A Group-Based, Videoconference-Delivered Physical Activity Program for Cancer Survivors

Abstract

Introduction/Purpose 

Virtually supervised, group-based exercise presents an innovative way to expand the reach of exercise-oncology programs and help cancer survivors increase physical activity (PA) and connect with other participants. This study examined the feasibility, acceptability, and preliminary effects of a group-based PA program delivered exclusively using videoconferencing software.

Methods 

This study used a single-group pre–post design. The 8-wk program consisted of aerobic and resistance exercise sessions once per week and three PA behavior change discussion sessions in groups of four to six. Feasibility was determined by enrollment, retention, safety, and adherence. Postprogram surveys evaluated acceptability using a Likert scale and open-ended responses. Changes in PA (Godin Leisure-Time Exercise Questionnaire), quality of life (QOL; Functional Assessment of Cancer Therapy—General), and upper and lower body muscular endurance (bicep curl and sit-to-stand test) were also evaluated.

Results 

Enrollment was feasible (n = 61 of 65 who expressed interest in the program), and retention (86.9%) and adherence (88% for exercise, 91% for discussion) were high; no adverse events were reported. Participants (mean age, 59.9 ± 10.1 yr; 96.2% female; 64.2% ovarian cancer, 28.3% breast cancer, 7.5% other cancer) reported they enjoyed the program (median, 7 of 7), and videoconferencing software was easy to use and had good video and audio quality (median, 5 of 5). From preprogram to postprogram, participants increased their weekly minutes of aerobic (mean (SD) change, 82.4 (144.2)) and resistance (mean (SD) change, 31.9 (42.7)) PA; sit-to-stand (mean (SD) change, 1.4 (3.9)) and bicep curl (mean (SD) change, 5.3 (6.8)) repetitions; and emotional (mean (SD) change, 0.82 (2.3) points), functional (mean (SD) change, 1.2 (3.6) points), and total QOL (mean (SD) change, 3 (7.9) points; all P < 0.05).

Conclusions 

A group-based PA program delivered using videoconference technology is feasible and acceptable for cancer survivors, and may increase PA and improve physical fitness and some aspects of QOL. A larger, controlled intervention is needed to determine efficacy, as well as pragmatic studies to directly compare this approach with conventional strategies (i.e., face-to-face programs).

INTRODUCTION

Moderate-to-vigorous physical activity (MVPA) has been shown to improve physical function and psychosocial outcomes (e.g., fatigue, quality of life (QOL), and depression) for cancer survivors (¹), and higher levels of physical activity (PA) may reduce cancer-specific mortality by up to 40% (²). This evidence has led organizations such as the American Cancer Society to issue PA recommendations for cancer survivors (³) and the American Society of Clinical Oncology to encourage PA as part of survivorship care (⁴). Despite these recommendations, recent estimates suggest that only 14.2% of individuals with a cancer history achieve recommended levels of PA (⁵). One proposed strategy to engage more cancer survivors in PA is to increase the availability and accessibility of interventions beyond randomized trials by providing evidence-based cancer-specific programs delivered in community-based settings (^6–8).

Cancer-specific PA programs have rapidly grown in popularity and, when studied, have demonstrated positive impacts on survivors’ PA, physical function, and QOL (^9–11). To date, a vast majority of these programs have been delivered face-to-face, which might limit potential for widespread scalability and reach for survivors living in remote or rural locations. Most recently, the coronavirus disease 2019 (COVID-19) pandemic exacerbated the need for distance-based delivery methods, with many cancer-specific PA programs having to temporarily close or adapt quickly to find ways to continue engaging participants in exercise while respecting social distancing orders.

