Journal of Strength and Conditioning Research, 2006, 20(3), 535–540
? 2006 National Strength & Conditioning Association
IS CARDIORESPIRATORY FITNESS RELATED TO
QUALITY OF LIFE IN SURVIVORS OF BREAST CANCER?
FERNANDO HERRERO,1,2JAMES BALMER,3ALEJANDRO F. SAN JUAN,1CARL FOSTER,4
STEVEN J. FLECK,5MARGARITA PE´REZ,1SILVIA CAN˜ETE,1CONRAD P. EARNEST,6AND
1European University of Madrid, Madrid, Spain;2Department of Sports Medicine, Miranda de Ebro, Burgos,
Spain;3Deanery of Sciences and Social Sciences, Liverpool Hope University, UK;4Department of Exercise and
Sport Science, University of Wisconsin–La Crosse, La Crosse, Wisconsin 54601;5Sport Science Department,
Colorado College, Colorado Springs, Colorado 80903;6The Cooper Institute Centers for Integrated Health
Research, Dallas, Texas 75230.
ABSTRACT. Herrero, F., J. Balmer, A.F. San Juan, C. Foster, S.J.
Fleck, M. Pe ´rez, S. Can ˜ete, C.P. Earnest, and A. Lucı ´a. Is car-
diorespiratory fitness related to quality of life in survivors of
breast cancer? J. Strength Cond. Res. 20(3):535–540. 2006.—The
purpose of this study was to investigate whether indices of car-
diorespiratory fitness are related to quality of life (QOL) in wom-
en survivors of breast cancer. Using the European Organization
for Research and Treatment of Cancer QLQ-30 questionnaire,
we assessed the QOL of 16 participants (age, 50 ? 9 years; body
mass, 66.6 ? 9.6 kg). All participants performed incremental
cycle ergometer exercise to determine several indices of cardio-
respiratory fitness (e.g., peak oxygen uptake [V˙O2peak, in
L·min?1, ml·kg?1·min?1]), peak power output (PPO, in W), PPO/
body mass (W·kg?1), peak heart rate (HRpeak, b·min?1), peak
ventilation (VEpeak), and V˙O2and heart rate (HR) at the ven-
tilatory (VT) and respiratory compensation (RCT) thresholds.
Relationships between QOL and variables were assessed using
Spearman rank-difference correlation tests. A significant in-
verse relationship (p ? 0.05) was found for QOL scores and val-
ues for age (years) and body mass (kg) (? ? ?0.53),
%HRpeak@VT (? ? ?0.59) and %VEpeak@VT (? ? ?0.61). A
significant positive relationship (p ? 0.05) was found for QOL
and PPO/body mass (? ? 0.59) and HRpeak (? ? 0.78), V˙O2@RCT
(ml·kg?1·min?1) (? ? 0.51), power output (PO, expressed as either
W or W·kg?1) at RCT, and HR at RCT (? ? 0.54). No other sig-
nificant relationship was found between QOL and variables ob-
tained from the tests. In conclusion, these findings highlightpos-
sible relationships between cardiorespiratory fitness and well-
being in survivors of breast cancer. From a practical point of
view, our data emphasize the need for this population to engage
in programmed cardiorespiratory exercise training, mainly de-
signed to improve VT and RCT. The improvement of both sub-
maximal indices can have a beneficial effect on QOL.
KEY WORDS. female, QLQ-30, respiratory compensation thresh-
old, ventilatory threshold
main reasons for the marked decline in cardiovascular
functional capacity is the sedentary lifestyle adopted dur-
ing illness, treatment, and recovery and the long-term ef-
fects of chronic fatigue (21). V˙O2peak (usually normalized
to body size as ml·kg?1·min?1) is considered by the World
Health Organization as a key indicator of aerobic physical
fitness (29) and is a powerful predictor of mortality in
ompared with age-matched healthy individuals,
indices of cardiorespiratory fitness such as peak
oxygen uptake (V˙O2peak) can be considerably
lower (?50%) in survivors of cancer (7, 23). The
both healthy and diseased populations (4, 25). However,
few studies (e.g., 7, 23) have directly assessed V˙O2peak in
survivors of cancer and even less data are available con-
cerning cardiorespiratory fitness and its relationship to
quality of life (QOL) in this population group. Further,
little information is available on this group concerning
other well-accepted indices of cardiorespiratory fitness,
such as the ventilatory (VT) and respiratory compensa-
tion thresholds (RCT) and possible relationships to QOL.
These latter indices do reflect physiologic phenomena
(muscle oxidative and buffer capacity, fatigue tolerance of
recruited fibers, ventilatory efficiency, and so on) that are
attenuated by disease (9, 19, 26). It can be hypothesized
that any of these cardiorespiratory parameters may be
associated with a person’s ability to perform physical
work and subsequently, QOL in survivors of cancer.
