Duijts, S.F., Faber, M.M., Oldenburg, H.S., van Beurden, M., & Aaronson, N.K. (2011). Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health-related quality of life in breast cancer patients and survivors—A meta-analysis. Psycho-Oncology, 20, 115–126. 

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STUDY PURPOSE: To examine the effects of behavioral techniques (e.g., behavioral therapy, cognitive therapy, mind-body and relaxation techniques, counseling, social support, hypnosis, biofeedback, exercise, physical exercise (PhysEx), aerobic exercise, physical activity, motor activity) on psychosocial functioning outcome measures, such as fatigue, depression, anxiety, body image, and stress, and on health-related quality of life

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

DATABASES USED: Cochrane Library, PubMed, EMBASE, CINAHL, PsycInfo, SPORTDiscus. MeSH search terms included the examples of behavioral techniques named above, including physical exercise (PhysEx) terms and outcome measures, combined with the population terms breast cancer and breast neoplasm.
INCLUSION CRITERIA: Randomized, controlled trials of how any of the named behavioral techniques or PhysEx affected the outcomes of interest (fatigue, depression, anxiety, body image, stress) or healthcare quality of life. Reference lists were reviewed to identify additional potential articles. 
EXCLUSION CRITERIA: Articles were excluded if calculating the effect size or standard error was not possible with the available information.

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 171 retrieved, 115 excluded because they were not randomized, controlled trials; they did not have enough quantitative data; the outcomes were not related to the current study; or their interventions were not related to the current study.
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No evaluation of study quality was reported, although the authors reported evaluation of publication bias.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED =  56 studies: 39 studies of behavioral techniques; 14 studies of physical exercise; 3 studies of both 
  • TOTAL PATIENTS INCLUDED IN REVIEW = Not reported. This meta-analysis reported the number of patients by each randomized, controlled trial: 5,462 (behavioral intervention patients), 1,457 (PhysEx patients), 6,919 (total)
  • SAMPLE RANGE ACROSS STUDIES: 28–558 (behavioral intervention), 22–242 (PhysEx)
  • KEY SAMPLE CHARACTERISTICS: 33 studies of patients with nonmetastatic cancer, 4 studies of patients with metastatic cancer, 5 studies with a mix of patients

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care, palliative care


The effect of these interventions on stress and anxiety were not consistently significant. In addition, publication bias on the outcome of behavioral techniques on depression and anxiety existed. Behavioral techniques showed positive (improvement) summary ejection fraction (EF) effect sizes on fatigue (14 studies: EF = –0.158,  p < 0.001), depression (23 studies: EF = –0.336, p < 0.001), anxiety (23 studies: EF = –0.346, p < 0.001), and stress (p = 0.038) scores, but not on body image scores (p = 0.051). Behavioral techniques had a small, insignificant effect on health-related quality of life (ES = 0.045, p = 0.322). PhysEx had a positive effect on fatigue (11 studies: EF = –0.315, p = 0.004), depression (6 studies: EF =  –0.262, p = 0.016) and body image (p = 0.007) but not on anxiety. PhysEx had a positive effect on health-related quality of life (ES = 0.298, p = 0.001). The effect size of PhysEx on stress could not be calculated. Publication bias was found for behavioral techniques on depression and anxiety. No publication bias was found for the effect of behavioral techniques on fatigue, body image, or stress. Publication bias was found for PhysEx on fatigue and health-related quality of life, but no publication bias was found for PhysEx on depression, anxiety, or body image.


Behavioral techniques affect specific aspects of psychosocial functioning but have a minor, insignificant effect on health-related quality of life. PhysEx has a positive effect on health-related quality of life. Behavioral techniques demonstrated a moderately significant effect on anxiety and depression and showed a significant but small effect on fatigue. PhysEx was effective for fatigue and showed a positive effect for depression.


  • No quality evaluation
  • High heterogeneity
  • The variety of behavioral interventions made it challenging to select which was more effective than others (e.g., telephone counseling, telephone support, education, body-mind social support self-help, therapeutic groups by telephone, nurse self-efficacy).
  • Studies were included only through 2008—more recent evidence has shown some different findings.
  • High heterogeneity in behavioral technique analysis
  • The studies used a wide range of different measurements and interventions.

Nursing Implications

A range of behavioral techniques may be effective for patients with breast cancer and fatigue, depression, and depressed body image. PhysEx was shown to improve health-related quality of life, fatigue, anxiety, and depression. Recognizing the symptoms of patients with breast cancer was emphasized as having positive effects (e.g., feeling relieved, hearing helpful strategies addressing quality of life and psychosocial problems).

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