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The TIME-L trial: Time-efficient minimal duration home exercise program for breast cancer survivors in low-resource settings: A pilot study
*Corresponding author: Dr. Vyoma Dani, Department of Physiotherapy, K M Patel Institute of Physiotherapy, Bhaikaka University, Karamsad, Anand, 388325, Gujarat, India. vyoma2412@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Dani V, Prakash R, Parikh SM. The TIME-L trial: Time-efficient minimal duration home exercise program for breast cancer survivors in low-resource settings: A pilot study. Asian J Oncol. 2025;11:28. doi: 10.25259/ASJO_83_2025
Abstract
Objectives:
Breast cancer survivors (BCSs) often experience long-term physical and psychosocial problems that negatively affect their health and overall quality of life (QOL). Exercise has been recommended as a safe and effective therapy; however, adherence is often limited by various challenges, including cost, accessibility, and the availability of resources, especially in low-resource settings. Home-based programs, carried out for a minimal duration, using household items, may offer a feasible alternative in such contexts. Thus, the present study aims to evaluate the feasibility and preliminary effects of a structured, time-efficient minimal duration home exercise protocol (TIME-L Trial) on functional capacity, muscle strength, and quality of life among post-treatment breast cancer survivors.
Material and Methods:
A single-group, pre–post, pilot study included 20 BCSs, who had completed their treatment. Participants followed a six-week, minimal-duration home exercise program including aerobic, strengthening, and flexibility exercises. The outcomes assessed before and after the intervention included functional capacity through six-minute walk distance (6MWD), muscle strength (one-minute sit-to-stand and wall press), and QOL with Functional Assessment of Cancer Therapy – Breast (FACT-B). Statistical analysis was performed using paired t-tests, with effect sizes (Cohen’s d) for paired data, and 95% confidence intervals (CIs) were calculated to determine the magnitude and precision of change.
Results:
The program was well tolerated, with no adverse events reported. Adherence was high, with >85% of sessions completed. Significant improvements (p<0.05) were observed in functional capacity, muscle strength, and physical and additional domains of FACT-B QoL following the six-week program. Effect sizes ranged from medium to large across most outcomes, and 95% CIs indicated clinically meaningful changes.
Conclusion:
The TIME-L Trial demonstrated that a structured, minimal-duration home exercise program is both feasible and effective for improving functional outcomes and quality of life in BCSs.
Keywords
Breast cancer survivors
Home-based exercise
Low resource settings
Functional capacity
Quality of Life
INTRODUCTION
Breast cancer (BC) is the leading cause of cancer incidence and mortality among women in India, accounting for 13.5% of new incidences and 10% of cancer-related deaths in 2020. [1] Breast cancer survivors (BCSs) may experience numerous adverse health effects that can persist for years after the diagnosis and treatment. Many breast cancer survivors experience a wide range of physical, emotional, psychological, and cognitive health effects related to their cancer or the treatment they receive.[2]
Pain, fatigue, lymphedema, sleep disturbances, bone loss, reduced muscle strength, cognitive problems, sexual issues, and hot flashes are the commonly reported symptoms among BCSs. These symptoms may have an adverse effect on the overall quality of life of BCSs.[3,4]
Numerous advantages of exercise have been demonstrated for women with breast cancer at every stage of the disease, including during and after the completion of therapies.[5]
Regular exercise or any physical activity has been shown to enhance functional capacity, muscle strength, cardiovascular fitness, and psychosocial well-being among BCSs. For BCSs, exercise is not only safe and practical, but it also serves as a supplemental treatment to enhance both physical and mental health. There is increasing evidence that regular exercise following a breast cancer diagnosis may significantly improve quality of life, prognosis, mortality, and morbidity. A multidisciplinary approach is recommended to encourage breast cancer survivors to engage in rehabilitation programs for the most beneficial results.[6]
However, various constraints like time and money, lack of family support, transport facility, and access to supervised programs, and competing family and job responsibilities often limit adherence to recommended exercise regimens, especially in low and middle-income countries.[7]
These challenges highlight the need for accessible, low-cost alternative models of exercises tailored for low-resource environments. Home exercise programs, using household items, offer a useful substitute, being accessible, affordable, and flexible, particularly for survivors living in remote or resource-constrained areas where access to facility-based, supervised treatments is sometimes limited.
Thus, the present pilot study aims to evaluate the feasibility and preliminary effects of a structured, time-efficient, minimal duration home exercise program (TIME-L Trial) on functional capacity, muscle strength, and quality of life among post-treatment breast cancer survivors in low-resource settings.
