	51.2 ± 10.9/52.1 ± 9.3	(aerobic and resistance) exercise	limit exercise practice or eat	18week	EORTC QLQ-C30	postsurgery radiotherapy and chemotherapy	
Basen 2020 [46]	USA	16/12	49.6 ± 13.3/49.2 ± 9.2	(aerobic and resistance) exercise	Usual care	24week	SF-36	newly diagnosed stage II or III breast cancer patients	
Antunes 2024 [47]	Portugal	44/41	49.66 ± 9.43/51.02 ± 9.54	(aerobic and resistance) exercise	Usual care	20week	EORTC QLQ-C30	with early-stage breast cancer	
Pasyar 2019 [48]	Iran	12/15	51.6 ± 10.46/51.8 ± 11.4	Yoga	routine care	8week	EORTC QLQ-C30	Chemotherapy treatment	
Moadel 2007 [49]	USA	84/44	55.11 ± 9.95/54.23 ± 10.07	Yoga	routine care	12week	FACT-G	Chemotherapy treatment	
Liu 2022 [50]	China	61/62	≥18	Yoga	routine care	20week	FACT-B	postoperative chemotherapy	
Littman 2012 [51]	USA	32/31	60.6 ± 7.1/58.2 ± 8.8	Yoga	routine care	24week	FACT-G	postsurgery radiotherapy and chemotherapy	
Eyigor 2018 [52]	Turkey	22/14	52.3 ± 9.5/51.5 ± 7.3	Yoga	routine care	10week	EORTC QLQ-C30	having completed surgical treatment, radiotherapy, and/or chemotherapy	
Eyigör 2021 [53]	Turkey	15/16	51.4 ± 10.6/50.7 ± 7.6	Yoga	routine care	10week	EORTC QLQ-C30	having completed surgical treatment, radiotherapy, and/or chemotherapy	
Culos 2006 [54]	Canada	18/18	≥18	Yoga	routine care	7week	EORTC QLQ-C30	No active treatment is currently received	
Ying 2019 [55]	China	46/40	≥18	Mind-body exercise(baduanjin)	routine care	24week	FACT-B	surgery, chemotherapy, and/or radiation	
Wei 2021 [56]	China	35/35	52(43–60)/55(50–62)	Mind-body exercise(baduanjin)	routine care	12week	FACT-B	scheduled to receive adjuvant chemotherapy	
Sandel 2005 [57]	UK	19/19	59.7 ± 9.8/59.5 ± 13.3	Mind-body exercise(dance)	routine care	26week	FACT-B	Surgical surgery within five years	
Loh 2014 [58]	Malaysia	32/32	18–65	Mind-body exercise(qigong)	routine care	8week	FACT-B	primary diagnosis of early stage (I-II) breast cancer	
Leite 2024 [59]	USA	18/16	55.29(10.93 ± 11)	Mind-body exercise(Pilates)	routine care	16week	EORTC QLQ-C30	Participated in any chemotherapy or radiation therapy	
Ho 2015 [60]	China	64/66	48.6 ± 7.7/49.1 ± 8.7	Mind-body exercise(dance)	routine care	3week	FACT-G	Have received surgical treatment	
He 2022 [61]	China	88/88	47.99 ± 8.62/48.32 ± 10	Mind-body exercise(dance)	routine care	16week	FACT-B	Have received surgical treatment	
Eyigor 2010 [62]	Turkey	15/27	48.52 ± 7.62/49.73 ± 8.71	Mind-body exercise(pilates)	routine care	8week	EORTC QLQ-C30	Surgical treatment, radiation therapy, or chemotherapy was completed	
Chang 2023 [63]	China	30/30	59.91 ± 10.51/52.77 ± 8.53	Mind-body exercise(qigong)	routine care	15week	EORTC QLQ-C30	undergoing chemotherapy	
Campo 2013 [64]	USA	29/25	66.54(55–89)/65.64(57–84)	Mind-body exercise(taiji)	routine care	12week	SF-36	Chemotherapy was completed	

3.3 Quality assessment

Statistically, all of the included studies reported the specific method of randomized sequence generation, and all were rated as low risk; three studies failed to blind the investigators and participants and were rated as high risk; one study failed to report basic information, such as age and disease duration in detail and was rated as high risk; and three studies had the potential for bias related to the specific study design and were rated as high risk. The specific bias assessment is shown in Fig. 2.Fig. 2 Literature quality bias assessment.

Fig. 2

3.4 NMA

Fig. 3 shows a comparative network of 45 studies comparing different forms of exercise after quality-of-life intervention in patients with breast cancer. The evidence network included five forms of exercise (aerobic, resistance, combination, mind–body, and yoga), with 4092 participants, 41 two-arm studies, and 4 multi-arm studies. The closed loop in the figure indicates both direct and indirect comparisons.Fig. 3 Evidence plot.

Note: The size of the sphere is proportional to the number of patients in this exercise intervention and the thickness of the connecting line is proportional to the number of experiments.

Fig. 3

A closed loop was formed among aerobic exercise, resistance exercise, and routine care, which was tested using an inconsistency model (IF = 0.817, P > 0.05). This indicated that the inconsistency test was insignificant in this study, suggesting that it could be analyzed using the consistency model.

