559046

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CNRXXX10.1177/1054773814559046Clinical Nursing ResearchClinical Nursing ResearchHwang et al.

Article
Clinical Nursing Research
2016, Vol. 25(2) 192­–208
The Effect of © The Author(s) 2014
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DOI: 10.1177/1054773814559046
Program for Ovarian cnr.sagepub.com

Cancer Survivors

Kyung-Hye Hwang, RN, PhD1,

Ok-Hee Cho, RN, PhD2,
and Yang-Sook Yoo, RN, PhD3

Abstract
This study was done to investigate the effects of comprehensive care
program on cardiopulmonary function, muscle strength, immune response,
and quality of life in ovarian cancer survivors. Participants were 40 ovarian
cancer survivors, 20 in the experimental group and 20 in the control
group, at C university hospital gynecological cancer center from May 2009,
to December 2010. The treatment was a comprehensive care program
for 8 weeks consisting of group education and self-help group support,
home-based exercise, and relaxation. Data were analyzed by t test and
repeated-measures ANOVA. Cardiopulmonary function, measured by
12-min walk distance; muscle strength, measured by the chair-stand test;
and quality of life were more increased in the experimental group. But
immune response was not statistically significant. These results indicate that
the comprehensive care program is an effective nursing intervention to
improve cardiopulmonary function, muscle strength, and quality of life in
ovarian cancer survivors.

1Suwon Science College, Hwaseong, Korea

2JejuNational University, Jeju, Korea
3The Catholic University of Korea, Seoul, Korea

Corresponding Author:
Yang-Sook Yoo, College of Nursing, The Catholic University of Korea, 222 Banpo-daero,
Seocho-gu, Seoul 137-701, Korea.
Email: ysyoo@catholic.ac.kr
Hwang et al. 193

Keywords
ovarian neoplasm, survivors, muscle strength, quality of life

Introduction
In South Korea, whereas the incidence of cervical cancer has been decreasing
in recent years, ovarian cancer has increased from 1,332 cases in 1999 to
1,981 cases in 2010 (The Korea Central Cancer Registry & National Cancer
Center, 2012).
Diagnosis of ovarian cancer is only made after the disease has signifi-
cantly progressed; in addition, even when the patient responds to treatment
and the disease goes into complete remission, around 60% of the patients
have a relapse, with a 5-year survival rate of approximately 60% (Diaz-
Montes & Bristow, 2005; The Korea Central Cancer Registry & National
Cancer Center, 2012).
Staging laparotomy is the most effective treatment for ovarian cancer; it
includes cytoreductive surgery followed by adjuvant chemotherapy with
paclitaxel-carboplatin (Diaz-Montes & Bristow, 2005; Polverino et al., 2005).
This process takes more than 6 months because of the surgery, six to nine
sessions of chemotherapy, and a second-look laparotomy. During this pro-
cess, patients experience physical symptoms such as fatigue, peripheral neu-
ropathy, lymphedema, anemia, immune suppression, weakening of
cardiopulmonary function and muscle strength because of lack of exercise,
and reduced quality of life because of negative emotions such as fear of
relapse, anxiety, and depression (American Cancer Society, 2013; Fairey,
Courneya, Field, & Mackey, 2002; Lockwood-Rayermann, 2006; Meraner
et al., 2012; Ryan et al., 2003).
Cancer is manageable within the framework of prevention, early detec-
tion, diagnosis, treatment, survivor management, and late adverse effect
management (National Cancer Institute, 2011). The main aspects of survivor
management are long-term follow-up management, rehabilitation, coping,
and health improvement. Ovarian cancer survivors often express a desire for
information about the side effects of treatment, care plans, relapse probabil-
ity, and so forth. Researchers must also encourage them to engage in health-
oriented behaviors through symptom management and education.
Education is important for survivors to change their lifestyles and encour-
age healthy behaviors (Demark-Wahnefried, Pinto, & Gritz, 2006; Otis-Green
et al., 2008). Furthermore, when their disease is in remission, ovarian cancer
survivors often experience various emotions such as gratitude, anxiety, and
fear, and these problems must be acknowledged and addressed to improve
194 Clinical Nursing Research 25(2)

