Older breast cancer survivors' exercise and support group program experiences and recommendations from the IMPROVE trial: a qualitative study.

Background and introduction
Breast cancer is prevalent among older women, with the majority of survivors in the United States aged 65 years or older [1]. For these women, physical activity plays a critical role in maintaining functional independence, improving quality of life, and reducing the risk of recurrence and mortality [2–4]. Despite these benefits, older breast cancer survivors remain less likely to meet national physical activity guidelines compared with their younger counterparts [5–7], underscoring the importance of interventions tailored to this growing population.
Disparities in physical activity are particularly pronounced among African American (AA) and socioeconomically disadvantaged (SES-disadvantaged) survivors with AA survivors, as well as women with lower income and education, less likely to achieve recommended levels of aerobic and strength activity than Non-Hispanic White (NHW) survivors [8]. In addition, large cohort studies, including the Southern Community Cohort Study, have shown that lower physical activity levels in AA women with breast cancer are associated with higher risk of both all-cause and breast cancer–specific mortality [9]. These disparities suggest that older breast cancer survivors, and in particular, older AA and SES-disadvantaged survivors may face unique challenges in sustaining healthy activity behaviors and underscore the importance of designing programs to increase physical activity in these populations.
Prior research indicates that social support and program accessibilty [10], are critical to fostering physical activity engagement, particularly for older survivors who may also contend with comorbidities, functional limitations, or caregiving responsibilities [11, 12]. Qualitative studies in older breast cancer survivors have offered valuable insights, but most have involved smaller or less diverse samples [13–15], leaving limited understanding of how older diverse breast cancer survivors, experience real-world community-based programs.
The present study addresses this gap by exploring the perspectives of older breast cancer survivors who participated in the IMPROVE trial, a randomized evaluation of structured exercise versus support group plus Fitbit [2]. We conducted qualitative exit interviews to examine participants’ experiences, perceived impacts, challenges, and recommendations. Our analysis drew on Social Cognitive Theory [16] and the Transtheoretical Model [17] to help better understand the mechanisms underlying behavior change. These frameworks underscore the role of social support and self-efficacy in maintaining physical activity, providing a lens through which to interpret our findings. This study, provides rare insights into how older survivors, including those who are AA or SES-disadvantaged, engage with physical activity interventions, and how future programs can be designed to enhance sustainability and improve health outcomes.

Methods

Overview of IMPROVE study
The study design and detailed procedures have previously been described elsewhere [2, 18, 19]. In brief, the IMPROVE study was a two-arm randomized-controlled trial designed to compare the effectiveness of a group-based 52-week exercise intervention (n = 107) versus support group plus Fitbit (SG + Fitbit), (n = 106). The exercise intervention consisted of a supervised 20-week program offered three sessions per week, one-hour per session, designed to achieve 150 min of moderate intensity aerobic activity and 90 min of resistance training per week. This was followed by 32 weeks of unstructured and unsupervised exercise program, designed for self-directed maintenance, where exercise participants had the flexibility to exercise at their own pace and preferred location. During the entire 52-week period all participants in the exercise arm were encouraged to supplement their exercise training with an unsupervised brisk home walking program. The SG + Fitbit intervention consisted of one hour per week of in-person support group sessions for 20 weeks and was also followed by an unsupervised phase for 32 weeks where participants could attend any support group session of their choice at the community cancer support center. In-person support group activities included health education classes, nutrition classes, drumming lessons, labyrinth walks and group discussions on survivorship, among many others. Participants in both study arms were provided with a Fitbit Blaze for physical activity tracking. Study measurements and assessments were completed at baseline, 20 and 52 weeks. Exit interviews were optional and conducted at study completion (52-weeks) to evaluate the intervention for the purpose of informing future program improvement.

Participants
Eligibility included females aged ≥ 65 years, who were no more than five years from treatment completion (surgery, chemotherapy and/or radiation, whichever was last) for pathologically confirmed stage I-III breast cancer and were Non-Hispanic White or African American. Using a self-report prescreening questionnaire, we purposely targeted the inclusion of patients who were “SES-disadvantaged” defined as having ≤ high school education and/or median household income ≤ $35,000 k [20]. Exclusion criteria included stage IV breast cancer, severe dementia, life expectancy of less than one year and high cardiac risk patients. The study was approved by the Institutional Review Boards of the participating hospitals.

Study setting and community partnership
The study was conducted at a community cancer support center, The Gathering Place (TGP), within the Cleveland Metropolitan area. The mission of the community cancer support center is to support individuals and families touched by cancer through programs and services, including exercise, Tai chi and yoga, which are all provided free of charge.

