Effects of Home-Based Exercise With Telehealth Guidance in Lymphoma Survivors Entering Cardio-Oncology Rehabilitation: A Randomized Controlled Trial

Abstract

Introduction

Lymphoma survivors are at increased cardiovascular risk due to cardiotoxic therapies and commonly experience reduced cardiorespiratory fitness and quality of life. Telehealth-supported home-based exercise (HBE) may extend access to cardio-oncology rehabilitation (CORE); however, evidence from randomized trials in lymphoma survivors remains limited. This trial compared the short-term effects of telehealth-supported HBE versus center-based exercise (CBE) in lymphoma survivors entering CORE.

Materials and Methods

In this single-center, single-blind, parallel-group randomized controlled trial, lymphoma survivors in remission were randomized 1:1 to a 12-week telehealth-supported HBE program or supervised CBE. The primary endpoint was cardiorespiratory fitness, operationalized as peak oxygen uptake (pVO₂, mL·kg^-1·min^-1) assessed by cardiopulmonary exercise testing (CPET) at 12 weeks. Key secondary outcomes were maximal workload (W) and SF-36 Physical Functioning. Between-group effects were estimated using ANCOVA with baseline adjustment (intention-to-treat; missing outcomes handled by multiple imputation).

Results

Eighty participants were randomized (HBE n=40; CBE n=40); post-intervention CPET outcomes were available for 69 participants (HBE n=34; CBE n=35). pVO₂ improved in both groups, with no significant baseline-adjusted between-group difference at 12 weeks (adjusted mean difference HBE–CBE −0.60 mL·kg^-1·min^-1, 95% CI −2.38 to 1.17; p=0.504). No between-group differences were observed for maximal workload (2.05 W, 95% CI −9.20 to 13.30; p=0.721) or SF-36 Physical Functioning (1.69 points, 95% CI −3.37 to 6.74; p=0.512). Adherence was high in both groups (HBE 80.1% vs CBE 77.9%). No adverse events were reported. Costs per participant were CZK 13,032 for HBE versus CZK 24,900 for CBE (48% lower for HBE).

Conclusion

Telehealth-supported HBE achieved comparable short-term improvements in exercise capacity and physical functioning to supervised CBE among lymphoma survivors entering CORE, with high adherence, no reported adverse events, and substantially lower provider costs. Telehealth-guided HBE represents a pragmatic, lower-cost delivery option to expand access to CORE.

Keywords

cardio-oncology rehabilitation cancer survivorship telehealth exercise therapy randomized controlled trial

Introduction

Cancer survivorship has emerged as a critical area in oncology care, particularly due to the increased survival rates attributed to advancements in diagnostic methods and therapeutic strategies.¹ Despite these improvements, survivors frequently face significant long-term adverse effects resulting from cancer treatments, including substantial declines in cardiorespiratory fitness, physical functionality, and overall quality of life (HRQL).² Among cancer populations, lymphoma survivors are particularly vulnerable to cardiovascular complications due to cardiotoxic treatments such as anthracycline-based chemotherapy and thoracic radiation therapy, which can lead to heart failure, arrhythmias, and accelerated coronary artery disease.^3,4 Additionally, lymphoma and its treatments often exacerbate chronic inflammatory states, contributing further to increased cardiovascular risk and morbidity.^5,6

Exercise rehabilitation has demonstrated robust effectiveness in mitigating these adverse cardiovascular and functional outcomes and is widely recommended as a core component of supportive cancer care.⁷ Traditional center-based exercise (CBE) programs, however, face considerable limitations, including accessibility barriers, logistical issues, and recently, disruptions due to global health crises such as the COVID-19 pandemic.⁸ Consequently, home-based exercise (HBE) interventions guided via telehealth technology have gained significant attention as feasible, accessible, and cost-effective alternatives.^9-11 Prior pilot studies have provided preliminary evidence that telehealth-supported HBE programs can achieve improvements comparable to traditional supervised training regarding cardiorespiratory fitness, muscle strength, adherence to exercise regimens, and patient-reported HRQL outcomes.^12-14