The QLQ-C30 questionnaire was developed by the Eu-
ropean Organization for Research and Treatment of Can-
cer (EORTC) and is a valid and reliable assessment of
QOL in survivors of cancer (1, 12). This questionnaire
considers a multitude of factors to provide a global eval-
uation of physical, social, and emotional factors associ-
ated with well-being. Although research has revealed
that cardiorespiratory fitness is a valid indicator of health
status and predictor of mortality in both healthy and dis-
eased individuals (4, 25), and although the ability to com-
fortably perform daily activities without undue exertion
is a reasonable predictor of QOL, the possible relationship
between cardiorespiratory fitness and QOL in survivors
of cancer is not well established. Adamsen et al. (2) found
no significant increase in the QOL of patients with cancer
after a 6-week exercise program despite significant in-
creases in physical capacity, whereas Courneya et al. (7)
reported parallel improvements in both the QOL and
V˙O2peak in survivors of breast cancer after a 15-week
training program. Because we know that survivors of can-
cer respond to exercise training in much the same way as
do healthy individuals or patients with cardiovascular
disease (21), establishing correlations between cardiore-
spiratory fitness and QOL would contribute to the ratio-
nale for specific exercise programming in this population.
Accordingly, the aim of this study was to examine the
relationship between indices of cardiorespiratory fitness
and the QOL of untrained survivors of breast cancer who
already had completed cancer treatment. Based on the
fact that most physical activities of daily living (e.g., out-
536HERRERO, BALMER, SAN JUAN ET AL.
TABLE 1. Main demographic characteristics of participants
(n ? 16). Values are mean ? SD.
Body mass (kg)
Body mass index (kg·m?2)
50 ? 9
66.6 ? 9.6
1.60 ? 0.05
26.2 ? 4.5
TABLE 2. Stage of disease and treatment protocol (with re-
spect to surgery and chemotherapy) of the 16 study subjects.*
A ? CFM
* All the subjects received radiotherapy; MRM ? modified rad-
ical mastectomy; RM ? radical mastectomy; CFM ? cyclophos-
phamide, methotrexate, and 5-fluorouracil; A ? adriamycin.
door walking, walking upstairs, household tasks) involve
submaximal efforts, we hypothesized that the QOL of sur-
vivors of cancer is related more to submaximal (e.g., VT
or RCT) than to maximal (e.g., V˙O2peak) indices of car-
Experimental Approach to the Problem
We examined 16 previously untrained women who were
survivors of breast cancer to determine the possible re-
lationship existing between their QOL (dependent vari-
able) and several valid indices of submaximal (VT and
RCT) and maximal cardiorespiratory fitness (V˙O2peak,
peak power output [PPO], the independent variables).
Participants’ QOL was measured using the questionnaire
developed by the EORTC: the EORTC QLQ-C30 (1, 12).
We used version 3.0, which has been shown to be valid
and reliable when applied to Spanish patients with can-
cer (3). This questionnaire includes 30 items relating to
physical, social, emotional, and cognitive functioning, and
a global scale of QOL (maximum score of 100). For sim-
plicity, we reported the results of the global scale.
The VT, RCT, V˙O2peak, and PPO were chosen, be-
cause they are widely accepted, valid indices of cardio-
respiratory fitness that are routinely measured by exer-
cise physiologists in all populations, including diseased
people. From a practical perspective, indeed, these indices
can be measured easily during routine graded exercise
testing. Finally, we chose to evaluate survivors of breast
cancer, because the high incidence and good survival rate
of breast cancer, compared with other types of tumors,
has considerably increased the necessity of improving
QOL during and after treatment. Most investigations in
the field have in fact evaluated patients with or survivors
of this type of tumor (21).
Before entering the study, informed consent was obtained
from each participant and the study was approved by the
local Human Ethics Committee (Universidad Europea de
Madrid, Spain). After the corresponding oncologist pro-
vided consent, subjects were deemed eligible for the study
if they met each of the following conditions: (a) postmen-
opausal women surviving breast cancer (2–5 years post-
treatment; age range, 40–60 years); (b) physical activity
level equal to walking a maximum of 30 minutes, 3 days
per week (as corroborated by the results of a specific ques-
tionnaire on physical activity that is explained below); (c)
performing no strenuous exercise such as running, cy-
cling, swimming, or resistance training and not being en-
rolled in any type of supervised exercise program; and (d)
previous anticancer treatment consisting of surgery and
both postsurgery radiotherapy and chemotherapy. Wom-
en were excluded from the study if they had cardiac dis-
ease (New York Heart Association II or greater), uncon-
trolled hypertension (blood pressure ?160/90 mmHg), un-
controlled pain, or any other condition that contraindi-
cated exhaustive exercise in survivors of cancer (21) (e.g.,
increased risk of bone fractures, severe anemia [?8g·dl?1]
or platelet count lower than 50 ? 109·?l?1).