The current evidence for distance-based delivery methods suggest that they are often less effective for increasing PA and improving health outcomes among cancer survivors than those that are delivered face-to-face (¹²). Key factors for this diminished intervention effect size might be lack of supervision from a qualified professional, lower adherence/compliance, and fewer opportunities for social interaction and support. The COVID-19 pandemic accelerated the need to develop innovative strategies to promote PA for cancer survivors that could overcome these limitations of traditional distance-delivered interventions, with some scholars suggesting that synchronous modalities (e.g., telehealth or videoconferencing) may be the answer, not only during but also the pandemic (^13,14). The feasibility and effects of videoconference-delivered interventions to improve PA and other health outcomes among cancer survivors are still emerging (¹⁵). To our knowledge, only five studies have reported on videoconference-delivered exercise-oncology interventions or programs (^16–20). Findings from these studies are promising in terms of feasibility, acceptability, and improvements in physical and psychosocial outcomes. However, only one described changes in PA (¹⁹). Limitations such as small sample size (i.e., n < 20), restricting enrollment to only one or two cancer types, and conducting preassessment and postassessment in person can limit generalizability and widespread dissemination for ongoing or future community-based cancer-specific exercise programs (^16,18–20). The only large study to report the feasibility and effects of an exercise program delivered virtually to cancer survivors was delivered individually (i.e., one-on-one with a trainer) (¹⁷).

A group-based PA program open to all cancer types and delivered exclusively online via videoconferencing has the potential to help cancer survivors increase PA and connect with other participants. However, before broad dissemination, translational clinical research is needed to establish the feasibility and effects of this type of program. Therefore, the purpose of this study was to assess the feasibility, acceptability, and preliminary effects of a group-based PA program for cancer survivors that was delivered exclusively using videoconferencing software.

METHODS

This study was a single-group, pre–post assessment of the videoconference delivery of an ongoing, 8-wk PA program called Fitness Therapy for Cancer (Fit Cancer). Fit Cancer has operated as a community outreach program in the Department of Health and Exercise Science at Colorado State University since 2017. The program is offered two to three times per year and was delivered face-to-face from 2017 to 2020. Face-to-face program implementation and results have been previously described in detail (²¹). The primary goal of Fit Cancer is to empower cancer survivors to engage in independent PA by providing them with knowledge, tools, and skills during the program. In March 2020, the program was shut down because of COVID-19 restrictions and safety protocols. In an attempt to resume services, Fit Cancer was adapted for delivery via Zoom videoconferencing (Zoom Video Communications Inc., San Jose, CA), and beta-testing was completed in Fall 2020 (²²). The current study reports on participants who enrolled in the program between January 2021 and January 2022.

Participants

To be eligible for Fit Cancer, participants must be 1) ≥18 yr old, 2) able to speak and read English, and 3) diagnosed with any type of cancer. For virtual delivery, participants also had to have Internet access and possess a computer, tablet, or smart phone with a front-facing camera. Exclusion criteria were 1) pregnant or planning to become pregnant, 2) surgery scheduled or planned, and 3) known contraindications for exercise (e.g., existing cardiovascular or metabolic disease, use of an assistive walking device, severe ataxia) that preclude participation in nonmedically supervised exercise (²³).

Procedures

All procedures performed in this study were in accordance with the ethical standards of the Colorado State University institutional review board for the protection of human subjects (CSU IRB Nos. 2482 and 2988). The program was advertised via email blasts to cancer survivor support groups and local cancer centers, Facebook and Twitter posts, and the Moving Through Cancer Exercise Program Directory as “Digital/Online.” Interested individuals completed an online PA readiness questionnaire (PAR-Q+) (²⁴) and provided contact information. The program coordinator contacted potential participants via telephone and assessed them for eligibility. Potential participants whose responses on the PAR-Q+ indicated a need for medical clearance were required to complete the electronic Physical Activity Readiness Medical Examination (ePARmed-X+) Physician Clearance Follow-up form to be cleared for exercise training with limited supervision.