Despite the established benefits of exercise-based rehabilitation, uptake remains suboptimal across both cardiovascular and oncology care. In cardiovascular disease, many eligible patients do not start, complete, or maintain rehabilitation because of travel burden, scheduling constraints, competing responsibilities, comorbidity, and organizational barriers. In oncology, implementation of physical activity programs is similarly limited by inadequate tailoring to patient needs, inconvenient timing and location, insufficient capacity and information, poor coordination across care settings, and reimbursement barriers. These gaps support the development of scalable rehabilitation models that can preserve the benefits of structured exercise while reducing barriers to participation.^15,16

The landmark joint position statement by the American Heart Association (AHA) and American Cancer Society (ACS) recently proposed the adoption of a cardiac rehabilitation care model tailored specifically to address unique cancer- and treatment-related mechanisms of cardiovascular injury, along with the educational and behavioral support needs of cancer survivors.¹⁷ This comprehensive model, termed cardio-oncology rehabilitation (CORE), emphasizes the integration of structured exercise, cardiovascular risk factor management, behavioral support, and education to improve cardiovascular outcomes among cancer survivors identified as ‘at-risk' due to their treatment history and comorbidities.^18,19 Despite these encouraging preliminary findings, the long-term effectiveness and sustainability of telehealth-guided HBE programs specifically tailored to lymphoma survivors remain unclear. Few randomized controlled studies have rigorously evaluated such interventions in this high-risk subgroup, underscoring a critical gap in supportive cancer care.²⁰

Evidence from other medically complex populations further supports the rationale for remote rehabilitation delivery.²¹ In a systematic review of home-based exercise interventions in congenital heart disease, Meyer et al identified 12 studies across pediatric and adult cohorts and concluded that HBE was generally feasible and safe, with several studies demonstrating improvements in peak oxygen uptake and walking capacity, although adherence and compliance remained important challenges.²² In oncology, home-based and remote-guided exercise interventions have shown encouraging results in broader cancer survivor populations; however, lymphoma-specific randomized evidence remains limited.²³

Therefore, the present randomized controlled trial was designed to evaluate the effects of telehealth-supported HBE compared with supervised CBE in lymphoma survivors entering CORE. The primary aim was to assess short-term changes in cardiorespiratory fitness, while secondary objectives included physical functioning, health-related quality of life, body composition, strength, adherence, safety, and provider costs. The novelty of this study lies in evaluating a lymphoma-specific telehealth-supported CORE model against a dose-matched center-based comparator within the same rehabilitation framework. This report presents the prespecified 12-week outcomes of the Tele@home trial; 12-month outcomes are reported separately in a companion manuscript.²⁴

Materials and Methods

Study Design

The present study was a single-center, single-blind, parallel-group randomized controlled trial with 1:1 allocation. This manuscript reports the prespecified short-term 12-week outcomes of the Tele@home trial. The study was conducted at University Hospital Brno, Brno, Czech Republic, and recruitment for the present report took place between March 2023 and June 2025. Eligible participants were randomly assigned to either HBE or CBE using a computer-generated sequence. Allocation was concealed in sequentially numbered, sealed, opaque envelopes. Because the mode of intervention delivery was apparent, participants and treating physiotherapists could not be blinded; therefore, blinding was limited to research assistants/outcome assessors responsible for follow-up data collection. The reporting of this trial conforms to the CONSORT 2025 statement.²⁵

Setting and Participants

Participants were recruited from the outpatient Hematology–Oncology Department at the University Hospital Brno, Brno, Czech Republic. Eligibility criteria included lymphoma survivors aged 18 years or older who had completed systemic chemotherapy-based treatment, were clinically stable and in remission, and were transitioning to outpatient CORE. Detailed inclusion and exclusion criteria have been published elsewhere in the study protocol.²⁶ All participants provided written informed consent before baseline assessment. No patient or public involvement occurred in the design, conduct, reporting, or dissemination plans of this trial.

