Rowing-Based Exercise Intervention on Health and Quality of Life in Breast Cancer Survivors

BACKGROUND AND THEORETICAL RATIONALE

The beneficial effects of adapted physical activity (APA) in cancer patients have been extensively demonstrated. Engaging in regular and sufficient levels of physical activity (PA) following a diagnosis of early-stage, potentially curable cancer is associated with a reduced risk of mortality from breast, prostate, and colorectal cancer. Emerging evidence also suggests that sedentary behavior and screen-based activities are independent risk factors for cancer mortality. Both aerobic and resistance exercise have been shown to provide physiological benefits and improvements in quality of life, including enhanced cardiovascular fitness, increased upper- and lower-limb muscle strength, and greater lean body mass. Reductions in fatigue, depression, and sleep disturbances have also been observed, and supervised exercise appears to produce greater improvements than unsupervised exercise.

Exercise volume often decreases during cancer treatment and may not return to pre-diagnosis levels after treatment completion. Only a very small proportion (8%) of individuals achieves 150 minutes per week of moderate-to-vigorous PA following diagnosis and surgery. Breast cancer survivors who have undergone surgery spend most of their day in sedentary activities (66%) or light-intensity PA (33%). Promoting exercise while avoiding unnecessary barriers to participation is therefore of fundamental importance. When appropriately structured, exercise is safe for nearly all patients, and its health benefits outweigh the risks for most individuals. A medical evaluation is necessary beforehand, particularly in the presence of comorbidities such as cardiovascular diseases. Breast cancer survivors are usually prescribed shoulder and arm mobility exercises and upper-body exercises, followed by flexibility exercises 2-3 times per week (for example yoga or Pilates), together with aerobic and resistance training. Aerobic training is recommended 3-5 times per week at 40-60% of oxygen uptake reserve or heart rate reserve, for more than 30 minutes per session (for example walking, cycling, or swimming). Resistance training is recommended 2-3 times per week at a moderate intensity (corresponding to 60-70% of 1-RM, or 6-15 repetitions per exercise), through a circuit of 8-10 exercises targeting all major muscle groups, using body weight or resistance machines.

Upper-limb lymphedema is a complication that may occur in women with breast cancer after surgery and/or radiotherapy. Several studies have reported that dragon boat paddling can be performed safely and may benefit these women. This activity is increasingly popular, partly because it is performed outdoors and has positive therapeutic effects. The paddling movement has been associated with a reduction in arm circumference without adversely affecting pre-existing lymphedema, and dragon boat training has been associated with improvements in anthropometric parameters, physical fitness, and myocardial function, contributing to better health and quality of life.

Few studies have investigated the effects of rowing. In one study, twelve weeks of rowing training (three sessions per week of 60-90 minutes) improved cardiorespiratory fitness, muscular strength, flexibility, and body composition. Because the present study involves women who have been diagnosed with breast cancer and have undergone treatments and/or surgery resulting in bodily alterations, it is important to evaluate the effectiveness of rowing not only in terms of physiological outcomes but also psychological outcomes, with attention to the impact of cancer on biopsychosocial well-being.

The theoretical framework is Individual Psychology, developed by Alfred Adler (1870-1937), who viewed individuals holistically, recognizing their uniqueness. According to Adler, individuals must address three fundamental life tasks: social life (friendship), work, and intimate relationships (love). The way they approach these tasks reflects their lifestyle and is related to their sense of community and social interest, which foster cooperation. When individuals experience feelings of organ inferiority, as may occur in women after the sudden onset of illness, they may withdraw from social, emotional, and professional life, and restoring self-esteem through encouragement becomes essential. Sports participation, and specifically rowing in this study, may be a valuable means of supporting this recovery.

OBJECTIVES

The primary aim is to investigate the effects of an exercise therapy program consisting of rowing, walking, and APA in breast cancer survivors who have undergone surgery, and to evaluate its therapeutic effectiveness on health-related parameters and quality of life after a six-month intervention. The study also aims to investigate the effects of rowing on metabolic parameters and to evaluate the psychological benefits associated with its practice. The psychological effects will be explored through self-report questionnaires, as part of a pilot study, focusing on the three life tasks of Adler's Individual Psychology: work, friendship, and love.