MATERIAL AND METHODS
Ethics and study design
The study was approved by the Institutional Ethics Committee. It was a single-centre, one-group, pre–test–post– test, a quasi-experimental pilot study.
The women, diagnosed as having breast cancer, who have completed their treatment, treated surgically and/or with adjuvant therapies like chemo/radiotherapy, and between the age group of 40 to 70 years, were included in the study.
Women, having metastasis, or reporting any musculoskeletal, neurological, cardio-respiratory, or psychiatric problems that can limit their participation in exercise, were excluded.
Patient consent
Written informed consent was obtained from all the BCSs after explaining the purpose and procedure of the study.
The BCSs were recruited with convenience sampling for this pilot study. Figure 1 shows the recruitment of BCSs for the study.
- Recruitment of BCSs. BCSs: Breast cancer survivors
Intervention: TIME-L Home-based exercise program
The BCSs were provided with the Time-Efficient Home-Based Exercise program, which can be carried out for the duration of six weeks to assess its efficacy on various physical fitness parameters, including functional capacity, muscle strength, and quality of life, in a low-resource setting.
A total of 20 BCSs completed the study protocol, which included the warm-up and cool-down exercises, aerobic exercise, and strength training using easily available household items, to be carried out for a minimal duration, in line with American Cancer Society recommendations.
Total treatment duration was six weeks [Table 1].[8] The exercise intensity was kept between 12 and13 on the Borg’s Rate of Perceived Exertion (RPE) Scale, corresponding to moderate.[9] The BCSs were provided with an exercise diary to record their daily exercise sessions. Exercise follow-up was carried out telephonically twice a week to provide support and guidance and to monitor compliance with the treatment program.
| Sr No | Exercise | Frequency | Duration /Repetitions | Description | Progression |
|---|---|---|---|---|---|
| 1 | Warm-up and Cool-down | Before and after each session | 2–3 minutes each | Upper limb stretching (before and after upper limb strength training- 2 days/week)
Lower limb stretching (before and after walking- 5 days/week)
|
--- |
| 2 | Aerobic | 5 days/week | 30 min/day (continuous or split into 2–3 bouts of 10–15 min) | Walking at a comfortable pace | --- |
| 3 | Strength Training | 2 days/week |
|
|
Progressive increase in load and sets as mentioned |
Outcome measures
Before and after six weeks of a home-based exercise program, the participants’ functional capacity was measured using the Six-minute walk distance (6MWD), their muscle strength was measured using the one-minute sit-to-stand test for lower extremities and the wall press test for upper extremities, and their QOL was measured using the Functional assessment of cancer therapy - breast (FACT-B) (Licence acquired).
FACT-B is a 37-item instrument designed to measure five domains of QOL in breast cancer patients including physical, social, emotional, functional well-being, and an additional breast cancer-specific subscale. The alpha coefficient (internal consistency) for the FACT-B total score was high (a=0.90), with subscale alpha coefficients ranging from 0.63 to 0.86. Evidence supported test-retest reliability, as well as convergent, divergent, and known groups validity.
Statistical analysis
The data were analyzed using STATA 14.2 Software. Descriptive statistics were used to describe the baseline characteristics of the study participants.
The results before and after the intervention were compared using the paired t-test with p-value < 0.05 as statistical significance.
To measure the degree and accuracy of changes observed at the end of this program, 95% confidence Intervals (CIs) and Cohen's d (for paired data) effect sizes were calculated. While effect sizes offer a standardized measure of clinical relevance, reporting CIs enables evaluation of the plausible range of the true effect, making it easier to interpret the impact of the intervention beyond statistical significance.
RESULTS
Participant characteristics
In Table 2, twenty BCSs completed the intervention All the BCSs underwent modified radical mastectomy (MRM) along with chemotherapy and radiotherapy. The average time since the completion of treatment was 4 years. Participants completed an average of 86% of the required sessions during the six-week TIME-L program, demonstrating good adherence. Exercise diaries and telephonic follow-ups indicated consistent engagement with both aerobic and strength training components.