Intervention

The same physiotherapist team delivered both intervention arms. Physiotherapists had foundational evidence-based training in exercise prescription and telehealth-supported rehabilitation, and intervention delivery was standardized using a prespecified manual and checklist covering exercise prescription, progression, weekly feedback, behavioral support, adherence monitoring, and safety reporting procedures.

Participants in the HBE group completed a 12-week telehealth-supported exercise program consisting of three aerobic and resistance training sessions per week. Before starting independent home training, participants attended three introductory supervised sessions to become familiar with the prescribed exercise intensity, duration, resistance exercises, and telemonitoring technology (Polar M430/Pacer wristwatch and/or Polar H7 chest-strap heart rate sensor). During these sessions, participants also established individualized training goals together with their physiotherapist.

After this familiarization phase, participants independently performed individually prescribed aerobic and resistance exercise at home three times weekly, with each session lasting 30–50 minutes and targeting 60–85% of maximal heart rate derived from baseline cardiopulmonary exercise testing (CPET).²⁷ Exercise data were uploaded to the PolarFlow web platform and reviewed weekly by the physiotherapist. During regular telecoaching contacts (telephone and/or text-based support), the physiotherapist reviewed exercise frequency, duration, and intensity; provided individualized feedback; addressed barriers to adherence; and adjusted the exercise plan when needed. Behavioral support was informed by goal-setting and motivational interviewing principles.

Control Group

Participants in the control group received a traditional supervised CBE program at an outpatient cardiac rehabilitation clinic. The frequency, duration, target intensity, and exercise components matched the HBE intervention and followed current American College of Sports Medicine recommendations.²⁸ Participants performed individually prescribed aerobic exercise on a treadmill and/or cycle ergometer with an accompanying resistance component under direct physiotherapist supervision.

Measurements

Sociodemographic data were collected at baseline. Clinical data were extracted from the electronic medical record and included lymphoma subtype, stage at diagnosis, time since diagnosis, treatment characteristics relevant to clinical description, and predefined cardiovascular risk factors (diabetes mellitus, hypertension, dyslipidemia, and current smoking). Anthracycline exposure was not present in this cohort. Outcomes were assessed at baseline (T0) and at the end of the 12-week intervention (T1) by assessors blinded to treatment allocation.

Primary Outcome

Cardiorespiratory fitness was assessed by symptom-limited CPET using peak oxygen uptake (pVO₂, mL·kg^-1·min^-1) as the primary endpoint. CPET was performed using an automated metabolic system (Metalyzer 3B, Cortex Biophysik GmbH, Leipzig, Germany) and a bicycle ergometer (Ergoselect 100, Ergoline, Germany). The ramp protocol consisted of a 2-minute warm-up at 10 W, followed by incremental increases of 15 W/min in men and 10 W/min in women, and a 2-minute cool-down at 10 W.²⁷ Peak VO₂ was selected as the primary outcome because it is a clinically relevant indicator of functional capacity and prognosis in cancer survivors.²⁹

Other Outcomes

Key secondary outcomes were maximal workload (W) achieved on CPET and the SF-36 Physical Functioning domain. Additional exploratory outcomes included the remaining SF-36 domains, handgrip strength, body composition, program satisfaction, safety, and cost.

Health-related quality of life (HRQL) was assessed using the validated SF-36 questionnaire.³⁰ Body composition was measured by bioelectrical impedance analysis (InBody 370S, InBody Co., Ltd., Seoul, Korea), and handgrip strength was assessed using a digital dynamometer (Sagita, Mariestad, Sweden).^31-33

Adverse events were defined as any unfavorable medical occurrence arising during or after the exercise intervention, regardless of whether it was judged to be exercise-related. Events were documented using the protocol-specified structured safety framework, including event type, start and end time, duration, severity, action taken, and relationship to exercise.³⁴ Participants were instructed to contact the investigators or their physician if symptoms occurred during or after training. Severe events were escalated to the study clinician within 24 hours. Malfunctions of the telehealth platform or monitoring devices were documented separately.