Subjects’ demographic characteristics are shown in
Table 1. The time posttreatment, type of breast cancer,
and treatment protocol for each of the 16 subjects is
shown in Table 2. Before entering the study, all the sub-
jects completed the International Physical Activity Ques-
tionnaire (IPAQ; short form). Using this questionnaire,
which has been shown to be valid and reliable for moni-
toring population levels of physical activity among 18- to
65-year-old adults in diverse settings (8), subjects recall
their levels of physical activity in the previous 7 days. The
results of the IPAQ are displayed in Table 3 and showed
that the level of physical activity attained by each subject
did not surpass the level of three 30-minute sessions per
week of walking exercise.
Exercise (Cardiorespiratory) Tests
All cardiorespiratory tests were performed at the same
time of the day (1000–1400 hours) under similar environ-
mental conditions (temperature, ?20? C; relative humid-
ity, 45–55%; barometric pressure, ?720 mmHg) on a pro-
grammable, electrically braked cycle-ergometer (Vario-
bike 600, Marquette Hellige, Freiburg, Germany). All the
participants were habituated to the equipment and pro-
tocol before the start of the study and refrained from per-
forming physical activity for 24 hours before the tests.
After a warm-up period of 5 minutes with no load, power
output was increased by 10 W·min?1from an initial value
of 20 W. Pedal cadence was maintained within the range
of 60–70 rev·min?1. The tests were terminated upon vo-
litional fatigue or when cadence could not be maintained
at a minimum of 60 rev·min?1. Respiratory gas exchange
was measured using open-circuit spirometry (Oxycon Del-
ta, Jaeger, Hoechberg, Germany). Peak oxygen uptake
(V˙O2peak) and peak ventilation (VEpeak) were recorded
as the highest average V˙O2and VE values obtained for
CANCER AND CARDIORESPIRATORY FITNESS
TABLE 3. Score results of the International Physical Activity
MET·min·week?1in either walking exercise or moderate/vigor-
ous activity (?6 METs: e.g., running, swimming).*
* MET ? metabolic equivalent (1 MET ? 3.5 mlO2·kg?1·min?1
or 1 kcal·kg?1·h?1).
TABLE 4. Maximal values determined from gradual exercise
test (n ? 16). Values are mean ? SD.*
PPO/body mass (W·kg?1)
* V˙O2peak ? peak oxygen consumption; PPO ? peak power
output; HRpeak ? peak heart rate; VEpeak ? peak pulmonary
1.64 ? 0.25
24.6 ? 5.8
93 ? 22
1.43 ? 0.46
163 ? 16
57 ? 13
TABLE 5. Absolute values for ventilatory (n ? 16) and respi-
ratory compensation thresholds (n ? 13) determined from grad-
ual exercise test. Values are mean ? SD.
V˙O2@ VT (L·min?1)
VO2@ VT (ml·kg?1·min?1)
PO @ VT
HR @ VT
VE @ VT
V˙O2@ RCT (L·min?1)
VO2@ RCT (ml·kg?1·min?1)
PO @ RCT
HR @ RCT
VE @ RCT
1.00 ? 0.22
15.3 ? 3.2
44 ? 10
117 ? 15
26 ? 7
1.34 ? 0.26
20.9 ? 5.4
77 ? 15
145 ? 14
41 ? 9
* VT ? ventilatory threshold; RCT ? respiratory compensa-
tion threshold; V˙O2? oxygen consumption; PO ? power output;
HR ? heart rate; VE ? pulmonary ventilation.
TABLE 6. Relative values for ventilatory (n ? 16) and respi-
ratory compensation thresholds (n ? 13) determined from incre-
mental test. Values are mean ? SD.
%V˙O2peak @ VT
%PPO @ VT
%HRpeak @ VT
%VEpeak @ VT
%V˙O2peak @ RCT
%PPO @ RCT
%HRpeak @ RCT
%VEpeak @ RCT
61 ? 11
49 ? 12
73 ? 10
48 ? 15
80 ? 9
79 ? 7
88 ? 5
68 ? 11
* VT ? ventilatory threshold; RCT ? respiratory compensa-
tion threshold; V˙O2peak ? peak oxygen consumption; PPO ?
peak power output; HRpeak ? peak heart rate; VEpeak ? peak
any continuous 20-second period. The PPO was computed
as indicated elsewhere (27). Heart rate (b·min?1) and
blood pressure were monitored during the tests using
electrocardiogram tracings and auscultation, respective-
ly. Peak heart rate (HRpeak) was accepted as the highest
recorded heart rate (b·min?1) during the test.