Participants who met the eligibility criteria were scheduled for two one-on-one appointments via videoconferencing software (Zoom) with the program coordinator. At the first appointment, the program coordinator reviewed information about the program with the participant, and a waiver of liability and informed consent for data to be used for research purposes was obtained using Research Electronic Data Capture (REDCap; REDCap Consortium, Nashville, TN) tools hosted at the University of Colorado Anschutz Medical Campus (²⁵). Participants provided a detailed health history and had the opportunity to ask any questions related to the program. Immediately after the first appointment, participants were sent program materials via US Postal Service, including a wrist-worn activity tracker (FitBit Inspire™, San Francisco, CA; or WYZE 47™, Kirkland, WA) and a set of five resistance bands (Odoland™, New York, NY) in tension weights equal to 5–25 lb with a door mount, handles and ankle straps, a sweat-wicking towel, a Fit Cancer t-shirt, a water bottle, and a workbook. During the second appointment (also via Zoom), participants completed baseline measures of self-reported anthropometrics (resting heart rate, last known resting blood pressure, height, and weight) and upper and lower body muscular endurance, and were instructed on how to set up their video cameras and exercise equipment. At the end of the second visit, participants were emailed program questionnaires via REDCap. After completing both initial one-on-one appointments, participants were assigned to a group of four to six individuals for the duration of the intervention based on their schedule/availability for weekly exercise sessions. Group size was kept relatively small to ensure safety during exercise sessions (i.e., so the instructor could closely monitor all participants) but still provide opportunity for social interaction.

Within 2 wk of completing the program, participants were scheduled for another one-on-one appointment with program staff via Zoom to complete a postprogram assessment consisting of the same measures of anthropometrics, upper and lower body muscular endurance, and questionnaires.

Program Content

Group-based exercise sessions were held once per week and lasted approximately 1 h. Exercise sessions were led by two program staff consisting of an American College of Sports Medicine–certified exercise physiologist with specialized training in exercise oncology and an undergraduate or master’s student in exercise science (²⁶). Sessions consisted of a 5-min warm-up followed by three mini-circuits consisting of two resistance exercises and one aerobic exercise (table, Supplemental Content 1, https://links.lww.com/TJACSM/A200). Participants were encouraged to exercise at a light-to-moderate intensity (i.e., rate of perceived exertion of 3–6 on a 10-point scale) and instructed to modify their intensity based on their fatigue and energy levels that day (e.g., if they felt more fatigued, the intensity should be on the less-intense end of the scale). Exercise sessions finished with a cool-down and light stretching for all major muscle groups, also led by the instructor. Participants were encouraged to exercise independently one to three times per week at an intensity commensurate with supervised sessions (i.e., light to moderate). Independent exercise frequency, type, and modality were self-selected by participants, and they were provided access to the recorded exercise sessions via a private YouTube (Google, San Bruno, CA) channel.

Group-based PA behavior-change discussion sessions operationalized behavior change techniques guided by the Social Cognitive Theoretical framework and aimed to increase PA both during and following completion of the intervention (^27,28). Participants were encouraged to achieve the exercise guidelines for cancer survivors and progress to achieving the US Department of Health and Human Services PA guidelines (^1,29). Three discussion sessions were held after the exercise session in weeks 2, 4, and 7, lasting approximately 30–45 min each. Program staff facilitated discussion sessions using a standardized checklist, whereas participants completed group and individual activities from a bound, printed program workbook. Behavior change techniques and discussion topics are outlined in Supplemental Content 2 (table, https://links.lww.com/TJACSM/A201.

Measures

Demographic and clinical data

Basic demographic and clinical information was self-reported at baseline. Data included age, sex, marital status, employment status, time since diagnosis, treatment type(s) and status, and tumor type.

Feasibility and acceptability

Feasibility of the program was assessed by tracking the following: 1) enrollment (number enrolled out of number who completed the online screening form), 2) adherence to the supervised exercise and discussion sessions (number of sessions attended out of number of available sessions), and 3) retention (number of complete postprogram assessments out of those who began the program). In addition, reasons for not enrolling, dropout or withdrawal, and any adverse events or serious adverse events (related or unrelated to the study) were reported to the institutional review board of record. To assess acceptability, participants completed a satisfaction questionnaire that consisted of Likert-scale questions evaluating enjoyment of the program and satisfaction with the technology used (i.e., Zoom), and provide written responses to the following additional open-ended question: what were the highlights of participating in the Fit Cancer program?