STUDY PROCEDURE

The project is presented at an open day at Canottieri Corgeno, where informational leaflets are distributed. Participants are then recruited through the Breast Unit and Physiotherapy Department of Ospedale di Circolo di Varese. The first contact provides a comprehensive overview of the research project. The first appointment is dedicated to obtaining medical clearance from a physiatrist. At the second appointment, a sports medicine physician assesses eligibility for the APA program and evaluates clinical and physical condition. At the third appointment (T0), baseline assessments are performed; they are repeated at three months (T1) and at six months (T2).

Participants are divided into three categories based on GPAQ results: active (physically active before and after surgery), semi-active (active before but inactive after surgery), and sedentary (inactive both before and after surgery). The aim is to provide an exercise program tailored as closely as possible to individual needs, with particular attention to the gradual introduction to rowing.

EXERCISE PROGRAM

The intervention lasts six months. Each week, participants perform one hour of rowing, one hour of walking, and one hour of online activity (APA, yoga, or Pilates). Participants are divided into two groups of a maximum of 10 women for the APA, yoga, Pilates, and rowing sessions, to allow optimal assessment, instruction, and supervision.

Adapted physical activity (APA): The online weekly session focuses on joint mobility, postural control, and functional strengthening, with progressively increasing resistance and movement complexity based on participants' weekly feedback and perceived physical condition. Each circuit consists of 4-5 exercises with 8-10 repetitions per exercise for the upper and lower limbs, while plank and crunch exercises are performed for 30 seconds. Rest lasts 40 seconds between successive rounds and two minutes between circuits. The first part of each session focuses on joint mobility and muscle activation. The second part includes functional exercises using resistance bands, bodyweight, or light external weights (0.5 kg and 1 kg): upper-body strengthening (presses, internal and external shoulder rotations), abdominal and core strengthening (planks, crunches), and lower-body strengthening (static or semi-static lunges, squats, band exercises). The last part is dedicated to relaxation and stretching. Progression may be achieved by increasing resistance, reducing rest intervals, or increasing the number of exercises or repetitions. Participants must not experience any discomfort, tingling, or sensation of heaviness in the arm on the side of the operated breast. APA sessions are delivered online by students holding a Bachelor's degree in Exercise and Sport Sciences (L-22), enrolled in the Master's Degree Program in Preventive and Adapted Physical Activity, and supervised by a qualified specialist in Preventive and Adapted Physical Activity. Yoga and Pilates sessions are conducted online by certified instructors.

Walking: Participants independently perform one walking session per week.

Rowing: Sessions involve a qualified instructor certified by the Italian Rowing Federation (FIC) and trained to instruct vulnerable populations, one psychologist and psychotherapist, two entry-level rowing instructors, and six volunteers trained in rowing techniques for vulnerable individuals. High-stability rowing boats designed for beginners are used (four-person, two-person, and single-person boats), with a coxswain on the four-person boats. Participants are accompanied and supervised by motorized catamarans provided by Società Canottieri Corgeno, the organization hosting the project, which allow researchers and instructors to monitor and assist participants during on-water activities. In the last three months of the intervention, participants are monitored on a rotational basis during selected rowing sessions, using indirect calorimetry, to investigate the metabolic responses to rowing.

ASSESSMENTS AND INSTRUMENTS

Medical screening: Family, physiological, and medical history; physical examination of the musculoskeletal, thoracic, respiratory, and cardiovascular systems; documentation of previous surgical procedures and injuries; resting blood pressure; and resting electrocardiogram (ECG P8000Power, Esaote, Italy). The sports medicine physician also assesses whether the participant has been undergoing psychotherapy and/or psychiatric treatment (including psychoactive medications) for less than six months. Screening is conducted at the Canottieri Corgeno rowing club, in a dedicated examination room, by a sports medicine physician from Centro Medico Loreto Nove (Milan, Italy).