The workload (V˙O2, W, HR, and VE) eliciting VT was
determined using the criteria of an increase in both the
ventilatory equivalent of oxygen (VE·V˙O2?1) and end-tidal
pressure of oxygen, with no concomitant increase in the
ventilatory equivalent of carbon dioxide (VE·V˙CO2?1),
whereas that eliciting the RCT was determined using the
criteria of an increase in both the VE·V˙O2?1and
VE·V˙CO2?1and a decrease in end-tidal pressure of carbon
dioxide (22). For VT and RCT determination, the values
of the aforementioned variables were averaged for every
1-minute period and plotted against workload. Two in-
dependent experienced observers detected VT and RCT.
If there was disagreement, we obtained the opinion of a
A Spearman rank-difference correlation test was used to
assess the relationships between variables, because the
QOL data did not meet the assumptions for parametric
statistics. The same correlation test was used to assess
whether time posttreatment (months) was significantly
related to QOL and thus could influence our results (i.e.,
the possible correlations existing between QOL and car-
diorespiratory variables determined during graded tests).
The level of significance was set at p ? 0.05. Results are
expressed as mean (SD) for parametric variables and me-
dian (minimum–maximum) for QOL scale.
The median (minimum–maximum) value for QOL scale
was 67 (33–100). No significant correlation was encoun-
tered between time posttreatment (months) and QOL.
Thus, the former variable was not a covariate that could
influence our results. The mean for the physiological var-
iables measured during the graded tests (n ? 16, except
for RCT, which was detected in only 13 patients) are
shown in Tables 4–6.
Significant relationships between QOL and the differ-
ent cardiorespiratory variables studied are shown in Ta-
ble 6. A significant inverse relationship (p ? 0.05) was
found for QOL scores and values for age (years) and body
mass (kg), VE·V˙CO2?1@VT, %HRpeak@VT and %VE-
peak@VT. A significant positive relationship (p ? 0.05)
was found for QOL and PPO/body mass and HRpeak,
V˙O2@RCT, power output (PO, expressed as either W or
W·kg?1) @RCT, and HR@RCT. We found a trend toward
a positive relationship between V˙O2peak (ml·kg?1·min?1)
and QOL (p ? 0.43), but significance was not reached (p
538HERRERO, BALMER, SAN JUAN ET AL.
The main finding of our study was that several indices of
cardiorespiratory fitness related to VT and RCT are as-
sociated with QOL in untrained survivors of breast can-
cer. This is an important finding, given the current in-
terest in exercise and cancer. Due to the high incidence
and good survival rate of some types of tumors such as
breast cancer, there is indeed an increasing need for im-
proving patients’ QOL through exercise interventions
during and after treatment. In fact, recent research has
shown the positive impact that exercise training has on
the QOL of patients with breast cancer (5) or of long-term
survivors of this disease (18). In addition, participation in
exercise programs can improve body mass index, anthro-
pometric measures, and patients’ psychological attitudes
toward exercise, all of which are associated with im-
proved QOL and reduced risk of cancer recurrence (36).
The position of oncologists toward exercise also is chang-
ing, in that most of them now have a favorable attitude
toward recommending exercise to patients with cancer, at
least in Western countries (17). For all these reasons,
there is an urgent need to develop an evidence-based set
of exercise guidelines, especially considering that direct
cancer-specific evidence about the best type, frequency,
duration, or intensity of exercise is still lacking in the
peer-reviewed literature (15). Thus, more studies such as
the present one are necessary to determine which indices
of cardiorespiratory fitness are related to QOL in survi-
vors of cancer (or in patients with this disease), depend-
ing on the type of tumor and posttreatment time. In
short- to mid-term (2–5 years) survivors of breast cancer,
VT and RCT should be evaluated in order to objectively
assess the beneficial effects brought about by regular ex-
ercise training in this population (i.e., both pre- and post-
training assessment). Further, future exercise interven-
tions should aim to improve the aforementioned indices.
On the other hand, future studies with survivors of breast
cancer and other types of tumors using more homoge-
neous groups (i.e., same time posttreatment in all sub-
jects) are needed to corroborate and extend our findings.
Research using a longitudinal, prospective approach also
is necessary to assess whether time elapsed after treat-
ment influences the magnitude of the relationship that
exists between QOL and cardiorespiratory fitness in sur-
vivors of cancers, including breast cancer.