Fig. 4 shows forest plots for pairwise comparisons. The results showed that aerobic exercise (SMD: 9.4 [CI 5.36, 13.43], P < 0.05), resistance exercise (SMD: 7.56 [CI 2.8, 12.31], P < 0.05), and combined exercise (SMD: 8.93 [CI 4.37, 13.48], P < 0.05) had a significant effect on the quality of life of patients with breast cancer in direct comparison with the controls. The cross-comparison between the five exercise interventions showed that mind-body exercise compared with resistance exercise (SMD: −6.53 [CI –12.66, −0.41], P < 0.05) had a significant effect, indicating that aerobic exercise was superior to mind-body exercise, and the other comparisons did not have a significant effect (Table 2).Fig. 4 Forest map.

Fig. 4

Table 2 Results of network Meta-analysis.

Table 2Aerobic	−1.84 (−7.34,3.65)	−6.53 (−12.66,-0.41)	−5.13 (−12.44,2.18)	−0.47 (−6.55,5.60)	−9.40 (−13.43,-5.36)	
1.84 (−3.65,7.34)	Resistance	−4.69 (−11.33,1.94)	−3.29 (−11.02,4.44)	1.37 (−5.21,7.96)	−7.56 (-12.31,-2.80)	
6.53 (0.41,12.66)	4.69 (−1.94,11.33)	Mind-body	1.40 (−6.25,9.06)	6.06 (−0.42,12.54)	−2.86 (−7.49,1.77)	
5.13 (−2.18,12.44)	3.29 (−4.44,11.02)	−1.40 (−9.06,6.25)	Yoga	4.66 (−2.95,12.27)	−4.27 (−10.36,1.83)	
0.47 (−5.60,6.55)	−1.37 (−7.96,5.21)	−6.06 (−12.54,0.42)	−4.66 (−12.27,2.95)	Combination	−8.93 (-13.48,-4.37)	
9.40 (5.36,13.43)	7.56 (2.80,12.31)	2.86 (−1.77,7.49)	4.27 (−1.83,10.36)	8.93 (4.37,13.48)	Usual care	

The effectiveness of the five different forms of exercise interventions on the quality of life of patients with breast cancer was ranked according to SUCRA values and combined with effect sizes: aerobic exercise (SUCRA = 84.1) > combined exercise (SUCRA = 78.8) > resistance exercise (SUCRA = 66.4) > yoga (SUCRA = 39.3) > mind–body exercise (SUCRA = 27.2) > usual care (SUCRA = 4.1) (Fig. 5).Fig. 5 Cumulative probability ranking.

Fig. 5

3.5 Publication bias

Comparison-corrected funnel plots were drawn using Stata18 software to assess publication bias based on quality of life. The positions of the scatter points in the funnel plot were visually symmetrical around the midline, and the auxiliary line was almost perpendicular to the midline, suggesting a low likelihood of bias in these studies (Fig. 6).Fig. 6 Funnel diagram.

Fig. 6

4 Discussion

This study analyzed direct and indirect comparative evidence from 45 randomized controlled trials, representing the most comprehensive current analysis of five forms of exercise (aerobic, resistance, mind–body, combination, and yoga) as quality-of-life interventions for patients with breast cancer. In total, 4092 study participants were included, and in a direct comparison with the usual care (control) group, the effects of aerobic, resistance, and combination exercises were statistically significant (P < 0.05). In the pairwise indirect comparison, aerobic exercise was significantly more effective than mind–body exercise (P < 0.05). The most effective type of exercise for rehabilitating patients with breast cancer was determined by ranking the SUCRA values as aerobic exercise > combination exercise > resistance exercise > yoga > mind–body exercise.

Aerobic exercise is the most effective form of exercise for improving the quality of life in patients with breast cancer. Seven of the 12 studies involving aerobic exercises in the literature reported that the intervention group performed moderate-intensity aerobic exercises, consistent with the exercises recommended by the American Cancer Society Diet and Exercise Guidelines. Patients with breast cancer may experience various sequelae after radiotherapy, chemotherapy, or surgical treatment, such as anxiety, depression, fatigue, lymphedema, depressed mood, and other adverse reactions that can seriously affect their quality of life and are detrimental to their recovery [65,66]. Rehabilitation of patients with breast cancer and survivors has long been recognized in clinical studies, suggesting the benefits of exercise [67,68]. The World Health Organization has recommended exercise for patients with breast cancer, and moderate exercise can enhance physical function and improve the quality of life to some extent [3]. Some studies have shown that patients with breast cancer have lower immune function and that aerobic exercise can increase metabolism, promote blood circulation, improve immunity, and improve patients' conditions, symptoms, and quality of life [26]. Aerobic exercise is characterized by low intensity, rhythm, and long duration, which makes it suitable as an auxiliary rehabilitation exercise for patients with breast cancer.