survivors’ quality of life. Therefore, comprehensive care program is necessary

to help increase the quality of life of ovarian cancer survivors through health
management education, regular exercise, and emotional stress management.
Recent studies from the West have reported that exercise and education
programs for ameliorating physical and psychosocial pain during treatment
have positive effects on the quality of life of cancer patients (Otis-Green
et al., 2008; Stevinson et al., 2007).
Previous studies showed that self-help group support reduces survivors’
emotional pain, while aerobic exercise improves physical function such as
cardiopulmonary and immunological functioning, muscle strength, and qual-
ity of life; in addition, relaxation therapy reduces fatigue and eases emotional
burden (American Cancer Society, 2013; Asher et al., 2010; Cho, 2004;
Fairey et al., 2002; Mock et al., 2005; Schmitz et al., 2010).
Only one study (Hwang, Choi, & Yoo, 2005) of ovarian cancer patients
exists in the South Korean nursing community, which detailed the effect of
foot reflex massage therapy in patients; however, this study did not intervene
in their physical and psychosocial problems in an integrative manner on
survivors.
Therefore, we applied a comprehensive care program, consisting of health
management education and self-help support group, exercise, and relaxation
and assessed its effect on survivors’ physical function and quality of life.

Materials and Method

Study Design
The study used a quasi-experimental, nonequivalent control group pretest–
posttest design. The comprehensive care program consisted of health manage-
ment education and a self-help group support (one 60-min session per week),
home exercise routines (three 50-min sessions per week), and relaxation
therapy (three 15-min sessions per week). The dependent variables were
survivors’ cardiopulmonary functions, muscle strength, immune response, and
quality of life.

Subjects
The subjects were patients who had undergone hysterectomy, oophorectomy,
and chemotherapy as treatments for ovarian cancer at the Gynecological
Cancer Center in C University Hospital in Seoul, South Korea. The disease
must have been in complete remission for 6 months to 3 years, a duration that
was based on the average disease-free survival rate of 16 to 38 months, after
Hwang et al. 195

which relapse is frequent (Kim et al., 2008). The detailed inclusion criteria
are as follows:

1. Older than 18 years of age and has given written informed consent;
2. Has Stage I ovarian cancer or later, based on the International
Federation of Gynecology and Obstetrics (FIGO);
3. Scored 0 to 2 on the Eastern Cooperative Oncology Group (ECOG)
criteria;
4. Does not exercise more than three 30-min sessions per week;
5. Does not have severe cardiovascular disease, acute or chronic pulmo-
nary diseases, diabetes, or mobility limitations.

The subjects were paired by age and disease stage and assigned to either
the experimental or control group. The sample size was calculated using the
G Power 3.1.2 program with an effect size of 0.3, statistical power of 0.8, and
a significance threshold of 0.05, giving us a required sample size of 18 in
each group for a repeated-measures ANOVA (Faul, Erdfelder, Buchner, &
Lang, 2009). Taking drop-out rates into consideration, we selected 25 poten-
tial patients for each group; however, in the final analysis, there were only 20
in the experimental group and 20 in the control group. During the experi-
ment, 5 patients (20%) dropped out of the experimental group; similarly, 5
patients (20%) dropped out of the control group. The participation rate of the
experimental group for the education sessions and self-help group support
was 91.87%, and for the home exercise and relaxation therapy it was 95.4%.
There were no differences between the general or clinical characteristics, or
dependent variables between the two groups before the experiment (Tables 1, 2).

Intervention
For the experimental group, we conducted the 40-min health management
education sessions in small groups once a week; the self-help group support
convened for 20 min at the end of each session. Subjects were told to engage
in exercise and relaxation therapy at home by themselves 3 times a week. The
duration of the experiment was 8 weeks, which we determined based on pre-
vious study (American College of Sports Medicine, 2006).

Education and the self-help group support.  The themes of the education sessions
were as follows: The first week was an overview of the exercise program and
practice; the second week covered ovarian cancer treatment side effects; third
week, nutrition and diet of cancer patients; fourth week, management and
adaptation of treatment-related physical symptoms; fifth week, management
196 Clinical Nursing Research 25(2)

Table 1.  General Characteristics between Groups.