To the best of our knowledge, this is the first study
that has directly assessed both (a) peak indices of cardio-
respiratory fitness and (b) values for VT and RCT in un-
trained survivors of breast cancer. The finding that QOL
is significantly related to cardiorespiratory fitness when
(ml·kg?1·min?1), is both novel and informative. In our
study, we found that measures other than V˙O2peak, such
as RCT (expressed as V˙O2) or VT (expressed as VE·V˙CO2?1
or VE relative to VEpeak), may provide a more valid in-
dicator of QOL in survivors of breast cancer. Scarce in-
formation is available on the VT and RCT of patients with
cancer or survivors of cancer, and these measures nor-
mally are associated with the evaluation of the cardiore-
spiratory fitness of elite athletes or patients other than
cancer sufferers, particularly in those with cardiac dis-
eases (24). Future studies should consider the incorpo-
ration of an assessment for VT and RCT when investi-
gating the link between cardiorespiratory fitness and
QOL of survivors of breast cancer. One of the advantages
of submaximal markers, such as VT and RCT, is that ac-
tual maximal V˙O2(i.e., V˙O2max) values are not easy to
obtain in nonathletes and particularly in diseased indi-
viduals. Indeed, diseased or deconditioned individuals fail
to stress their cardiorespiratory system maximally (i.e.,
such as demonstrating a ‘‘plateau phenomenon’’ in V˙O2
values at the end of a gradual stress test), because of ‘‘the
unpleasant symptoms of exhaustion, dyspnea and/or leg
pain’’ (32). This often results in early termination of ex-
ercise and so underestimation of V˙O2maximal values (32).
The mean value for V˙O2peak attained by the partici-
pants in the present study is below mean values reported
for healthy (sedentary or active) age-matched women in
other studies (see meta-analysis, Fitzgerald et al. ).
For instance, the average V˙O2peak expected for active
women with a mean age of 50 years is ?25% higher than
the mean value obtained in our participants (13). These
data highlight that the age-associated decline in V˙O2peak
in survivors of breast cancer appears to be more pro-
nounced than in the general population and is probably
due to the acute and chronic effects of the disease and
anticancer treatment, together with the sedentary life-
style usually adopted by survivors of cancer (21). For ex-
ample, Courneya et al. (7) reported a significant correla-
tion between improvements in both QOL and V˙O2peak af-
ter a 15-week training program in survivors of breast can-
cer. Nevertheless, the baseline V˙O2peak levels of their
patients were ?23% lower than in our subjects, and only
?30% higher than those values (13 ml·kg?1·min?1) con-
sidered necessary for independent living (30). This could
explain why the significant training-induced increase in
V˙O2peak (i.e., ?13% change, to reach posttraining values
that were still lower than those of our subjects) was as-
sociated with an improvement in the QOL. Taken togeth-
er, these data would suggest that V˙O2peak is a good pre-
dictor of QOL mainly in diseased individuals or survivors
of chronic diseases whose physical condition is very low,
with the strength of the correlation decreasing when
V˙O2peak levels are above that required for independent
living. This may explain why we found a trend toward a
positive relationship between QOL and V˙O2peak in our
participants (p ? 0.10) whose V˙O2peak was well above the
value needed to maintain independent living. However,
the influence of body mass and indices of fitness is high-
lighted by our finding that QOL was related positively to
PPO values when expressed relative to body mass, but
not as an absolute value. The finding that QOL was in-
versely related to body mass is interesting. One possible
explanation is that increased body mass negatively af-
fects mobility and physical functioning. Therefore, a large
body mass may hinder the performance of day-to-day ac-
tivities and this is associated with a low QOL. In our
study, the mean value for body mass index (BMI) re-
vealed that the group was overweight according to Amer-
ican College of Sports Medicine guidelines (BMI, 25–29.9
Our data revealed that participants with a high HR
value at both RCT and HRpeak had high scores for global
QOL. This shows that the HR response to intense exer-
tion (?RCT—i.e., ?85% of V˙Opeak or ?89% of HRpeak)
can play a key role in the functional capacity and QOL of
survivors of breast cancer. The HR response to exercise
is related to a complex interplay among many factors in-
cluding age, sex, physical conditioning, sympathetic
CANCER AND CARDIORESPIRATORY FITNESS
drive, baroreceptor reflexes, and venous return, as has
been reviewed elsewhere (14). It is common knowledge
that submaximal HR response is dependent on fitness
state, which is to say that at any given submaximal work-
load, HR significantly decreases after a period of endur-
ance training (34). In fact, pioneer findings by Dimeo et
al. (11) reported that submaximal HR levels at an abso-
lute workload decreased after training in cancer patients.