The combination exercise included in this study was primarily aerobic exercise combined with resistance exercise. Combining exercise improved both the cardiovascular health of patients with breast cancer with aerobic exercise alone and the effect on muscle strength enhancement in the resistance training group alone. Combination exercise can maximize the physical function of patients with breast cancer and improve their frailty and quality of life [42,43]. Milne et al. stated that the reason why aerobic and resistance combination exercise improves the quality of life of patients with breast cancer is related to fatigue and anxiety and that patients show reduced fatigue indices and anxiety levels after exercise, which improves their quality of life [40]. Basen-Engquist et al. reported that a combination of aerobic and resistance exercises during chemotherapy in patients with breast cancer prevented weight gain [46]. However, Dieli-Conwright et al. showed that a combination of aerobic and resistance exercises improved physical fitness, bone health, and quality of life in overweight or obese patients with breast cancer in a 16-week intervention [43]. The benefits of aerobic exercise combined with resistance exercise on the quality of life of patients with breast cancer are the second most important forms of exercise limited to aerobic exercise alone.

In this study, resistance, aerobic, and combination exercises were the three forms of exercise with the highest probability of being effective in rehabilitating patients with breast cancer. Resistance exercise counteracts external resistance by mobilizing the skeletal muscle contractions of the body and is a form of exercise that maintains or builds muscle strength, size, and endurance [69]. Some studies have indicated that resistance exercise maintains or enhances muscle strength, improves body composition in patients with breast cancer lymphedema, and reduces some of the deleterious effects of cancer treatment (including fatigue and weakness) [70]. Huo et al. indicated that resistance exercise has a significant effect on the physical functioning of patients with breast cancer who developed shoulder dysfunction during postoperative chemotherapy and was able to improve the symptoms of shoulder dysmobility and pain in patients [71]. Many studies have shown that resistance exercise has a significant effect on improving the quality of life of patients with breast cancer and that resistance exercise is an integral part of exercise rehabilitation therapy for such patients [72,73].

Yoga was the only separate exercise program included in this study. Yoga belongs to the mind-body exercise category. However, many relevant studies exist on yoga for breast cancer; therefore, we distinguished yoga from mind–body exercises and analyzed them separately. In a direct comparison with the conventional care (control) group, yoga and mind–body exercises did not have a significant effect (P < 0.05). The results of our analysis differed from those of previous studies on the participants [74,75], but with the same results as Wen et al. and Zhang et al. [76,77], who found that yoga does not significantly improve the quality of life of patients with breast cancer. We included Eyigor 2018 [52] and Eyigor 2020 [53] in the original literature. Both randomized controlled trials indicated that yoga did not significantly improve the quality of life in patients with breast cancer. Therefore, the current inconclusive findings on the effect of yoga on quality-of-life interventions in patients with breast cancer suggest the need for better study design, scientific rigor, and quality control.

4.1 Limitations

In this study, data extracted from randomized controlled trials were secondarily analyzed along with the quality of life of patients with breast cancer. However, this study is limited to the original literature published in English languages, excluding studies in other languages and thus may have increased the bias of the findings.

Systematic biases or errors may exist in the study design, data collection, analysis, or reporting of results in the included primary literature. This implies that the results of these experiments may have been affected by neglect, thereby reducing their reliability and credibility. The literature mentions some issues regarding methodology, such as the quality of studies and the risk of bias. In addition, the small sample sizes of some studies may have led to biased results.

Quality of life includes several indicators, including the measurement tool used in this study, the EORTC QLQ-C30, which comprises five functional scales, three symptomatic scales, and six single-item measures. The outcome included in the analysis of this study is one of the entries: the patient's quality of life (total health status). Therefore, the results of this study are relatively simple.

The effect of yoga and mind–body exercises on the quality of life of patients with breast cancer is inconclusive. Larger, higher-quality randomized controlled trials are needed to study the effects of yoga and mind-body exercises in depth. Only then can better exercise intervention programs be offered to patients to improve their quality of life.

5 Conclusion

This study identifies the optimal exercise program for the quality-of-life rehabilitation of patients with breast cancer and provides evidence of the effectiveness of different forms of exercise as an intervention for enhancing the quality of life(total health status) in these patients. Aerobic exercise is the most effective form of exercise rehabilitation for improving the quality of life(total health status) of patients with breast cancer, followed by combined and resistance exercises. However, patients should choose the appropriate type of exercise according to their conditions; for example, patients with shoulder dysmobility may choose resistance exercises.

Funding

This work was supported by the 2023 Shanghai Philosophy and Social Science Planning Project [grant number 2023BTY002 ].

Declaration of generative AI in scientific writing

The authors did not use the AI and AI-assisted techniques in this study.

CRediT authorship contribution statement

Liang Li: Writing – review & editing, Writing – original draft, Software, Methodology, Investigation, Data curation. Yutong Wang: Supervision, Software, Methodology, Investigation, Formal analysis, Data curation. Mingzhou Cai: Software, Methodology, Investigation, Data curation. Tonggang Fan: Writing – review & editing, Supervision, Project administration, Methodology, Funding acquisition, Formal analysis, Conceptualization.

Declaration of competing interest

The authors have no conflicts of interest relevant to this article.

Acknowledgements

We sincerely thank the Shanghai Philosophy and Social Sciences Planning Project for providing financial support.
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