Study design, participants and recruitment for exit interviews
The Exit Interview qualitative study was embedded within the IMPROVE randomized controlled trial. All participants who completed the 12-month IMPROVE study were invited to participate in an exit interview to maximize perspectives. Adequacy of sample size was supported by the concept of “information power” [21], given the broad aim of intervention refinement, heterogeneity of participants, and depth of material. This approach ensured inclusion of diverse perspectives, particularly African American and socioeconomically disadvantaged survivors who are often underrepresented in survivorship research.

Data collection
Semi-structured interviews were conducted at the end of the 12-month intervention. Interviews lasted 30–60 min and were held in private rooms at a community cancer center. Interviews were conducted by a trained graduate nursing student with qualitative interviewing expertise who was unaffiliated with trial delivery and other study procedures to minimize bias. The interview guide was developed collaboratively by study investigators with expertise in geriatric-oncology, exercise and nutrition science, behavior science, qualitative research, and social work, in consultation with community partners to ensure cultural and contextual relevance. The interview guide focused on program experiences, perceived benefits and challenges, and suggestions for improvement. Although the qualitative study was not guided by a theoretical framework, we interpreted our findings in light of the Social Cognitive Theory (SCT) [16] and Transtheoretical Model (TTM) [17], both of which emphasize the importance of social support and self-efficacy in sustaining physical activity.
The final interview guide is provided in Supplementary File 1. All interviews were audio-recorded and professionally transcribed by a HIPAA-compliant external transcription service under a confidentiality agreement. All transcripts were de-identified before analysis, with personal identifiers removed during the transcription review process. The research team then cross-checked transcripts against the audio recordings for accuracy. De-identified transcripts were stored on a secure, password-protected institutional server accessible only to study personnel. These procedures ensured both accuracy of the data and adherence to ethical standards for confidentiality and data protection. Field notes were taken after each session by the interviewer and incorporated into analysis for contextual validity.

Data analysis
We applied thematic analysis as described by Braun and Clarke [22], using an inductive approach and constant comparison [23]. Transcripts were read repeatedly to ensure familiarity, then coded into meaning units as part of the coding process. One researcher coded all transcripts, while a second researcher independently coded a subset (20%) to enhance reflexivity and deepen interpretation. These transcripts were discussed in team meetings to enrich understanding. The remaining transcripts (80%) were coded by the primary researcher, with ongoing input from the research team.
Codes were grouped into candidate themes, which were iteratively refined to capture shared meaning across participants. Themes were generated based on shared meaning. The two coders included an epidemiologist/biostatistician and a psychologist, both experienced in qualitative analysis but not involved in delivering the intervention. A reflexivity statement was maintained to acknowledge their perspectives and potential influence on interpretation.
We used a thematic saturation approach to assess data sufficiency. The two coders independently reviewed transcripts, and by approximately 100 interviews, no new themes were emerging, suggesting saturation had been reached. Because all intervention participants were invited, we continued to analyze additional interviews to maximize representation and ensure subgroup perspectives (e.g., race, SES, intervention arm) were adequately captured. NVivo software (QSR International) supported data management. Reporting followed the COREQ checklist (Supplementary File 2).

Results

Enrollment and baseline characteristics
The consort diagram for the IMPROVE Study is presented in Fig. 1. Between 2016 and 2020, 213 older breast cancer survivors were enrolled into the IMPROVE study and randomized into an exercise arm, (n = 108) or a Support Group + Fitbit arm, (n = 105). 184 (86%) participants completed follow-up at 52 weeks. At study completion, 145 (68%) study participants opted to participate in exit interviews.
Table 1 displays baseline characteristics of 145 participants who opted to complete Exit Interviews, by intervention arm. The median age at enrollment was 70.0 years, range 65–88 years. 44% were African American, 18% had ≤ high school education, 38% had a median household income of ≤ $35,000 and 43% met our definition [24] of being SES-disadvantaged. Groups were balanced with respect to race, socioeconomic status, and age distribution.

Themes across the entire cohort (N = 145)
Across the full cohort, participants described a range of experiences and recommendations that clustered into five broad categories: program experiences, transition challenges, Fitbit experiences, program impact, and recommendations (Table 2).