Outcomes

MVPA was assessed using a modified version of the Godin Leisure-Time Exercise Questionnaire, which has been used extensively in cancer populations (^30,31). The modified Godin Leisure-Time Exercise Questionnaire asks about the frequency and duration of aerobic and resistance exercise performed in a week (³²). Specifically, participants were asked to recall their exercise during a typical 7 d over the last month and were provided space to write the average frequency (i.e., days per week) and duration (i.e., minutes per session) for moderate and vigorous aerobic and at least moderate-intensity strengthening exercise. PA outcome variables were calculated using the following equations:

$\begin{array}{l}\text{Weekly minutes of moderate and vigorous aerobic exercise (MVAE)}\\ =\begin{array}{l}((\text{moderate frequency}\times \text{moderate duration})\\ +(\text{vigorous frequency}\times \text{duration}\times 2))\end{array}\end{array}$

$\begin{array}{l}\text{Weekly minutes of resistance training or strengthening exercise}\left(\mathrm{RSE}\right)\\ =\left(\text{frequency}\times \text{duration}\right)\end{array}$

$\text{Total weekly minutes of MVPA}\left(\text{MVAE}+\mathrm{RSE}\right)=\text{weekly minutes MVAE}+\text{weekly minutes}\mathrm{RSE}$

QOL was measured using the Functional Assessment of Cancer Therapy—General (FACT-G), a quantitative, self-report measure of QOL. The FACT-G (version 4) is a 27-item self-report measure, with subscales evaluating physical, social, emotional, and functional well-being. FACT-G scores range from 0 to 108, with higher total and subscale scores indicating better QOL. The FACT-G has been found to be a reliable and valid measure (³³).

Upper and lower body muscular endurance was measured using the arm curl and sit-to-stand tests (³⁴). This is the number of bicep curls using a 5-lb resistance band, and the number of full stands from a chair that can be completed in 30 s.

Data Analyses

Data were collected and managed using REDCap tools hosted at Colorado State University (²⁵). The minimum target sample size for this pilot study (n = 35) was based on our primary aim to assess feasibility and acceptability of the virtual delivery of the program. A sample size of 35 produces a two-sided 95% confidence interval with a width equal to 0.2 when the hypothesized acceptability is 0.8. In terms of effectiveness outcomes, a minimum sample size of n = 35 was required to detect a moderate effect size with α = 0.05 and β = 0.8 (G*Power 3.1.9.7) (³⁵) using a two-tailed t-test to detect a difference between two-dependent means.

Cohort characteristics and feasibility and acceptability metrics were summarized utilizing counts and percentages for categorical variables and means, SD, medians, and quartiles for continuous variables. The differences between baseline and postintervention for PA, QOL, and upper and lower body muscular endurance were evaluated with the Wilcoxon signed rank test because of violations of the normality assumption. The effect size for each comparison was calculated by dividing the absolute standardized test statistic by the number of pairs. Significance was defined as a P value ≤0.05 and based on a two-sided alternative. Quantitative analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). To analyze open-ended responses on the program satisfaction survey, one author (M. E. C.) and a research assistant reviewed all participant written responses. Line-by-line inductive coding was performed using NVivo software, Version 12 (QSR International, Doncaster, Australia) to allow themes to emerge. All coauthors reviewed the final coding mechanisms and resulting themes, and data triangulation was performed by consulting Likert for each participant to enhance rigor and credibility (³⁶).