Cost was evaluated using a structured per-participant cost comparison model adapted from Whittaker et al.³⁵ Costs were compiled from medical records, structured consultations, hospital financial reports, and internal registries. Total expenditure covered the 12-week CORE intervention and included personnel, facility, monitoring, equipment, communication, administration, technology, and patient travel.

Data Collection and Ethics Considerations

Baseline questionnaires and clinical assessments were completed at the rehabilitation department, while clinical variables were extracted from electronic medical records by study investigators. Follow-up outcome assessments at 12 weeks were performed at the study center by assessors blinded to treatment allocation. Data were anonymized before analysis and stored on secure institutional systems.

The study was approved by the Multicentric Ethics Committee of University Hospital Brno (approval no. 05-080622/EK; project no. 93/22; approved 8 June 2022), and was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2024. Written informed consent was obtained from all participants prior to enrollment. The trial was registered at ClinicalTrials.gov (NCT05779605).

Sample Size

The a priori sample size calculation was based on an anticipated between-group difference of 4.7 mL·kg^-1·min^-1 in peak oxygen uptake, with a standard deviation of 8.6 mL·kg^-1·min^-1, according to the published protocol.²⁶ With 90% power and a two-sided alpha of 0.05, 36 participants per group were required. Allowing for 10% attrition, the planned sample size was 80 participants randomized 1:1.

Statistical Analysis

Continuous variables are presented as mean (SD) and categorical variables as n (%). Baseline characteristics were summarized by randomized group using standardized mean differences rather than formal hypothesis testing.

The primary endpoint was peak oxygen uptake at 12 weeks. The primary analysis followed the intention-to-treat principle and used analysis of covariance (ANCOVA), with the 12-week value as the dependent variable, treatment group (HBE vs CBE) as the independent variable, and the corresponding baseline value as a covariate. Adjusted between-group mean differences (HBE–CBE) with 95% confidence intervals (CI) were reported.

Missing 12-week outcome data were handled using multiple imputation under a missing-at-random assumption. The imputation model included treatment group and relevant baseline variables to improve plausibility of the imputation model. To evaluate the plausibility of the missing-at-random assumption, we examined patterns of missingness across randomized groups and baseline characteristics. Because a missing-not-at-random mechanism cannot be fully excluded, sensitivity analyses included complete-case ANCOVA and a post hoc model additionally adjusted for baseline BMI for the primary endpoint.

Maximal workload and SF-36 Physical Functioning were analyzed analogously as key secondary outcomes. Additional HRQL domains, handgrip strength, body composition, satisfaction, and cost variables were considered exploratory and interpreted cautiously. In addition to the per-participant cost comparison, an exploratory incremental cost-effectiveness ratio (ICER) was calculated using the between-group difference in per-participant costs divided by the adjusted between-group difference in pVO₂ at 12 weeks. All tests were two-sided, with α=0.05.

Results

Between March 2023 and June 2025, 80 participants were enrolled and randomized to either the HBE group (n=40) or the CBE group (n=40) (Figure 1). Post-intervention (12-week) CPET outcomes were available for 69 participants (HBE n=34; CBE n=35). No adverse events were reported in either group.

Figure 1.

CONSORT patient flow diagram

Baseline characteristics are presented in Table 1. Participants had a mean age of 55.5 years (SD 12.1); 66.3% were female (n=53). Cancer diagnoses included follicular lymphoma (n=43), diffuse large B-cell lymphoma (n=24), and chronic lymphocytic leukemia (n=13). Fifty-nine participants (73.8%) were within ≤3 years from diagnosis. Most baseline characteristics were similar between groups, although imbalance was observed in BMI categories and a moderate difference was present for follicular lymphoma.

Table 1.