Anthropometric measurements: Height and body weight are measured with a mechanical scale and a portable stadiometer (Seca models 761 and 213, Germany), with participants barefoot and wearing only underwear, and body mass index (BMI) is calculated. Waist circumference is measured at the midpoint between the lower costal margin and the iliac crest, and hip circumference at the widest part of the hips. Upper-limb circumference measurements include seven measurements along the upper arm and forearm.

Body composition is assessed by measuring skinfold thickness with a Harpenden caliper (Lanzoni, Italy). The Jackson and Pollock three-site method (triceps, suprailiac, anterior thigh) is used to estimate body density, and the Siri equation to calculate body fat percentage.

Aerobic capacity: VO2max is estimated with a direct submaximal test on a cycle ergometer, consisting of three 4-minute stages at progressively increasing workloads (30, 40, 50, 60, or 70 W depending on initial physical condition) at a cadence of 50-60 rpm. Heart rate and oxygen uptake are continuously monitored with a metabolic analyzer (K5, COSMED, Italy). At the end of each stage, perceived exertion is rated on the Borg CR10 scale. The test ends at 85% of age-predicted maximum heart rate or a rating of perceived exertion of 7 or higher. Medical personnel or highly qualified specialists are present throughout.

Handgrip strength: Maximal isometric handgrip strength is assessed with a hydraulic hand dynamometer (JAMAR, Lafayette Instrument, USA): three maximal voluntary contractions of up to 3 seconds per hand, separated by 60 seconds of rest.

Flexibility: V-Sit-and-Reach Test and Back Scratch Test.

Questionnaires: Administered on two separate days (day 1: GPAQ, EORTC QLQ-C30, EORTC QLQ-FA12; day 2: PACES, RSES, and Life Tasks Questionnaire), in a dedicated room, in the presence of a psychologist registered with the Order of Psychologists of the Lombardy Region, for about 45 minutes in total.

Global Physical Activity Questionnaire (GPAQ): 16 questions developed by the World Health Organization on sedentary behavior and physical activity at work, in travel, and in recreation.

EORTC QLQ-C30: 30-item cancer-specific questionnaire assessing global health status/quality of life, five functional scales (physical, role, emotional, cognitive, social), symptom scales (fatigue, pain, nausea/vomiting), and other cancer-related symptoms and problems.

EORTC QLQ-FA12: 12-item questionnaire assessing the physical, cognitive, and emotional dimensions of cancer-related fatigue and its interference with daily and social life in the previous week.

Physical Activity Enjoyment Scale (PACES): 16 items on a 5-point Likert scale assessing enjoyment of PA. It is administered at baseline and after each training session.

Rosenberg Self-Esteem Scale (RSES): 10 statements assessing self-worth and self-satisfaction (items scored 0-3, negatively worded items reverse-scored).

Self-Assessment Questionnaire on Life Tasks According to Individual Psychology: three self-administered questions on work, friendship, and love and sexuality, rated on a 5-point Likert scale.

Training sessions: At the end of each session (30 minutes post-exercise), the session rating of perceived exertion (session-RPE) is assessed. During the last three months, heart rate and oxygen uptake are continuously monitored during selected rowing sessions, on a rotational basis, using a portable metabolic analyzer (K5, COSMED, Italy

Single-arm, six-month exercise therapy program for women aged 40-65 who have undergone breast cancer surgery and completed post-surgical treatments. Each week, participants perform three hours of exercise: one hour of supervised on-water rowing, one hour of independent walking, and one hour of online adapted physical activity (APA), yoga, or Pilates. For each training session, groups include a maximum of 10 women. Rowing is performed in high-stability beginner boats (single, double, and coxed four) with certified rowing instructors, a psychologist, and trained volunteers, accompanied by motorized support boats. Online APA sessions include joint mobility, postural control, and progressive functional strengthening with bodyweight, light weights (0.5-1 kg), or elastic bands (1.3-1.7 kg). Exercise is adapted to each participant's baseline activity level and progresses gradually. Assessments are performed at baseline, 3 months, and 6 months.