Exp. (n = 20) Cont. (n = 20)

Characteristics n (%) n (%) χ2 p

Age (year)a
 30-39 4 (20.0) 3 (15.0) .963
 40-49 4 (20.0) 6 (30.0)  
 50-59 9 (45.0) 8 (40.0)  
  ≥ 60 3 (15.0) 3 (15.0)  
Religiona
 Yes 17 (85.0) 17 (85.0) 1.000
 No 3 (15.0) 3 (15.0)  
Spouse
 Yes 14 (70.0) 16 (80.0) 0.53 .465
 No 6 (30.0) 4 (20.0)  
Educationa
  ≤ Middle school 2 (10.0) 1 (5.0) .805
  High school 9 (45.0) 11 (55.0)  
  ≥ College 9 (45.0) 8 (40.0)  
Family income (10,000 won)
  ≤ 200 8 (40.0) 10 (50.0) 0.40 .525
 >200 12 (60.0) 10 (50.0)  
Job
 Yes 6 (30.0) 4 (20.0) 0.53 .465
 No 14 (70.0) 16 (80.0)  
FIGO stagea
 I 7 (35.0) 7 (35.0) 1.000
 II 4 (20.0) 4 (20.0)  
 III 9 (45.0) 9 (45.0)  
Postoperation period (month)a
 6-12 14 (70.0) 14 (70.0) 1.000
 13-18 5 (25.0) 6 (30.0)  
 19-24 0 (0.0) 0 (0.0)  
 25-30 1 (5.0) 0 (0.0)  
ECOG
 0 8 (40.0) 8 (40.0) 1.000
 1 12 (60.0) 12 (60.0)  
Chemotherapy cyclea
  ≤3 1 (5.0) 0 (0.0) .605
 4-6 18 (90.0) 17 (85.0)  
 7-9 1 (5.0) 3 (15.0)  
Secondary operation
 Yes 8 (40.0) 5 (25.0) 1.03 .311
 No 12 (60.0) 15 (75.0)  

Note. Exp. = experimental group; Cont. = control group; FIGO = International Federation of Gynecology
and Obstetrics; ECOG = Eastern Cooperative Oncology Group.
aFisher’s exact test.
Hwang et al. 197

Table 2.  Homogeneity Test for Research Variables.

Exp. (n = 20) Cont. (n = 20)

Variables M ± SD M ± SD t p
Cardiopulmonary function
  12-min walking 879.59 ± 223.15 849.85 ± 82.76 0.46 .647
distance (m)
Muscle strength
  Chair-stand frequency 12.60 ± 2.48 11.15 ± 2.11 1.99 .054
(time/30 s)
  Natural killer cell 15.67 ± 7.09 15.58 ± 11.30 0.03 .975
ratio (%)
  Quality of life (score) 62.55 ± 15.31 62.40 ± 18.43 0.03 .978

Note. Exp. = experimental group; Cont. = control group.

of daily life and psychological well-being; sixth week, effective communica-

tion and social activities; seventh week, spiritual well-being; and the eighth
week covered an overview and the effects of laughter therapy.
To assess survivors’ need for education, 19 questions in eight categories
were developed based on previous study (Cho, 2004; Stewart et al., 2000).
The questions covered exercise, the ovarian cancer treatment process,
nutrition, symptom management, daily life management, psychological well-
being, social communication, and spiritual well-being; the contents were
reviewed by a gynecological oncologist and two nursing professors. A pilot
study was conducted with eight ovarian cancer patients who agreed to a tele-
phone interview; all 19 questions were in demand and they also expressed
interest in laughter therapy. The contents were validated by eight experts
(exercise instructor, gynecological oncologist, nursing professors, nutrition-
ist, social worker, and laughter therapist).
Education sessions were conducted in a quiet and comfortable conference
room, using a slide presentation format, for 40 min. In the self-help group
support sessions, subjects shared their experiences and conflicts about the
theme of the week.

