**1. Introduction**

The National Cancer Institute considers individuals as survivors of breast cancer (BC) beginning from the time of diagnosis through the end of life [1]. According to this definition, there were 4.1 million survivors of BC living in the United States in 2022 [2]. Although it is encouraging that the survival rate has increased, substantial evidence shows that cancer and cancer treatment can exacerbate age-related declines in physical function [3,4]. Thus, aging survivors of BC are at elevated risk for poor physical function [4] and, consequently, are at higher risk of premature death [5].

Physical activity (PA) has emerged as a key strategy to prevent functional decline and improve quality of life [6]. PA is defined as "any bodily movement that results in energy expenditure" over a period [7]. However, PA engagement in survivors of BC remains

**Citation:** Swartz, M.C.; Robertson, M.C.; Christopherson, U.; Wells, S.J.; Lewis, Z.H.; Bai, J.; Swartz, M.D.; Silva, H.C.; Martinez, E.; Lyons, E.J. Assessing the Suitability of a Virtual 'Pink Warrior' for Older Breast Cancer Survivors during COVID-19: A Pilot Study. *Life* **2023**, *13*, 574. https://doi.org/10.3390/ life13020574

Academic Editor: Daniele Giansanti

Received: 14 January 2023 Revised: 13 February 2023 Accepted: 15 February 2023 Published: 18 February 2023

**Copyright:** © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

suboptimal despite strong evidence of its beneficial effect on physical function, healthrelated quality of life, and mortality. The prevalence of insufficient PA in breast cancer survivors ranged widely depending on the location and the study population, age, and treatment status, and how PA was measured. For example, a recent study in 2042 women pre and post diagnosed with breast cancer in Germany found that approximately 50% of the participants were insufficiently active pre and post diagnosed, while only 18.2% were sufficiently active [8]. In the United States, a recent study of 1340 female at high risk of developing breast cancer found that one year after treatment, 31.6% were not engaging in recreational/leisure time PA [9].

Adherence to the recommended PA guideline is needed to fully realize the benefits of PA in decreasing symptom burden and improving physical function in BC survivors. Nevertheless, BC survivors reported various perceived barriers to engage in sufficient PA. These include fatigue, pain, limited mobility, and other cancer treatment-related side effects, lack of motivation, time, social support, and limited access to PA programs [10–13]. Barriers such as lack of motivation, time, social support, and limited access to PA programs are common regardless of disease type [11,14]. However, the added cancer-related symptom burden, such as fatigue, pain, and limited mobility from cancer or cancer treatment, can further impact how BC survivors perceive PA-related barriers and respond to PA interventions [11,12,15,16]. Previous exergame interventions primarily focused on using exergame itself to impact health, but it was not paired with behavioral coaching to enhance self-management skills to overcome PA-related barriers [17,18]. Thus, there is a need to pilot test PA interventions designed to provide both self-management skills to overcome PA-related barriers and enhance survivors' motivation to engage in PA despite the experience of cancer-related symptoms.

We previously tested the feasibility of promoting PA in an in-person group setting using exergames along with PA behavioral coaching and BC support discussions among survivors of BC aged 18 years and older [19]. PA behavioral coaching was designed to provide self-management skills to overcome PA-related barriers [19]. Exergame was chosen as a tool to promote PA to help reframe PA as a pleasurable activity [20,21]. Accumulating evidence indicates that targeting a person's motivation and reframing the internal reaction to PA as a fun activity may lead to a more effective intervention [22–27]. Our pilot study's results indicated high levels of acceptance of using exergames and being active in a group setting [19]. Similar to Wurz and colleagues' findings, feedback from survivors indicated that attending in-person sessions remained a barrier for survivors in all stages of their cancer care continuum (e.g., limited ability to travel because of cancer treatment side effects, traffic) [13]. Thus, there is a need to test the use of videoconference platforms to deliver the intervention to increase participation in group-based exercise, and, in turn, increase physical function capabilities.

The COVID-19 pandemic accelerated advances in videoconferencing technology and made it a more common method of communication via smartphones [28]. Additionally, the COVID-19 pandemic also significantly impacted the conduct and participation of in-person PA interventions targeting medically complex populations, such as older survivors of BC [29]. Thus, we adapted a previously tested exergame- and group-based PA intervention [19] to be delivered via videoconference platform. We also adapted our physical function assessments to be conducted via a videoconference platform [30,31]. The goal was to prevent a decline in physical function among older survivors of BC. Therefore, the overall purpose of this study was to test the feasibility of virtually delivering an exergame- and group-based PA intervention in a sample of older survivors of BC during the COVID-19 pandemic.