RESULTS

Feasibility and Acceptability

Out of n = 65 that completed the online screening form, 61 people (93.8%) enrolled in the program, 53 (86.9%) of which completed the program. Flow through the program and reasons for withdrawal/dropout are shown in Supplemental Content 3 (figure, https://links.lww.com/TJACSM/A202). Most participants heard about the program through a support group (n = 38 (74.5%)), referral (i.e., oncologist or health care provider; n = 8 (15.6%)), or family or friend (n = 5 (9.8%)). The majority of participants were ovarian (n = 34 (64.2%)) and breast (n = 15 (28.3%)) cancer survivors. The average age was 59.6 ± 10.1 yr, and time since diagnosis was 49.9 ± 66.5 months. Additional participant characteristics are shown in Table 1. In terms of safety, one participant had a hospital visit because of existing hypertension and one reported nausea and dizziness, but none of these events were attributed to the program and did not limit participation. Class size ranged from 3 to 6 (median, 5). Average adherence for exercise sessions was 88.1% ± 13.0% (7.1 ± 1.1 sessions attended). Average adherence for discussion sessions was 91.1% ± 17.7% (2.7 ± 0.53 sessions attended).

TABLE 1 - Characteristics of Participants Who Completed the Program (n = 53 Unless Otherwise Noted).

	Mean (SD); Median (IQR)
Age, yr	59.57 (10.10); 61 (54.00, 64.00)
Time since diagnosis (n = 50), mo	49.90 (66.51); 33.46 (16.49, 57.88)
Time since chemotherapy (n = 31), mo	38.45 (76.03); 20.11 (7.85, 37.45)
Time since radiation (n = 18), mo	66.20 (122.49); 18.05 (7.49, 30.39)
Time since surgery (n = 48), mo	43.68 (67.83); 25.54 (12.98, 40.34)
	n (%)
Sex
Female	51 (96.23)
Male	2 (3.77)
Ethnicity
White	48 (90.57)
Black or African American	1 (1.89)
Hispanic or Latino	2 (3.77)
Asian/Pacific Islander	2 (3.77)
Highest level of education
High school graduate or GED	1 (1.89)
Some college/associate’s degree/technical school training	12 (22.64)
College graduate (bachelor’s degree)	14 (26.42)
Graduate school degree (master’s or doctorate)	26 (49.06)
Cancer diagnosis
Brain and nervous system	1 (1.89)
Breast	15 (28.30)
Colorectal	2 (3.77)
Prostate	1 (1.89)
Ovarian	34 (64.15)
Ever received chemotherapy
No	6 (11.32)
Yes	47 (88.68)
Receiving chemotherapy upon enrollment
No	38 (71.70)
Yes	15 (28.30)
Ever received radiation therapy
No	35 (66.04)
Yes	18 (33.96)
Receiving radiation upon enrollment
No	53 (100)
Surgery as a part of cancer treatment
No	1 (1.96)
Yes	50 (98.04)

GED, General Educational Development Test.

All participants who completed the program evaluation survey (n = 53) responded “yes” or “definitely yes” that they “looked forward to exercise sessions,” “felt physically stronger,” felt the “staff and group environment provided a sense of community and support,” “would recommend this program to a fellow cancer patient/survivor,” and “have the knowledge and skills to exercise safely and effectively on their own.” Regarding satisfaction with the technology used, all participants were either “very satisfied” or “completely satisfied” with the ease and comfort of using Zoom and the visual and sound quality of exercise and discussion sessions. The median and interquartile range (IQR) of all program satisfaction items are shown in Supplemental Content 4 (table, https://links.lww.com/TJACSM/A203). In response to the open-ended question, “What were the highlights of your participation in the Fit Cancer program?” four major themes were identified from a total of 74 responses: instructors (n = 16 (21.6%)), social support (n = 15 (20.2%)), exercise sessions (n = 32 (43.2%)), and real-world resources (n = 11 (15.0%)). See Table 2, for example quotations underlying each major theme.

TABLE 2 - Qualitative Themes and Representative Quotes from Program Evaluation Questionnaire.