Exercise and relaxation therapy.  As in previous studies (Meston, 2004; Schmitz

et al., 2010; Williams et al., 1988), the main exercise was brisk walking and
strength exercises, which do not significantly increase pressure in the weak-
ened abdominal and pelvic regions. Warm-ups and cooldowns consisted of
flexibility exercises. The exercise routine was developed in eight consultation
meetings with a nursing professor, a sports medicine professor, an exercise
198 Clinical Nursing Research 25(2)

instructor, and an exercise therapist. The routine was tested on four ovarian
cancer patients and weekly walking time and frequency were readjusted with
exercise therapists or instructors.
The sessions comprised 10 min of warm-up, 30 min of aerobic exercise, 5
min of strength exercises, and 5 min of cooldown at medium intensity. All
exercises measured between 11 and 13 on the rating of perceived exertion
(RPE) and used 40% to 60% of patients’ maximum heart rate. If the subject
felt tired during the session, it was recommended that he or she take a 5- to
10-min walk several times.
After the experimental group learned and had practiced about methods of
exercise, they were given a handout with the lecture material and a CD con-
taining an exercise video and asked to keep an exercise log. Twice a week,
subjects were contacted to confirm that they were doing the exercise ses-
sions. During each educational session, the exercise log was checked for
problems and subjects were given feedback. Relaxation therapy was per-
formed at home after the exercise sessions. The program, “Muscle Relaxation
and Guided Imagery,” was developed and recorded by the Korean Society of
Muscle and Joint Health and the background music was “Wonderful Day” by
Sweet People. The program consists of images intending to relax the body
and mind and elicit positive feelings.

Instruments
Cardiopulmonary function. We measured cardiopulmonary function by the
maximum distance, in meters, that subjects could walk in a straight line in 12
min at a normal walking pace; longer distances indicated better function.
As this test is closely correlated with the oxygen consumption test typi-
cally used in the laboratory (Mock et al., 2005), we conducted it in the hospi-
tal corridor, where the temperature and moisture is constant.

Muscle strength. Because cancer patients who have undergone abdominal

surgery might face difficulties in performing sit-up tests (Rikli & Jones,
2001), we tested muscle strength using the sit–stand test, which can be used
to measure everyday life functioning. This test is easy to perform, is safe, and
has significant construct validity (Jones, Rikli, & Beam, 1999). In this test,
subjects repeatedly sit down and stand up with their arms crossed over their
chest. A stopwatch is used to measure the number of times the patient is able
to completely stand and sit down in 30 s.

Immune response.  Immune response was measured according to the percent-

age of natural killer (NK) cells in subjects’ blood. We collected 3 ml of
Hwang et al. 199

venous blood from peripheral blood vessels in tubes with ethylenediamine-

tetraacetic acid (EDTA) as the anticoagulant. Blood samples were immedi-
ately sent to the Hospital Immunology Lab for analysis. Monoclonal
antibodies conjugated with fluorophores (fluorescein isothiocyanate [FITC],
phycoerythrin [PE]) were bound to the surface of lymphocytes, and the sam-
ples were treated with the Q-prep and analyzed using flow cytometry. In each
sample, the percentage (%) of NK cells was determined by flow cytometry of
10,000 cells.

Quality of Life
The quality-of-life analysis was conducted using the Korean translation of
the Functional Assessment of Cancer Therapy–General (FACT-G), with per-
mission from the Functional Assessment of Chronic Illness Therapy (FACIT).
The FACT-G consists of 27 questions, divided into the following four sub-
scales: Physical Well-Being, Social/Familial Well-Being, Emotional Well-
Being, and Functional Well-Being. It is measured using 5-point scale scores,
and higher scores indicate better quality of life (Webster, Cella, & Yost,
2003). The internal consistency reliability (Cronbach’s α) of the survey, pre-
experiment was .91 and the postexperiment value was .96.

Data Collection
This study was approved by Seoul St. Mary’s Hospital Bioethical Institutional
Review Board (KC09FZZZ0124) and conducted between May 2009 and
December 2010, at the Gynecological Cancer Center in Seoul St. Mary’s
Hospital. Data were collected only from ovarian cancer patients who met the
selection criteria, ECOG 0-1, and provided consent to participate in the study.
The pretest evaluation was collected 1 week before the start of the program,
during an outpatient visit. Data from the 12-min walking test, sit–stand test,
and survey were collected by a trained researcher under our direction.
The experimental group took the 8-week comprehensive care program,
while the control group received usual care services. The posttest evaluation
was conducted in a similar manner for both the experimental and control
groups; after the evaluation, the control group received the same educational
information as the experimental group.