Program experiences (in-the-moment perceptions)
Survivors reflected on what they valued during their participation in the program. Many emphasized camaraderie and bonding, describing the encouragement and accountability that came from exercising alongside peers. For example, one participant noted, “Very good experience … enjoyed the company of not only the program participants but the instructors as well.” (65 yrs, African American, SES-disadvantaged, Exercise arm). Others highlighted enjoyment of specific enrichment activities such as drumming or labyrinth walking: “The drumming was fun and unexpected. It reminded me to move my body in new ways.” (66 yrs, African American, SES-disadvantaged, Fitbit arm). Staff and instructor support was also valued, with one participant observing, “They really cared about us, and it made a difference.” (68 yrs, Non-Hispanic White, SES-disadvantaged, Exercise arm).

Transition challenges
For some, the shift from structured program activities to independent exercise was difficult. Survivors reported losing motivation once group sessions ended, as one noted: “When the program ended, it was hard to keep it up on my own.” (67 yrs, Non-Hispanic White, SES-disadvantaged, Exercise arm). Others underscored the preference for exercising alongside peers rather than alone: “I lost my motivation without the group sessions each week.” (69 yrs, African American, SES-disadvantaged, Exercise arm).

Fitbit experiences
The Fitbit elicited mixed responses. Many participants found it motivating and helpful for accountability, explaining, “If I saw I hadn’t reached 10,000 steps, I would walk around the block just to get there.” (68 yrs, African American, SES non-disadvantaged, Fitbit arm). Others highlighted specific features, such as sleep tracking: “I liked seeing my sleep—it helped me understand why I was tired.” (70 yrs, Non-Hispanic White, SES non-disadvantaged, Exercise arm). However, some struggled with barriers, particularly technical issues or discomfort, reporting, “Sometimes it didn’t sync right, which was frustrating.” (69 yrs, Non-Hispanic White, SES non-disadvantaged, Fitbit arm).

Program impact (lasting effects beyond program)
In contrast, participants also described how the program influenced their lives after participation. Several reported sustained improvements in energy and vitality: “I have more energy now than before the program.” (71 yrs, African American, SES non-disadvantaged, Exercise arm). Emotional benefits were also highlighted, particularly the sense of solidarity and understanding gained from peers: “I didn’t feel so alone anymore. We understood each other.” (65 yrs, African American, SES-disadvantaged, Fitbit arm). Others described increased accountability to their health, with one woman sharing, “The Fitbit reminded me to pay attention to myself, not just everybody else.” (70 yrs, African American, SES non-disadvantaged, Exercise arm).

Recommendations
Survivors offered suggestions to strengthen future programs. Several requested longer program durations or maintenance phases: “I wish it had gone on longer, so I could keep the habit.” (68 yrs, African American, SES-disadvantaged, Exercise arm). Others wanted expanded content such as cooking or nutrition sessions: “I would have liked more classes on healthy cooking.” (70 yrs, Non-Hispanic White, SES non-disadvantaged, Fitbit arm). Concerns about assessment burden were common, with participants reporting, “The surveys were too long and personal.” (65 yrs, African American, SES-disadvantaged, Fitbit arm). Finally, transportation challenges were frequently raised, as noted by one woman: “Transportation was hard; sometimes I almost gave up.” (72 yrs, Non-Hispanic White, SES non-disadvantaged, Exercise arm).