Theme, n (%)	Representative Quotes
Instructors, 16 (21.6)	“Attitude, expertise, and support of the Fit Cancer staff” “I really enjoyed our leaders” “The instructors were AWESOME” “Personal attention from the instructors helped me jump start more regular exercise”
Social support, 15 (20.2)	“The social aspect of exercising together” “Group motivation” “The encouragement of fellow team members” “It was powerful to meet other survivors”
Exercise sessions, 32 (43.2)	“it got me back into the mindset that regular and consistent exercise will help me feel better” “Getting into a sustainable exercise routine, I’m still exercising regularly after the sessions ended!” “Learning new cardio, resistance, and stretching exercises”
Real-world resources, 11 (15.0)	“the bands are truly life changing addition to my routine and make at home exercise easy to do, it eliminates all my barriers” “Receiving some tools have been VERY helpful (Fitbit, bands)” “Having access to the YouTube channel has been life changing to continue exercising”

Outcomes

Physical activity

There was a difference in MVAE from preprogram to postprogram, with an average increase of 82.4 ± 144.2 min·wk⁻¹ (P < 0.001). There was a difference in RSE from preprogram to postprogram, with an average increase of 31.9 ± 42.7 min·wk⁻¹ (P = 0.001). There was also a difference in total PA (MVAE + RSE) from preprogram to postprogram with an average increase of 114.3 ± 156.2 min·wk⁻¹ (P < 0.001). Baseline and postprogram means, SD, medians, and effect sizes are shown in Table 3.

TABLE 3 - Changes in Outcomes from Baseline to Postprogram.

	Baseline	Post Program	Change
	n; Mean (SD); Median (IQR)	n; Mean (SD); Median (IQR)	n; Mean (SD); Median (IQR)	Pa	Effect Size b
Moderate and vigorous aerobic exercise, min·wk−1	53; 133.7 (175.7); 60 (0, 180)	50; 218.9 (185.8); 180 (90, 270)	50; 82.4 (144.2); 90 (0, 160)	<0.001	0.61
Resistance/strengthening exercise, min·wk−1	53; 20.0 (38.6); 0 (0, 20)	50; 53.1 (50.3); 40 (15, 75)	50; 31.9 (42.7); 27.5 (10.0, 60.0)	<0.001	0.74
Total exercise, min·wk−1c	53; 153.7 (183.0); 70 (15, 240)	50; 272.0 (197.4); 245 (150, 355)	50; 114.3 (156.2); 115 (30, 205)	<0.001	0.73
Bicep curl (repetitions)	52; 28.7 (9.7); 26.5 (21.8, 34.0)	51; 34.1 (10.5); 31.0 (26.5, 39.5)	50; 5.3 (6.8); 5.8 (1.0, 8.5)	<0.001	0.77
Sit to stand (repetitions)	53; 12.2 (4.0); 12 (9, 14)	50; 13.8 (2.7); 14 (11, 16)	50; 1.4 (3.9); 1 (0, 3)	<0.001	0.58
Quality of life
Emotional well-being subscale	52; 16.9 (4.2); 18.0 (14.5, 20.0)	50; 17.6 (4.1); 19 (16, 21)	49; 0.8 (2.3); 1 (−1, 2)	0.01	0.39
Functional well-being subscale	52; 17.8 (5.1); 17 (15, 21)	50; 18.7 (5.0); 19 (15, 23)	49; 1.2 (3.6); 1 (−1, 4)	0.03	0.37
Social family well-being subscale	52; 19.7 (4.7); 19.5 (17.0, 23.0)	50; 19.7 (5.3); 20.5 (17.0, 24.0)	49; 0.1 (2.7); 0 (−2, 2)	0.73	0.06
Physical well-being subscale	52; 20.2 (5.3); 21 (16, 25)	50; 21.1 (4.8); 22 (17, 25)	49; 0.8 (3.7); 1 (−1, 3)	0.09	0.29
Total quality of life	52; 74.5 (13.4); 75.0 (66.5, 83.0)	50; 77.1 (14.6); 77.5 (70.0, 87.0)	49; 3.0 (7.9); 3 (−2, 8)	0.01	0.42

^aWilcoxon signed rank test.

^bCalculated by dividing the absolute standardized test statistic by the number of pairs. Using Cohen’s classification of effect sizes, the results can be interpreted as 0.1 (small effect), 0.3 (moderate effect), and 0.5 and greater (large effect).