Ethical Considerations
All of the subjects were provided with information about the purpose and process
of the study, their rights to refuse participation at any point without disadvantage,
200 Clinical Nursing Research 25(2)

and the voluntary nature of participation, and written consent was obtained. Once
all of the data had been collected, all subjects received a small gift.

Statistical Analysis
The data were analyzed using SAS for Windows (ver. 9.1). The homogeneity
test between the experimental and control groups were conducted using chi-
square and t tests. The 12-min walking test, sit–stand test, NK cell percent-
age, and quality-of-life changes in the experimental and control groups,
before and after the experiment, were analyzed using ANOVAs and t tests.

Results
Cardiopulmonary Functions
Cardiopulmonary functions, measured by the 12-min walking test, showed
an interaction between group and time point (p = .005). The experimental
group’s distance increased by 239.12 m after the experiment, and the control
group’s distance increased by 12.57 m, showing that there was a significant
difference between the two groups (Table 3).

Muscle Strength
Muscle strength, measured by the 30-s sit–stand test, showed an interaction
between group and time point (p = .001). In the experimental group, muscle
strength increased by 2.90 sitting/standing cycles after the experiment,
whereas in the control group, it increased by 0.20, signifying a significant
difference between the groups (Table 3).

Immune Response
There were no significant differences in NK cell percentage between the
groups before and after the experiment (Table 3).

Quality of Life
In the Physical, Social/Familial, Emotional, and Functional Well-Being sub-
scales of the Quality of Life Scale, there were significant interactions between
group and time point (p = .003, p = .004, p = .001, p = .002). In the experimen-
tal group, scores on the physical, social/familial, emotional, and functional
well-being subscales improved after the experiment. In the control group, the
Hwang et al. 201

Table 3.  Changes of 12-Min Walking Distance, Chair-Stand Frequency, Natural

Killer Cell Ratio between Groups.

Before Tx. After Tx.

Variables M ± SD M ± SD F p
12-min walking distance (m)
 Exp. 879.59 ± 223.15a 1,118.71 ± 328.56a,b G 5.17 .029
  T 11.02 .002
 Cont. 849.85 ± 182.76 862.42 ± 156.83b  
  G×T 8.93 .005
Chair-stand frequency (time/30 s)
 Exp. 12.60 ± 2.48a 15.50 ± 3.35a,b G 14.31 .001
 Cont. 11.15 ± 2.11 11.35 ± 2.41b T 16.83 .001
  G×T 12.77 .001
Natural killer cell ratio (%)
 Exp. 15.67 ± 7.09 16.67 ± 8.10 G 0.05 .818
 Cont. 15.58 ± 11.30 15.62 ± 6.97 T 0.22 .641
  G×T 0.18 .670

Note. Tx. = treatment; Exp. = experimental group (n = 20); Cont. = control group (n = 20).
a,bSame letters are significantly different; G = Group; T = Time; G × T: Group × Time.

scores in all of the subscales decreased except in functional well-being, show-

ing a significant difference between the two groups (Table 4).

Discussion
With improvement in ovarian cancer treatment and medical technologies, the
number of ovarian cancer survivors has increased, while the improvement of
survivors’ daily life management and quality of life after surgery and chemo-
therapy has recently become more important.
In the previous study (Cho, 2004), an integrated program was recommended
to effectively improve the physical and psychosocial quality of life in cancer
patients. However, studies on ovarian cancer survivors are extremely rare.
Patients with ovarian cancer desire social support from families, friends,
and other cancer patients. They also wish for education regarding the pro-
gression of disease, therapeutic effects, and self-care as well as emotional
support to help improve their physical, psychosocial, and spiritual well-being
(Ferrell, Smith, Ervin, Itano, & Melancon, 2003; Otis-Green et al., 2008).
Exercise is one measure of rehabilitation often recommended to cancer sur-
vivors to help them return to daily living. Exercise is usually recommended
202 Clinical Nursing Research 25(2)

Table 4.  Changes of Quality of Life (FACT-G) between Groups.

Before Tx. After Tx.