Decreased HR at an absolute workload is indeed a normal
response to endurance training. There is less agreement
concerning the HR response at near-maximal or maximal
workloads. In fact, an association exists between de-
creased HR response at high workloads (i.e., failure to
achieve 85% of maximal predicted HR) and coronary ar-
tery disease prognosis (20). Such an impaired maximal
exercise HR response may well represent an early man-
ifestation of cardiac ischemia (33) due to attenuated sym-
pathetic drive, but also could reflect decreased physical
fitness, which has been shown to be predictive of cardiac
risk (6). In chronic patients and survivors of chronic dis-
eases such as cancer, the inability to reach actual maxi-
mal HR levels also could reflect decreased physical fit-
ness, that is, lack of peak muscle power due to the muscle
wasting phenomenon associated with anticancer treat-
ment, combined with sedentary lifestyle (21). Indeed, in
our study we also found a positive relationship between
QOL and the ability to reach PPO values (W·kg?1). Many
patients or survivors of diseases including cancer are pos-
sibly unable to reach maximal HR values due to the oc-
currence of early muscle fatigue before their cardiovas-
cular system is maximally stressed. An additional prac-
tical implication of our study is the usefulness of deter-
mining the easily and routinely obtained exercise HR
response at high workloads as an indicator of QOL in sur-
vivors of cancer.
The VE·V˙CO2?1@VT and ventilation at VT expressed
relative to VEpeak were inversely related to QOL. The
importance of the ventilatory response to gradual exercise
(e.g., VE at VT or VE·V˙CO2?1) as an indicator of functional
capacity has been extensively documented in both
healthy adults (6) and older individuals (28), as well as
in chronically diseased populations (10, 19, 31). Thus, the
ventilatory cost of sustaining high, submaximal intensi-
ties (?VT) is higher as physical condition decreases. For
instance, an attenuation of VE in proportion to V˙CO2re-
sponse and improved overall ventilatory efficiency has
been reported after training in patients with chronic
heart failure (10, 19, 31). Such a training effect results in
attenuation of breathlessness and improved capacity to
exercise at submaximal levels, and contributes to the
well-being of patients in their daily activities (19). Thus,
our results are in agreement with previous research on
diseased individuals and highlight the importance of the
ventilatory work as a determinant of overall functional
capacity and QOL in cancer sufferers.
In summary, several indices of cardiorespiratory fitness
and overall endurance capacity, particularly submaximal
indices such as the various measures of VT, are related
to QOL in survivors of breast cancer. Our data, together
with those of previous research in the field, emphasize
the need for this population to engage in programmed
aerobic exercise training involving large muscle groups
(i.e., 3–5 weekly sessions, each lasting a maximum of 20
minutes) of indoor cycling, walking (including uphill
walking), swimming, or group aerobics at submaximal in-
tensities (70–90% of HRpeak) and performed at submax-
imal intensities to improve VT and RCT. Future studies
on exercise training, physical capacity, and well-being of
cancer sufferers should include determination of submax-
imal measures such as VT and RCT, because they are
correlated to global QOL. Further, these submaximal car-
diorespiratory indices ideally would be evaluated in this
subpopulation by fitness specialists (particularly, clinical
exercise physiologists) in order to objectively assess the
beneficial effects brought about by regular exercise train-
ing (i.e., both pre- and posttraining assessment).
1.AARONSON, N.K., S. AHMEDZAI, B. BERGMAN, M. BULLINGER,
A. CULL, N.J. DUEZ, A. FILIBERTI, H. FLECHTNER, S.B. FLEISH-
MAN, J.C.J.M. DEHAES, S. KAASA, M. KLEE, D. OSOBA, D. RA-
ZAVI, P.B. ROFE, S. SCHRAUB, K. SNEEUW, M. SULLIVAN, AND
F. TAKEDA. The European Organization for Research and
Treatment of Cancer QLQ-C30: A quality-of-life instrument for
use in international clinical trials in oncology. J. Natl. Cancer
Inst. 85:365–376. 1993.
ADAMSEN, L., J. MIDTGAARD, M. RORTH, N. BORREGAARD, C.
ANDERSEN, M. QUIST, T. MOLLER, M. ZACHO, J.K. MADSEN,
AND L. KNUTSEN. Feasibility, physical capacity, and health
benefits of a multidimensional exercise program for cancer pa-
tients undergoing chemotherapy. Support Care Cancer 11:707–
ARRARAS, J.I., F. ARIAS, M. TEJEDOR, E. PRUJA, M. MARCOS, E.
MARTINEZ, AND J. VALERDI. The EORTC QLQ-C30 (version 3.0)
Quality of Life questionnaire: Validation study for Spain with
head and neck cancer patients. Psychooncology 11:249–256.