^cTotal exercise = Aerobic minutes per week + resistance/strengthening minutes per week.

Quality of life

There was a difference in emotional well-being, with an average increase of 0.8 ± 2.3 points (P = 0.02), functional well-being with an average increase of 1.2 ± 3.6 points (P = 0.03), and a difference in the total QOL score with an increase of 3.0 ± 8.0 points (P = 0.01) from preprogram to postprogram. There was no difference in social or physical well-being subscale scores between preprogram and postprogram (all P > 0.05). Baseline and postprogram means, SD, medians, and effect sizes are shown in Table 3.

Upper and lower body muscular endurance

There was a difference in the number of bicep-curl repetitions from preprogram to postprogram, with an average increase of 5.3 ± 6.8 repetitions (P < 0.001). There was a difference in the numbers of sit-to-stand repetitions from preprogram to postprogram with an average increase of 1.4 ± 3.9 repetitions (P < 0.001). Baseline and postprogram means, SD, medians, and effect sizes are shown in Table 3.

DISCUSSION

Findings from this study fill gaps in the current literature by providing evidence for the feasibility and acceptability of a group-based PA program open to all cancer types, delivered exclusively online via videoconferencing, and preliminary support for this type of program to help cancer survivors increase MVPA.

Feasibility of the program was assessed based on enrollment (94%), retention (87%), adherence to exercise (88%), and discussion sessions (91%), and no adverse events attributed to the program. In addition, responses on the program evaluation questionnaire reflected very high satisfaction, including acceptability of Zoom technology. In program highlights, participants described the instructors, exercising with fellow cancer survivors, and program resources as positive aspects of their experience. Previous studies in cancer survivors and older adults similarly concluded that a group-based, and videoconference- or telehealth-delivered exercise program was feasible in terms of adherence, retention, safety, and satisfaction (^19,20,37). These and the current study’s findings support videoconference as a viable way to enhance the scalability and dissemination of supervised, group-based exercise interventions, and programs for cancer survivors who may face accessibility barriers to these resources. However, further study is still required to determine for whom online exercise is or is not appropriate (e.g., adults with multiple comorbidities requiring supervision and monitoring or those with limited Internet access).

In terms of effects, there was a statistically significant increase in MVPA (i.e., aerobic and resistance exercise) from preprogram to postprogram, with large effect sizes for resistance exercise and total MVPA. Only one previous study has measured changes in cancer survivors’ PA after a group-based videoconference intervention (¹⁹). That study showed nonstatistically significant increases in PA but was limited by a small sample size (n = 13) (¹⁹). When compared with group-based videoconference PA interventions in other populations, increases in PA in the current study were larger: an average increase of 114.3 min·wk⁻¹ of total MVPA in the current study versus 34.9 min of MVPA per week in a study of mothers (³⁸), and 23.9 moderate PA minutes per week in a study of adults with Alzheimer’s disease (³⁹). It is difficult to ascertain the reason(s) for the larger increases in MVPA in our study compared with these two other studies; however, potential explanations could be the method of assessing PA (e.g., steps using an activity tracker vs self-reported aerobic and resistance exercise in the current study), population characteristics, or inclusion of targeted behavior change techniques to increase PA outside of the supervised sessions (see table, Supplemental Content 2, https://links.lww.com/TJACSM/A201).

Regarding QOL, two subscales (emotional and functional well-being) as well as total QOL showed a statistically significant increase, with small to medium effect sizes, which was similar to the face-to-face Fit Cancer program (²¹). One previous study also found that an 8-wk telehealth exercise intervention improved QOL with larger effect sizes than the current study; however, those participants were all postadjuvant treatment, and exercise sessions were held three times per week (¹⁶). Thus, it remains unclear whether a more intensive videoconference intervention is needed to achieve QOL improvements that are similar to previously reported face-to-face exercise interventions (⁴⁰), or if effects should be interpreted specific to treatment status (i.e., for participants who are undergoing adjuvant treatment, the goal for QOL may be to prevent declines, not improve).