Group M ± SD M ± SD F p
Physical well-being (0-28)
 Exp. 20.20 ± 4.54a 23.70 ± 3.37a,b G 2.34 .134
  T 4.15 .049
 Cont. 20.05 ± 6.42 19.30 ± 5.79b  
  G×T 9.91 .003
Social/familial well-being (0-28)
 Exp. 13.90 ± 5.41a 18.70 ± 5.05a,b G 4.06 .051
  T 5.62 .023
 Cont. 13.70 ± 5.24 13.10 ± 5.66b G×T 9.30 .004
Emotional well-being (0-24)
 Exp. 13.95 ± 4.22a 19.75 ± 2.77a,b G 3.17 .083
  T 13.71 .001
 Cont. 14.95 ± 4.74 14.55 ± 5.38b  
  G×T 18.08 .001
Functional well-being (0-28)
 Exp. 14.50 ± 5.49a 20.75 ± 4.19a,b G 6.41 .016
  T 15.74 .001
 Cont. 13.70 ± 5.95 14.30 ± 5.36b  
  G×T 10.71 .002

Note. FACT-G = Functional Assessment of Cancer Therapy–General; Tx. = treatment; Exp. =

experimental group (n = 20); Cont. = control group (n = 20);
a,bSame letters are significantly different; G = Group; T = Time; G × T: Group × Time.

after the end of aggressive treatment, when patients have the ability to carry out
daily life activities. Physicians should consider cancer type and age-dependent
characteristics when selecting exercise routines, which should involve aerobic
exercises such as walking and bicycling, strength exercises to improve the flex-
ibility of joint muscles and prevent fractures or lymphedema, and flexibility
exercises to improve overall activity (Schmitz et al., 2010).
Relaxation therapy was reported to reduce symptom-related distress and
have a positive influence on the immune response (Asher et al., 2010; Hosaka,
Tokuda, & Sugiyama, 2000). Therefore, in this study, we developed and car-
ried out an integrated 8-week-long nursing program that consisted of educa-
tion, support from self-help groups, exercise, and relaxation therapy in
ovarian cancer survivors.
The results of our study show that the experimental group showed a 27.18%
improvement in the 12-min walking test after the experiment. This was similar
Hwang et al. 203

to studies where breast cancer patients undergoing outpatient treatment

showed a 5.9% improvement in walking distance due to exercises conducted
at home (Mock et al., 2005), In the studies of Mock et al. (2005), subjects were
in the process of undergoing adjuvant therapy. However, in our study, whole-
body endurance and cardiopulmonary function increased to a greater degree
because aggressive treatment had already been completed and subjects were
undergoing follow-up management, where physical function has recovered
somewhat and muscular exercises are being performed regularly.
In the sit–stand test, the number of times the patient completed the sit to
stand repetition in 30 s was significantly increased. Although the type of can-
cer and age of patients, and the method of measurement were different and
direct comparison is difficult, the results of Herrero et al. (2006)—who used
an 8-week exercise routine conducted 3 times per week, involving walking
and strength exercises for breast cancer survivors between 45 and 55 years of
age—showed that the time it took subjects to sit in and stand up 5 times from
a chair decreased, which is roughly consistent with the results of our study.
The increase in lower body muscle strength signifies that functional physical
fitness needed for daily life activities, such as climbing stairs, balancing, or
standing up, has recovered and patients are more self-sufficient. We believe
that of the exercises used in this study, walking and upper–lower abdominal
strength exercises led to an increase in lower body balance, which in turn
increased overall flexibility and balance.
NK cells are important predictors for antitumor immune response and their
levels change due to therapy, exercise, stress, anxiety, and fatigue (Fairey et al.,
2002). We observed a trend of increasing NK cell percentage in the experimen-
tal group after the experiment, which was similar to the results of studies of
breast cancer patients (Cho, 2004). A study showed that exercise increased NK
cell activity in stomach cancer patients (Na, Kim, Kim, Ha, & Yoon, 2000).
In addition, the support from self-help groups and the relaxation exercises
performed in this study seemed to indirectly affect the increase of NK cells.
However, further studies need to be conducted on this topic.
Our experimental duration was 8 weeks, but as NK cell percentage can be
affected by exercise duration, amount of exercise, or mood (Goodfellow,
2003), and aerobic exercises are known to be effective in improving physical
function and immune response, longitudinal studies assessing the changes in
NK cell percentage depending on exercise duration are necessary.
Quality of life in ovarian cancer survivors decreases especially when
physical symptoms or cognitive impairment increases (Liavaag, Dørum,
Fosså, Tropé, & Dahl, 2007); however, when medical staff understand these
symptoms and support the patients emotionally, providing them with infor-
mation about their disease, patients’ quality of life can increase (Otis-Green
204 Clinical Nursing Research 25(2)