| Categories | Number of BCSs n (%) |
|---|---|
| Age | Mean + SD 57.35 + 11.08 |
| Education Un-educated Primary education Secondary and higher secondary education Graduation and post-graduation |
0 3 (15%) 9 (45%) 8 (40%) |
| Occupation House work Job Retired |
11 (55%) 5 (25%) 4 (20%) |
| Socio-economic status (As per revised Prasad’s classification revision for October 2023)[10] I II III to IV |
19 (95%) 1 (5%) 0 |
| Co-morbidities Hypertension Diabetes type II Hypothyroidism |
8 (40%) 5 (25%) 2 (10%) |
SD: Standard deviation, BCSs: Breast cancer survivors
The participants had a significant improvement with regard to functional capacity and muscle strength of upper and lower extremities at the end of six weeks of this minimal-duration home-based exercise program [Table 3]. With regard to quality of life, the BCSs had significant improvement in physical well-being and additional concerns (shortness of breath, self-consciousness while dressing, arm/arms swollen or tender, bothered by hair loss, worrying about getting the same illness as other family members, worrying about stress on illness, body weight changes, and pain experienced in other body parts), whereas the improvement noted in other areas like social, emotional and functional well-being was not statistically significant.
| Outcome (units) | Pre mean ± SD | Post mean ± SD | Mean difference (Post − Pre), 95% CI | p-value | Cohen’s d, 95% CI | Interpretation |
|---|---|---|---|---|---|---|
| 6MWD (m) | 323.32 ± 48.55 | 358.72 ± 53.12 | 35.40 (11.58 to 59.22) | 0.034* | 0.70 (0.21 to 1.19) | Medium–large |
| One-minute Sit-to-Stand (n) | 18.60 ± 4.40 | 20.66 ± 4.02 | 2.06 (0.03 to 4.09) | 0.050* | 0.49 (0.02 to 0.95) | Medium |
| One-minute Wall Press (n) | 23.85 ± 5.59 | 26.93 ± 4.73 | 3.08 (0.67 to 5.49) | 0.020* | 0.60 (0.12 to 1.07) | Medium–large |
| Physical well being (FACT-B) |
22.65 ± 4.28 | 25.58 ± 2.56 | 2.93 (1.22 to 4.63) | 0.0037* | 0.83 (0.32 to 1.34) | Large |
| Social/family well-being (FACT-B) | 18.63 ± 4.44 | 19.31 ± 3.46 | 0.68 (−0.86 to 2.22) | 0.5305 | 0.17 (−0.28 to 0.62) | Small (ns) |
| Emotional well-being (FACT-B) | 21.24 ± 3.54 | 22.07 ± 2.64 | 0.83 (−0.59 to 2.25) | 0.2038 | 0.27 (−0.18 to 0.72) | Small (ns) |
| Functional well-being (FACT-B) | 26.04 ± 2.74 | 26.53 ± 1.44 | 0.49 (−0.44 to 1.42) | 0.2865 | 0.22 (−0.23 to 0.67) | Small (ns) |
| Additional concerns (FACT-B) | 29.34 ± 5.40 | 33.04 ± 6.11 | 3.70 (1.01 to 6.39) | 0.0023* | 0.64 (0.15 to 1.13) | Medium |
| FACT-B Total score | 120.10 ± 14.74 | 129.45 ± 11.57 | 9.35 (3.15 to 15.55) | 0.0001* | 0.71 (0.22 to 1.20) | Medium–large |
Effect sizes ranged from medium (sit-to-stand, d = 0.49; wall press, d = 0.60) to large (6f, d = 0.70; total Functional Assessment of Cancer Therapy – Breast (FACT-B), d = 0.71; Physical well-being FACT-B, d = 0.83), suggesting clinically meaningful improvements despite the small sample size [Table 3].
DISCUSSION
In a low-resource context, this pilot trial assessed the viability and preliminary outcomes of a structured, minimal-duration, home-based exercise program (TIME-L Trial) for breast cancer survivors. The results show that the program was workable, had high adherence rates (86%), and resulted in significant gains in muscular strength, functional ability, and a few other quality of life categories. Crucially, the approach was feasible and scalable in settings with limited resources since it did not require any specific equipment or supervision.
Our results align with prior evidence demonstrating the benefits of exercise for breast cancer survivors, including improvements in aerobic capacity, muscle strength, and psychosocial well-being.[11-13]
The TIME-L Trial uniquely combined aerobic and resistance training using household items and a flexible walking routine, thereby overcoming common barriers such as cost, time, transport, and access to facilities. The substantial gains in 6MWD and upper- and lower-body strength seen here are on par with those documented in more resource-intensive treatments, highlighting the potential of simple, home-based models.[14-16]
While improvements in emotional, social, and functional well-being were modest and not statistically significant, quality of life increased significantly in terms of physical well-being and other issues. These results suggest that short-term exercise programs primarily influence physical dimensions, whereas longer duration, additional psychological support, or larger group-based programs may be essential for psychosocial advantages.[17,18] Despite the small sample size, the medium-to-large effect sizes across functional and quality-of-life endpoints demonstrate clinically significant advantages.