The current study also demonstrated statistically significant improvements in muscular endurance, as measured by the number of bicep-curl repetitions (with a 5-lb resistance band) and sit-to-stand repetitions completed in 30 s. This finding is consistent with a previous telehealth intervention for breast cancer survivors, which elicited large improvements in handgrip and sit-to-stand (¹⁶). The effect size observed for sit-to-stand repetitions (d = 0.55) was smaller than observed following the face-to-face Fit Cancer program (d = 0.62) (²¹), similar to a study in breast and prostate cancer survivors that found smaller improvements in chair stand time when their in-person exercise intervention was adapted for videoconference delivery (²⁰).

Taken together, these findings suggest that a group-based, videoconference-delivered program is feasible and can provide real-time PA support for cancer survivors in their own homes, including interaction with group members and supervision from a qualified exercise professional. This offers an opportunity for social connectedness with fellow cancer survivors and allows facilitators to ensure that exercises are being performed safely and effectively, both elements that are widely acknowledged as important factors for PA adherence (^40,41).

Strengths and Limitations

Strengths of the current study include the group-based approach, real-time supervision by a qualified exercise professional, the inclusion of theory-informed behavior change techniques (i.e., goal setting, self-monitoring, problem solving), and opportunities for social contact and support from other cancer survivors, which are consistent with best-evidence strategies for PA behavior change in cancer survivors (⁴²). Our sample was diverse in terms of age, cancer type, and varying stages of treatment, which may be viewed as a strength in terms of generalizability of findings to existing exercise oncology programs and which likely contributed to successful recruitment and enrollment in the program. However, this may also be viewed as a limitation, in that a large, diverse sample is heterogeneous, which introduces more variability in the behavioral and physiologic responses to an exercise program (e.g., it is expected that individuals undergoing active cancer treatment(s) will demonstrate a lesser magnitude of increase in PA and physical function than those who have completed treatment(s)). In addition, the diversity of our sample was limited in terms of sex, race/ethnicity, and socioeconomic status, with most of our sample consisting of highly educated, non-Hispanic White women. This lack of diversity is consistent with other community-based exercise programs for cancer survivors (⁹), suggesting a pressing need to find ways to expand the reach of videoconference exercise programs to cancer survivors from underserved and/or racial/ethnic minority groups (e.g., establishing a network and relationships in underserved communities, increasing the diversity of investigators and study staff, implementing culturally relevant recruitment strategies).

Other important limitations of the study should also be noted. First, given that participants were self-referred, there was likely a sampling bias (i.e., cancer survivors interested in an exercise program enrolled, so they were already willing/able to exercise); thus, given the pre–post study design, we cannot definitively conclude that the program provided benefits over time alone, and efficacy cannot be determined. Second is the absence of objective measures of PA (i.e., accelerometer or pedometer) in addition to self-reported PA. However, because the nature of the exercise sessions was mixed aerobic and resistance training, and we observed large increases in resistance exercise, pedometers or accelerometers likely would not have accurately captured the types of activities done during the program. Third, although the program was feasible in terms of retention and adherence, information about compliance to the exercise prescription (i.e., intensity) and any dose modifications was not recorded.

Future Directions

Given the feasibility demonstrated in this and previous studies (^19,20), and the preliminary effects on PA, physical function, and QOL, the results indicate a need for a definitive randomized trial to determine efficacy of a group-based, videoconference PA intervention for cancer survivors and studies that directly compare effects between a virtually supervised approach and traditional face-to-face delivery. Because participants were provided with the knowledge, skills, and equipment to exercise independently, future studies should also examine the effect of a videoconference PA program on long-term PA behavior change (i.e., PA maintenance). Furthermore, with the concerns for social isolation among cancer survivors during the COVID-19 pandemic and those living in rural areas (^43,44), the extent to which a group-based videoconference program can facilitate social processes should be explored.