et al., 2008). Therefore, more careful attention must be paid to patients and
health management. In this study, scores on all areas of quality of life—
physical well-being, social/familial well-being, emotional well-being, and
functional well-being—improved in the experimental group after the com-
prehensive care program was complete. This was similar to the results
where an integrative rehabilitation program for breast cancer patients (Cho,
2004) led to an increase in quality of life in terms of physical, social/famil-
ial, and functional well-being. In addition, the results of this study were
consistent with those of a previous study that reported a higher quality of
life in ovarian cancer survivors who had received an exercise intervention
(Stevinson et al., 2007), and with those of another study that reported a
higher physical, psychological, social, and spiritual quality of life in a
group of participants who had received structured integrative education,
from a sample of ovarian cancer survivors who were receiving regular
checkups (Otis-Green et al., 2008).
In the present study, the improvement in the physical well-being is
believed to result from enhanced physical functions, improved cardiopulmo-
nary functions, and reinforced muscle strength. These changes occurred
because of the education that was provided regarding physical symptom
management, nutrition, diet, and daily life management as well as the con-
tinuous walking and strength exercise for 8 weeks.
Along with this, education in effective communication and the support
obtained from self-help groups and sharing experiences contributed to the
improvement in social/family well-being. Education in psychological well-
being, spiritual well-being, and laughter therapy is considered helpful in
improving the emotional well-being. However, our study is limited in that we
relied on phone interviews and exercise logs to confirm the execution of
home exercise and relaxation therapy and, as the intervention period was
only 8 weeks, we were unable to confirm immune response improvements.
These results demonstrate that comprehensive care program, which took
patients’ physical and psychosocial aspects into consideration, has a positive
effect on the cardiopulmonary function, muscle strength, and quality of life of
ovarian cancer survivors. The clinical significance is that we have developed
an intervention easily applicable in a clinical setting for survivors of ovarian
cancer. Another strength of this study was the use of objective measures of
cardiopulmonary function, muscle strength, and immune response.

Conclusion
The comprehensive care program for ovarian cancer survivors—consisting
of health management education, a self-help group support, exercise, and
Hwang et al. 205

relaxation therapy—led to an increase in cardiopulmonary function, muscle

strength, and quality of life.
Follow-up management for cancer survivors needs to be planned within
framework of continuum from rehabilitation to end-of-life care.
The significance of this study was that it was the first study to develop and
apply comprehensive care program to ovarian cancer survivors to confirm
whether it is an effective intervention in recovering physical function and
increasing quality of life. In addition, we developed educational material to
help survivors exercise and relax at home and promote increases in physical
function, emotional stability, and self-care.
However, cardiopulmonary function and muscle strength were measured
using only functional physical activity tests, so in the future, tests using spe-
cialized equipment are necessary. Moreover, future studies investigating pain
experienced by ovarian cancer survivors, as well as their adjustment process,
would benefit from conducting in-depth interviews as well as process evalu-
ation measures to assess program implementation. Long-term follow-up
studies on the effects of this intervention are also required. Finally, the devel-
opment and evaluation of interdisciplinary intervention programs to promote
the overall health of survivors of other types of cancers are needed.
In addition, interdisciplinary intervention programs need to be developed
and applied, to promote the overall health of survivors of various types of
cancer.

Authors’ Note
This article is based on part of the first author’s doctoral thesis from the Catholic
University of Korea.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

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Author Biographies
Kyung-Hye Hwang, RN, PhD is an assistant professor at Suwon Science College,
Department of Nursing.
Ok-Hee Cho, RN, PhD is an associate professor at Jeju National University, College
of Nursing.
Yang-Sook Yoo, RN, PhD is a professor at The Catholic University of K orea,
College of Nursing, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea. She is the
Corresponding author. She can be contacted at the following email address. E mail:
ysyoo@catholic.ac.kr