Comparison between exercise and Support Group + Fitbit participants
While participants across both study arms described positive experiences, their reflections diverged in focus and emphasis (Table 3). Survivors in the exercise arm generally expressed satisfaction with their program, appreciating access to structured fitness sessions. One woman explained, “I was glad to be in the exercise group—I needed that structure.” (68 yrs, Non-Hispanic White, SES non-disadvantaged). In contrast, participants in the SG + Fitbit often voiced disappointment at not being assigned to the exercise arm, though many still found value in discussions. As one participant noted, “I really wanted to exercise with the others. I felt left out at first.” (69 yrs, African American, SES-disadvantaged).
Camaraderie was valued in both groups but described differently. Exercise participants emphasized accountability and motivation fostered by working out together. “We pushed each other to keep going, and that made me stronger.” (66 yrs, African American, SES-disadvantaged). SG + Fitbit participants, however, highlighted emotional support and shared understanding. “The relationship with the women in the group … we learned … bond with each other.” (70 yrs, African American, SES non-disadvantaged).
Enjoyment also diverged. Exercise participants frequently described the structured sessions as rewarding. “The exercise sessions made me feel stronger every week.” (71 yrs, African American, SES non-disadvantaged). SG + Fitbit participants most often identified enrichment activities as highlights. “The drumming was the highlight for me—I never thought exercise could be this fun.” (65 yrs, African American, SES non-disadvantaged).
When discussing program transitions, only exercise participants described difficulty sustaining activity after the intervention. “When the program ended, I just didn’t keep it up on my own.” (67 yrs, Non-Hispanic White, SES-disadvantaged). SG + Fitbit participants rarely raised this concern, reflecting the less exercise-focused nature of their sessions. One woman remarked, “We mostly talked, so I didn’t feel that challenge—it wasn’t about keeping up exercise.” (72 yrs, Non-Hispanic White, SES non-disadvantaged).
Fitbit was both a motivator and a challenge. Exercise participants generally saw it as reinforcing existing routines. “The sleep tracker helped me realize I wasn’t getting enough rest.” (70 yrs, Non-Hispanic White, SES non-disadvantaged). In contrast, SG + Fitbit participants often described frustrations with the device. “Sometimes it didn’t sync right, which was frustrating and made me not want to wear it.” (69 yrs, Non-Hispanic White, SES non-disadvantaged).
Program impacts were also distinct. Exercise participants reported increased energy and accountability to health. “The program made me more conscious of my health and sticking to routines.” (68 yrs, Non-Hispanic White, SES-disadvantaged). SG + Fitbit participants, however, emphasized encouragement from peers as their most meaningful outcome. “The group kept me going—I didn’t feel alone in this.” (65 yrs, African American, SES-disadvantaged).
Finally, recommendations reflected these different experiences. Exercise participants frequently called for extended supervision. “I wish we had a few more weeks—it ended too soon.” (70 yrs, African American, SES-disadvantaged). SG + Fitbit participants emphasized accessibility and transportation. “Getting there was sometimes the hardest part.” (72 yrs, Non-Hispanic White, SES non-disadvantaged).
Together, these findings underscore how the structured exercise program fostered accountability and physical benefits, while the SG + Fitbit program promoted peer bonding and emotional support, highlighting the complementary value of both approaches.

Study participants recommendations
In addition to describing their experiences and program impacts, survivors offered detailed recommendations for strengthening future interventions. These suggestions span the timing of recruitment, supervision and structure, addressing barriers, content, and program promotion, see subsections of Tables 2 and 3, and entire Table 4.

Timing of recruitment
Some participants expressed that joining the program earlier in their survivorship journey would have maximized its benefits. As one woman explained, “If I had started right after treatment, it would have helped me recover faster.” (68 yrs, African American, SES-disadvantaged, Exercise arm).

Supervision and maintenance
A common recommendation was to extend structured supervision or introduce a lighter “maintenance phase” once the core program ended. Survivors described wanting ongoing support to sustain their activity. “I wish it had gone longer—having the group kept me motivated.” (70 yrs, Non-Hispanic White, SES non-disadvantaged, Exercise arm). Others suggested periodic booster sessions or monthly check-ins.

Program structure
Participants recommended adjustments to program delivery, including smaller groups to allow more individualized attention and feedback from instructors. “With fewer people, the trainer could have worked with me more on my form.” (66 yrs, African American, SES-disadvantaged, Exercise arm).

Addressing barriers
Transportation challenges were commonly mentioned as barriers to consistent participation. Some described missing sessions due to travel limitations. “Getting to the site was the hardest part—sometimes I almost gave up.” (72 yrs, Non-Hispanic White, SES non-disadvantaged, Exercise arm). Survivors suggested more transportation support or offering programs at locations closer to where participants live.

Integration of exercise and support
Participants in the Fitbit arm, in particular, voiced a desire for structured physical activity to be integrated into their support groups. “It would have been nice if we could exercise too, not just talk.” (65 yrs, African American, SES non-disadvantaged, Fitbit arm).

Assessment burden
Some participants felt the surveys were overly long and, at times, intrusive. They recommended shortening and streamlining assessments to reduce burden. “The surveys were too long and personal—it made me tired of answering.” (65 yrs, African American, SES-disadvantaged, Fitbit arm).

Nutrition content
Requests for expanded nutrition sessions were common. Survivors asked for more practical, hands-on content, such as recipes and cooking demonstrations. “I wanted more on food—like how to cook healthier meals at home.” (70 yrs, Non-Hispanic White, SES non-disadvantaged, Fitbit arm).

Program promotion and reach
Several participants emphasized the importance of promoting the program more broadly, expressing enthusiasm to serve as “ambassadors” to encourage others. “I tell other survivors about it—more people need to know this program exists.” (68 yrs, African American, SES-disadvantaged, Exercise arm).