A wide range of exercise programs has been described in the available literature for breast cancer survivors, which have been delivered during chemotherapy, radiotherapy, or after completion of treatment, focusing on various outcomes such as lymphedema, fatigue, and overall quality of life. These programs vary considerably in exercise type (resistance, aerobic, combined, yoga), intensity and frequency (daily or several times per week), duration of training (from less than 4 weeks to more than 24 weeks), and mode of delivery (structured/unstructured, supervised/unsupervised, online/offline). Many also require devices such as pedometers,TheraBands, or gym-based machines. Although these programs work effectively in well-resourced and controlled settings, they are sometimes difficult to follow in low-resource environments due to limited access to equipment and supervision.[15,16,19-25]
In the present study, no specific treatment completion window was applied since the survivorship symptoms and recovery trajectories vary substantially between as early as ≤1 year to as long as >5 years. By including survivors at different stages of post-treatment, the study enhances the ecological validity of the TIME-L protocol and demonstrates its potential applicability across a broad spectrum of breast cancer survivors.
The study has a few limitations. A comparator arm was not included, as there is no conventional exercise or rehabilitation program followed at our center for breast cancer survivors after the completion of treatment. Breast cancer survivors typically do not return for structured physical activity after completing treatment, making a single-group design the most appropriate and realistic approach for this pilot. The sample size was intentionally small, considering the exploratory nature of pilot research, and the consistent medium-to-large effect sizes observed strengthen the clinical relevance of the intervention. Adherence was monitored mainly through self-reported exercise diaries, which may present reporting bias; however, this practical approach reflects the real-world conditions in low-resource settings where we need to rely on patients’ words about their compliance with any treatment approaches, and this was strengthened by twice-weekly telephonic follow-ups to ensure accuracy and engagement.
This study possesses several notable strengths. To our knowledge, it is one of the initial studies to assess a systematic, time-effective, home-based exercise regimen specifically tailored for breast cancer survivors in a resource-limited environment. The program integrated aerobic and strength exercises with common household items, removing the necessity for specialized tools or monitored environments. The study showed high adherence and favorable responses (gathered verbally during phone follow-ups and upon treatment completion), highlighting the practicality and acceptability of this treatment regimen among BCSs. Moreover, since no structured exercise program is delivered at our center for BCSs, this intervention directly addressed a real-world challenge, representing the wider hitches met in numerous low to middle-income countries. This study creates a strong foundation for escalating and evaluating the protocol in large controlled trials by showing clinically significant improvements within a short, cost-effective, and practical framework.
CONCLUSION
Considering the practical implications for practice and policy, the present study provides novel information that low-cost home interventions carried out even for a minimal duration are feasible, acceptable, and effective to bring meaningful improvements among BCSs, where formal rehabilitation programs are lacking. It also supports the inclusion of such programs in survivorship care pathways, especially in lowand middle-income countries, where resource restraints limit access to supervised rehabilitation programs.
Acknowledgment:
We gratefully acknowledge the university and the institute for providing the resources and environment necessary for this study. We sincerely thank the Department of Oncology at Shree Krishna Hospital, Karamsad, for the invaluable support in facilitating our research through access to a diverse pool of patients. Our deepest gratitude goes to the brave breast cancer survivors, whose willingness to participate made this study possible. We are also profoundly grateful to our dedicated interns, Dr. Hiral Upadhyay and Dr. Khushi Sureja, for their technical expertise and unwavering assistance in data collection. Without their collective contributions, this research would not have been realized.
Author contributions:
VD, RHP, and SMP: All authors have significantly contributed for concepts, design, definition of intellectual content, data collection and analysis, manuscript writing, editing and review.
Ethical approval:
The research/study was approved by the Institutional Review Board at INSTITUTIONAL ETHICS COMMITTEE-2, Bhaikaka University, Karamsad, Anand, Gujarat-388325, number IEC/BU/140/Faculty/08/241/2022, dated 17/10/2022.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of Interest
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that they have used artificial intelligence (AI)-assisted technology solely for language refinement and to improve the clarity of writing. No AI assistance was employed in the generation of scientific content, data analysis or interpretation.