BLAIR, S.N., J.B. KAMPERT, H.W. KOHL III, C.E. BARLOW, C.A.
MACERA, R.S. PAFFENBARGER JR, AND L.W. GIBBONS. Influenc-
es of cardiorespiratory fitness and other precursors on cardio-
vascular disease and all cause mortality in men and women.
JAMA. 276:205–210. 1996.
CAMPBELL, A., N. MUTRIE, F. WHITE, F. MCGUIRE, AND N.
KEARNEY. A pilot study of a supervised group exercise pro-
gramme as a rehabilitation treatment for women with breast
cancer receiving adjuvant treatment. Eur. J. Oncol. Nurs. 9:56–
CASABURI, R., T.W. STORER, AND K. WASSERMAN. Mediation of
reduced ventilatory response to exercise after endurance train-
ing. J. Appl. Physiol. 63:1533–1538. 1987.
COURNEYA, K.S., J.R. MACKEY, G.J. BELL, L.W. JONES, C.J.
FIELD, AND A.S. FAIREY. Randomized controlled trial of exer-
cise training in postmenopausal breast cancer survivors: Car-
diopulmonary and quality of life outcomes. J. Clin. Oncol. 21:
CRAIG, C.L., A.L. MARSHALL, M. SJOSTROM, A.E. BAUMAN, M.L.
BOOTH, B.E. AINSWORTH, M. PRATT, U. EKELUND, A. YNGVE,
J.F. SALLIS, AND P. OJA. International physical activity ques-
tionnaire: 12-country reliability and validity. Med. Sci. Sports
Exerc. 35:1381–1395. 2003.
CURNIER, D., M. GALINIER, J. FOURCADE, M. BOUSQUET, S.
BOVEDA, M. DELAY, J.M. SENARD, J.M. FAUVEL, J.P. BOUN-
HOURE, AND J.L. MONTASTRUC. Utilization of heart rate at the
ventilatory threshold for the prescription of intensity of exer-
cise training in cardiac failure. Arch. Mal. Coeur Vaiss. 93:71–
DAVEY, P., T. MEYER, A. COATS, S. ADAMOPOULOS, B. CASADEI,
J. CONWAY, AND P. SLEIGHT. Ventilation in chronic heart fail-
ure: Effects of physical training. Br. Heart J. 68:473–477. 1992.
DIMEO, F., B.G. RUMBERGER, AND J. KEUL. Aerobic exercise as
therapy for cancer fatigue. Med. Sci. Sports Exerc. 30:475–478.
540HERRERO, BALMER, SAN JUAN ET AL. Download full-text
12.FAYERS, P.M., N.K. AARONSON, K. BJORDAL, D. CURRAN, AND
M. GROENVOLD. On behalf of the EORTC Quality of Life Group.
The EORTC QLQ-C30 Scoring Manual (3rd ed.). Brussels: Eu-
ropean Organisation for Research and Treatment of Cancer.
2001. pp. 1–86.
FITZGERALD, M.D., H. TANAKA, Z.V. TRAN, AND D.R. SEALS.
Age-related declines in maximal aerobic capacity in regularly
exercising vs. sedentary women: A meta-analysis. J. Appl. Phy-
siol. 83:160–165. 1997.
HAMMOND, H.K., AND V.F. FROELICHER. Normal and abnormal
heart rate responses to exercise. Prog. Cardiovasc. Dis. 27:271–
HUMPEL, N., AND D.C. IVERSON. Review and critique of the
quality of exercise recommendations for cancer patients and
survivors. Support Care Cancer 13:493–502. 2005.
JAKICIC, J.M., K. CLARK, E. COLEMAN, J.E. DONNELLY, J. FOR-
EYT, E. MELANSON, J. VOLEK, S.L. VOLPE, AND AMERICAN COL-
LEGE OF SPORTS MEDICINE. American College of Sports Medi-
cine position stand. Appropriate intervention strategies for
weight loss and prevention of weight regain for adults. Med.
Sci. Sports Exerc. 33:2145–2156. 2001.
JONES, L.W., K.S. COURNEYA, C. PEDDLE, AND J.R. MACKEY.
Oncologists’ opinions towards recommending exercise to pa-
tients with cancer: A Canadian national survey. Support Care
Cancer 13:929–937. 2005.
KENDALL, A.R., M. MAHUE-GIANGRECO, C.L. CARPENTER, P.A.
GANZ, AND L. BERNSTEIN. Influence of exercise activity on qual-
ity of life in long-term breast cancer survivors. Qual. Life Res.
KIILAVUORI, K., A. SOVIJARVI, H. NAVERI, T. IKONEN, AND H.