Other: Behavioral Rowing-based exercise therapy program

Six-month multimodal program, three hours per week. Rowing (1 h/week, on water): led by an Italian Rowing Federation-certified instructor with a psychologist and trained volunteers, with gradual progression from technique introduction in stable boats. Walking (1 h/week): independent. Online session (1 h/week): APA or yoga/Pilates. APA sessions start with joint mobility and muscle activation, then circuits of 4-5 exercises (8-10 repetitions for limb exercises; 30-second planks and crunches; 40 s rest between rounds, 2 min between circuits) with bodyweight, bands or light weights, and end with relaxation and stretching. Progression: more resistance, shorter rests, or added exercises/repetitions, guided by weekly feedback. Exercises are modified if arm discomfort, tingling or heaviness occurs on the operated side. APA is delivered by Master's students under specialist supervision; yoga/Pilates by certified instructors.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

VO2max is estimated from a direct submaximal exercise test on a cycle ergometer, consisting of three 4-minute stages at progressively increasing workloads (30 to 70 W, depending on initial fitness) at 50-60 rpm. Oxygen uptake and heart rate are measured continuously with a portable metabolic analyzer (K5, COSMED). The test is stopped at 85% of age-predicted maximum heart rate or a Borg CR10 rating of perceived exertion of 7 or higher. Change from baseline is evaluated at 3 and 6 months.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

Health-related quality of life is assessed with the EORTC QLQ-C30, a 30-item self-administered cancer-specific questionnaire. It includes a global health status/quality of life scale, five functional scales (physical, role, emotional, cognitive, and social functioning), three symptom scales (fatigue, pain, nausea/vomiting), and single items on cancer-related symptoms and problems (dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties). All scales are scored from 0 to 100; higher scores on the global health status and functional scales indicate better functioning, while higher scores on the symptom scales indicate more severe symptoms. Change from baseline is evaluated at 3 and 6 months.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

The Rosenberg Self-Esteem Scale consists of 10 statements assessing self-worth and satisfaction with oneself. Positively worded items are scored from 0 (strongly disagree) to 3 (strongly agree); negatively worded items are reverse-scored.

Time frame: Baseline (T0), after each training session, 3 months (T1), and 6 months (T2)

The Physical Activity Enjoyment Scale (PACES) consists of 16 items rated on a 5-point Likert scale and assesses the level of enjoyment experienced during physical activity. It is administered at baseline and after each training session.

Time frame: During selected rowing sessions in the last three months of the intervention (months 4 to 6)

During selected rowing sessions, participants are monitored on a rotational basis using a portable metabolic analyzer (K5, COSMED), which continuously records oxygen uptake and heart rate through indirect calorimetry.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

Maximal isometric handgrip strength is measured bilaterally (right and left hand) with a hydraulic hand dynamometer (JAMAR). Participants perform three maximal voluntary contractions of up to 3 seconds per hand, separated by 60 seconds of rest.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

Flexibility is assessed with the V-Sit-and-Reach Test and the Back Scratch Test.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

Skinfold thickness is measured with a Harpenden caliper at three sites (triceps, suprailiac, anterior thigh). Body density is estimated with the Jackson and Pollock three-site method, and body fat percentage is calculated with the Siri equation.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

Height and body weight are measured with a mechanical scale and a portable stadiometer to calculate body mass index (kg/m2). Waist circumference is measured at the midpoint between the lower costal margin and the iliac crest, and hip circumference at the widest part of the hips. Upper-limb circumference is measured at seven points along the upper arm and forearm.

Time frame: Baseline (T0), 3 months (T1), and 6 months (T2)

The EORTC QLQ-C30 assesses five functional scales (physical, role, emotional, cognitive, and social functioning), three symptom scales (fatigue, pain, nausea/vomiting), and single items on cancer-related symptoms and problems (dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulties). Scores range from 0 to 100.

Time frame: From enrollment to 6 months

The number of adverse events related to physical exercise, the underlying disease, and its treatments is recorded throughout the intervention.

Time frame: From the start of the intervention to 6 months

Adherence is defined as the percentage of scheduled training sessions completed by each participant. It is considered satisfactory if at least 75% of scheduled sessions are completed

Effect and Efficacy of RowIng in Breast CancEr Survivors/The Same Boat