Financial support and sponsorship: Nil
References
- Burden of female breast cancer in India: Estimates of YLDs, YLLs, and DALYs at national and subnational levels based on the National Cancer Registry Programme. Breast Cancer Res Treat. 2024;205:323-332.
- [CrossRef] [PubMed] [Google Scholar]
- Adverse health effects after breast cancer up to 14 years after diagnosis. Breast. 2022;61:22-28.
- [CrossRef] [PubMed] [Google Scholar]
- Problems in living among breast cancer survivors. Curr Cancer Rep. 2021;3:101.
- [CrossRef] [PubMed] [Google Scholar]
- The bone-muscle connection in breast cancer: Implications and therapeutic strategies to preserve musculoskeletal health. Breast Cancer Res. 2022;24:84.
- [CrossRef] [PubMed] [Google Scholar]
- Effectiveness of home-based exercise in breast cancer survivors: A randomized clinical trial. BMC Sports Sci Med Rehabil2023;. ;15:96.
- [CrossRef] [PubMed] [Google Scholar]
- Exercise in patients coping with breast cancer: An overview. World J Clin Oncol. 2014;5:406-412.
- [CrossRef] [PubMed] [Google Scholar]
- Barriers and facilitators to physical activity in cancer survivors with pain: Systematic review. Support Care Cancer. 2023;31:668.
- [CrossRef] [PubMed] [Google Scholar]
- Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: Pre-post intervention study. J Rehabil Res Dev. 2011;48:10.
- [CrossRef] [PubMed] [Google Scholar]
- Exercise testing and prescription for populations with other chronic diseases and health conditions. American College of Sports Medicine In: ACSM's Guidelines for Exercise Testing and Prescription (10th ed). New York: Lippincott Williams & Wilkins; 2013. p. :423-436.
- [Google Scholar]
- Updated modified BG Prasad classification for October 2023. Natl J Community Med. 2024;15:89-90.
- [CrossRef] [Google Scholar]
- Implementing the exercise guidelines for cancer survivors. J Support Oncol. 2012;10:171.
- [CrossRef] [PubMed] [Google Scholar]
- Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc2019;. ;51:2375-2390.
- [CrossRef] [PubMed] [Google Scholar]
- American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc2010;. ;42:1409-1426.
- [CrossRef] [PubMed] [Google Scholar]
- Exercise-based interventions for cancer survivors in India: A systematic review. SpringerPlus2015;. ;4:655.
- [CrossRef] [PubMed] [Google Scholar]
- A 4-week home-based aerobic and resistance exercise program during radiation therapy: A pilot randomized clinical trial. J Support Oncol. 2009;7:158.
- [Google Scholar]
- Different methods of physical training applied to women breast cancer survivors: A systematic review. Front Physiol2021;. ;12:639406.
- [CrossRef] [PubMed] [Google Scholar]
- Do we need physical activity guidelines for mental health: What does the evidence tell us? Ment Health Phys Act. 2020;18:100315.
- [CrossRef] [Google Scholar]
- Group-based exercise therapy improves psychosocial health and physical fitness in breast cancer patients in Hawai'i. Hawaii J Health Soc Welf. 2021;80:263.
- [Google Scholar]
- An online home-based exercise program improves autonomic dysfunction in breast cancer survivors. Front Physiol2023;. ;14:1256644.
- [CrossRef] [PubMed] [Google Scholar]
- The effect of a home-based tele-exercise training program on the quality of life and physical performance in breast cancer survivors. Sports. 2023;11:102.
- [CrossRef] [PubMed] [Google Scholar]
- Effects of scheduled exercise on cancer-related fatigue in women with early breast cancer. Sci World J. 2014;2014:271828.
- [CrossRef] [PubMed] [Google Scholar]
- Resistance training improves fatigue and quality of life in previously sedentary breast cancer survivors: A randomised controlled trial. Eur J Cancer Care. 2016;25:784-794.
- [CrossRef] [PubMed] [Google Scholar]
- Resistance training in breast cancer survivors: A systematic review of exercise programs. Int J Environ Res Public Health. 2020;17:6511.
- [CrossRef] [PubMed] [Google Scholar]
- Home-based exercise interventions' impact on breast cancer survivors' functional performance: A systematic review. J Cancer Surviv. 2024;18:1-4.
- [CrossRef] [PubMed] [Google Scholar]
- Evaluation of resistance training to improve muscular strength and body composition in cancer patients undergoing neoadjuvant and adjuvant therapy: A meta-analysis. J Cancer Surviv. 2017;11:339-349.
- [CrossRef] [PubMed] [Google Scholar]