Gradual Increase in Daily Activity With Psychological Therapies May Improve Mental and Physical Health for Patients and Survivors of Breast Cancer

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Patients and survivors of breast cancer may have better mental health, physical health, and quality of life when taking part in a “behavioral graded activity” in combination with psychological therapies, according to a new study published by Lahousse et al in the European Journal of Cancer. The new findings were also presented at the 13th European Breast Cancer Conference (Abstract 23).

Research Background

A behavioral graded activity is a physical activity program that allows physiotherapists to gradually increase the amount of patients’ physical activity, and to continue to adhere to the program so that, ultimately, the increased activity is integrated into their daily lives. The activities are tailored to patients’ needs, graded over time, and involve the setting of specific goals.

“[This study is] focusing on pain education and behavioral interventions relating to persistent pain after breast cancer. [The] goal is to decrease patients’ pain and increase patients’ quality of life by being physically active. Long-term use of pain medication is not appropriate and nonpharmacologic treatments are needed. We already know that exercise can be beneficial, but some patients do not remain active when their exercise program has finished. Until now, there has been no systematic review of the effects of behavioral graded exercise on different outcomes among [patients with breast] cancer,” said first study author Astrid Lahousse, a PhD student in the Department of Physiotherapy, Human Physiology, and Anatomy at the Vrije Universiteit Brussel and a PhD fellow at the Research Foundation–Flanders.

Study Methods and Results

Ms. Lahousse and her colleagues carried out a systematic review and meta-analysis of 33 studies involving 4,330 patients and survivors of breast cancer—comparing the effectiveness of behavioral graded activities and psychological therapies (such as cognitive behavioral therapy and acceptance commitment therapy) with outcomes for patients on waiting lists for treatment, receiving usual care, receiving psychological therapies only, or participating in behavioral graded activities only.

The researchers found that patients who underwent psychological therapies combined with behavioral graded activities demonstrated significant effects compared with those on waiting lists receiving neither. These included large to medium improvements for fatigue, the ability to manage everyday tasks, anxiety, depression, psychological distress, physical activity, quality of life, and social impairment. After a period of 1 to 3 months, only the effects on psychological distress remained statistically significant.

When comparing patients who underwent psychological therapies combined with behavioral graded activities with those who received the usual standard of care, the researchers found significant medium improvements for anxiety, depression, fatigue, and physical activity. After 1 to 3 months, the medium effects on anxiety, depression, and fatigue remained significant.

No statistically significant effects were seen when comparing patients who underwent psychological therapies combined with behavioral graded activities with those who participated in behavioral graded activities or psychological therapies only.

“When comparing behavioral graded activit[ies] with usual care such as leaflets, education, and standard recommendations, fatigue, anxiety, and depression were reduced and physical activity increased due to the behavioral intervention. When comparing behavioral-graded activit[ies] with no intervention, only psychological problems were reduced in the long term,” Ms. Lahousse highlighted.

“It underlines to researchers that new, nonpharmacologic interventions are needed. Doctors need to know about other non–drug-related possibilities for care after cancer treatment, and that medication should not be prescribed in the long term. They should consider transferring the care of patients to other appropriate health-care providers, such as physiotherapists and psychologists. The study also shows patients how they could improve their everyday functioning and quality of life during and after cancer treatment,” said Ms. Lahousse, who stressed that “[f]or [breast] cancer survivors, it is important to improve nonpharmacologic treatments after cancer care.”

She continued: “Currently, oncologists are providing the best care during [breast] cancer treatment. However, after [breast] cancer, patients often feel lost and ill-informed about the side effects of the treatment. For this reason, more research is needed not only on what should be provided but also on how, because each patient needs personalized care. So, a general, postcancer program may not be best for everybody. For this reason, behavioral interventions could be more appropriate and should be investigated further.”


The study was the first to analyze behavioral interventions among patients and survivors of breast cancer, which is a step toward more personalized treatment involving patients setting their own goals. A limitation was the large variation between the different studies included in the systematic review, which made it difficult to draw strong conclusions without further research.

“How patients and survivors of breast cancer live their lives after their cancer treatment has finished is an important but often neglected area of investigation,” commented David Cameron, MD, Professor of Medical Oncology at the University of Edinburgh Cancer Research Centre, Deputy Director of the Innovative Health Care Delivery Programme, and President of the European Breast Cancer Council, who was not involved in the study. “Survivors can live for years, if not decades, so support from the health-care community is necessary to help them achieve a good quality of life. This study identifies interventions that could help, but more research is needed. Any such interventions also need to be fully funded so that every patient can have access to therapies that could help them enjoy a fulfilling and pain-free life. This remains a challenge in some countries.”

Disclosure: For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.