LEINONEN. Effect of physical training on exercise capacity and
gas exchange in patients with chronic heart failure. Chest 110:
LAUER, M.S., P.M. OKIN, M.G. LARSON, J.C. EVANS, AND D.
LEVY. Impaired heart rate response to graded exercise. Prog-
nostic implications of chronotropic incompetence in the Fra-
mingham Heart Study. Circulation 93:1520–1526. 1996.
LUCIA, A., C. EARNEST, AND M. PEREZ. Cancer-related fatigue:
How can exercise physiology assist oncologists? Lancet Oncol.
LUCIA, A., J. HOYOS, A. SANTALLA, C. EARNEST, AND J.L. CHI-
CHARRO. Tour de France versus Vuelta a Espan ˜a: Which is
harder? Med. Sci. Sports Exerc. 35:872–878. 2003.
MACVICAR, M.G., M.L. WINNINGHAM, AND J.L. NICKEL. Effects
of aerobic interval training on cancer patients’ functional ca-
pacity. Nurs. Res. 38:348–351. 1989.
MEYER, T., A. LUCIA, C.P. EARNEST, AND W. KINDERMANN. A
conceptual framework for performance diagnosis and training
prescription from submaximal parameters—Theory and appli-
cation. Int. J. Sports Med. Suppl. 1:S38–S48. 2005.
25.MYERS, J., M. PRAKASH, V. FROELICHER, D. DO, S. PARTINGTON,
AND J.E. ATWOOD. Exercise capacity and mortality among men
referred for exercise testing. N. Engl. J. Med. 346:793–801.
NIEUWLAND, W., M.A. BERKHUYSEN, D.J. VAN VELDHUISEN, E.
VAN SONDEREN, J.W. VIERSMA, K.I. LIE, AND P. RISPENS. Im-
pairment of exercise capacity and peak oxygen consumption in
patients with mild left ventricular dysfunction and coronary
artery disease. Eur. Heart J. 19:1688–1695. 1998.
PADILLA, S., I. MUJIKA, G. CUESTA, AND J.J. GOIRIENA. Level
ground and uphill cycling ability in professional road cycling.
Med. Sci. Sports Exerc. 31:878–885. 1999.
POULIN, M.J., D.A. CUNNINGHAM, D.H. PATERSON, P.A. RE-
CHNITZER, N.A. ECCLESTONE, AND J.J. KOVAL. Ventilatory re-
sponse to exercise in men and women 55 to 86 years of age.
Am. J. Respir. Crit. Care Med. 149:408–415. 1994.
SHEPHARD, R.J., C. ALLEN, A.J.S. BENADE, C.T.M. DAVIS, R.
HEDMAN, J.E. MERRIMAN, K. MYHRE, P.E. DI PRAMPERO, AND
R. SIMMONS. The maximum oxygen intake. An international
reference standard of cardiorespiratory fitness. Bull. World
Health Organ. 38:757–764. 1968.
SPIRDUSO, W.W. Physical Dimensions of Aging. Champaign,IL:
Human Kinetics, 1997. pp. 95–121.
SULLIVAN, M.J., M.B. HIGGINBOTHAM, AND F.R. COBB. Exercise
training in patients with chronic heart failure delays ventila-
tory anaerobic threshold and improves submaximal exercise
performance. Circulation 79:324–329. 1989.
WAGNER, P.D. New ideas on limitations to V˙o2max. Exerc.
Sports Sci. Rev. 28:10–14. 2000.
WIENS, R.D., P. LAFIA, C.M. MARDER, R.G. EVANS, AND H.L.
KENNEDY. Chronotropic incompetence in clinical exercise test-
ing. Am. J. Cardiol. 54:74–78. 1984.
WILMORE, J.H., P.R. STANFORTH, J. GAGNON, T. RICE, S. MAN-
DEL, A.S. LEON, D.C. RAO, J.S. SKINNER, AND C. BOUCHARD.
Heart rate and blood pressure changes with endurance train-
ing: The HERITAGE family study. Med. Sci. Sports Exerc. 33:
WILSON, D.B., J.S. PORTER, G. PARKER, AND J. KILPATRICK. An-
thropometric changes using a walking intervention in African
American breast cancer survivors: A pilot study. Prev. Chronic
Dis. 2:A16. 2005. Available at: http://www.pubmedcentral.gov/
articlerender.fcgi?tool?pubmedid?15888227. Accessed March
This research was supported by a grant from Universidad
Europea de Madrid (UEM2004/02). The results of the present
study do not constitute endorsement of the product by the
authors or the National Strength and Conditioning Association.
There is no conflict of interest.
correspondenceto Dr.Alejandro Lucı ´a,