Discussion
This study provides insights from one of the largest qualitative samples of older breast cancer survivors to date (n= 145). Participants, nearly half of whom were African American and socioeconomically disadvantaged, shared candid reflections on structured exercise, group-based support, and wearable technology. Their perspectives extend prior research by highlighting both the benefits and limitations of exercise interventions for older, diverse survivors—populations frequently underrepresented in physical activity and exercise studies [25–27].

Contribution to literature
Consistent with previous studies, participants valued the social and physical benefits of exercise [27–29]. However, the prominence of camaraderie in our data, with many reporting group connection as a motivator, underscores the centrality of social support in sustaining participation. Enjoyment of diverse activities such as drumming and labyrinth walking suggests that novel, engaging formats may increase adherence. Few prior studies have documented these preferences among older and minority survivors, making this contribution particularly important for designing culturally relevant interventions [13].

Theoretical implications
Findings from this study can be understood through Social Cognitive Theory (SCT) and the Transtheoretical Model (TTM). Within SCT, social support was a central mechanism through which survivors built confidence and sustained engagement. Group camaraderie, accountability to peers, and encouragement from staff reinforced self-efficacy, a core SCT construct [16]. Similarly, the Fitbit promoted self-monitoring and goal setting, which fostered accountability and a sense of progress, though technical challenges highlighted the need for age-appropriate, user-friendly tools. These findings are consistent with prior survivorship research showing that peer reinforcement and accessible self-regulation strategies strengthen physical activity adherence in breast cancer survivors [10].
From the perspective of TTM, participants’ challenges in maintaining activity after the program ended illustrate the vulnerability of survivors in the maintenance stage when structured reinforcement is withdrawn [17]. Survivors’ calls for extended supervision or ongoing group support highlight the need for structured maintenance strategies, such as booster sessions, peer-led programs, or community partnerships, to prevent relapse and sustain gains over time. Recent evidence support this approach, demonstrating that ongoing social and environmental supports are critical for physical activity maintenance among breast cancer survivors [30, 31]. Together, these findings suggest that SCT mechanisms (social reinforcement, self-monitoring, self-efficacy) and TTM processes (progression through and relapse from stages of change) operate synergistically, underscoring the importance of embedding structured, socially supportive maintenance opportunities into survivorship interventions.

Practical implications
The findings have several practical implications for the design of survivorship interventions. Participants’ emphasis on camaraderie, peer bonding, and accountability underscores the importance of integrating structured social support into physical activity programs for breast cancer survivors. Prior research has shown that social support is a key determinant of physical activity maintenance in this population [10, 31]. This support may take the form of ongoing group sessions, peer-led maintenance groups, or community partnerships that extend beyond the intervention period. Survivors’ difficulty sustaining activity once the supervised program ended highlights the need for maintenance phases or booster sessions, consistent with evidence that structured follow-up enhances long-term adherence [30].
Experiences with Fitbit illustrate both the potential and limitations of digital tools: while some participants found self-monitoring motivating, others encountered technical and comfort-related barriers. This aligns with recent findings that digital health interventions must be accessible and user-friendly for older survivors and often require technical support [32]. In addition, participants recommended reducing the burden of lengthy assessments and addressing transportation challenges, both of which have been identified as barriers to participation in physical activity trials among cancer survivors [13]. Finally, calls for nutrition-related content point to the value of multi-component interventions that address survivors’ broader health and wellness needs alongside physical activity, as supported by integrative lifestyle intervention trials in breast cancer survivors [33].

Strengths and limitations
Strengths of this study include its large qualitative sample, racial and socioeconomic diversity, and systematic analytic approach with double coding and reflexivity [21, 22]. Limitations include the fact that although there study population is diverse, AA still represented a minority, reliance on self-reported experiences and the potential for positive bias, as participants who dropped out were not interviewed. Additionally, theoretical frameworks were applied post hoc, which may limit interpretive depth. Nevertheless, the study provides robust insights from older breast cancer survivors and other underrepresented groups whose perspectives are rarely captured in exercise survivorship research [13, 34].

Conclusions
Older breast cancer survivors described the value of structured exercise, peer support, and wearable technology in promoting activity and well-being, while highlighting challenges with sustainability, technology, and access. Their recommendations point to clear strategies—longer-term supervision, group-based programming, simplified assessments, and tailored technological support—that can improve the feasibility and acceptability of future interventions. Incorporating survivor voices into program design is critical to addressing disparities and enhancing survivorship outcomes [35].

Supplementary Information