Baseline Characteristics

Variable	Total	CBE	HBE	SMD
Age, years	55.5 (12.1)	55.8 (13.1)	55.1 (11.3)	-0.061
Female	53 (66.2%)	24 (60.0%)	29 (72.5%)	0.264
Married	64 (80.0%)	32 (80.0%)	32 (80.0%)	0.0
Completed university education	35 (43.8%)	18 (45.0%)	17 (42.5%)	-0.05
Retired	22 (27.5%)	12 (30.0%)	10 (25.0%)	-0.112
Cancer type: Follicular lymphoma	43 (53.8%)	18 (45.0%)	25 (62.5%)	0.351
Cancer type: Diffuse large B-cell lymphoma	24 (30.0%)	14 (35.0%)	10 (25.0%)	-0.218
Cancer type: Chronic lymphocytic leukemia	13 (16.2%)	8 (20.0%)	5 (12.5%)	-0.203
Time since diagnosis: ≤3 years	59 (73.8%)	30 (75.0%)	29 (72.5%)	-0.057
Time since diagnosis: >3 years	21 (26.2%)	10 (25.0%)	11 (27.5%)	0.057
Stage at diagnosis: Stage I	9 (11.2%)	5 (12.5%)	4 (10.0%)	-0.079
Stage at diagnosis: Stage II	32 (40.0%)	15 (37.5%)	17 (42.5%)	0.102
Stage at diagnosis: Stage III	25 (31.2%)	13 (32.5%)	12 (30.0%)	-0.054
Stage at diagnosis: Stage IV	14 (17.5%)	7 (17.5%)	7 (17.5%)	0.0
Diabetes mellitus	21 (26.2%)	10 (25.0%)	11 (27.5%)	0.057
Hypertension	29 (36.2%)	15 (37.5%)	14 (35.0%)	-0.052
Dyslipidemia	29 (36.2%)	14 (35.0%)	15 (37.5%)	0.052
Current smoker	13 (16.2%)	6 (15.0%)	7 (17.5%)	0.068
BMI category: Healthy weight	21 (26.2%)	9 (22.5%)	12 (30.0%)	0.17
BMI category: Overweight	31 (38.8%)	22 (55.0%)	9 (22.5%)	-0.667
BMI category: Obese	28 (35.0%)	9 (22.5%)	19 (47.5%)	0.524

Values are mean (SD) or n (%). No significance testing was performed; standardized mean differences (SMD) quantify balance.

Effects on exercise data

Table 2 presents CPET outcomes at baseline and after 12 weeks. pVO₂ improved in both groups, with no evidence of a between-group difference at 12 weeks after baseline adjustment (adjusted mean difference HBE–CBE −0.60 mL·kg^-1·min^-1, 95% CI −2.38 to 1.17, p=0.504).

Table 2.

Primary and Key Secondary Outcomes Results

Outcome	CBE baseline	HBE baseline	CBE 12w	HBE 12w	n at 12w (CBE/HBE)	Adjusted difference (HBE–CBE)	95% CI	p
pVO₂ (mL·kg^-1·min^-1) [primary]	22.64 (5.23)	23.50 (3.86)	25.19 (6.43)	25.69 (5.56)	35/34	-0.60	-2.38 to 1.17	0.504
Max workload (W) [key secondary]	166.58 (49.93)	158.91 (36.78)	183.74 (50.33)	178.72 (48.93)	35/34	2.05	-9.20 to 13.30	0.721
SF-36 Physical Functioning (0–100) [key secondary]	58.38 (22.49)	64.00 (21.34)	65.14 (17.68)	71.76 (17.66)	35/34	1.69	-3.37 to 6.74	0.512

Values are mean (SD). Adjusted differences are baseline-adjusted between-group mean differences (HBE–CBE) from the ITT analysis with multiple imputation; n at 12w indicates observed (available) outcomes.

Missing 12-week CPET data were balanced across groups (HBE 6/40; CBE 5/40). A post hoc sensitivity analysis additionally adjusting the primary ANCOVA model for baseline BMI yielded a materially unchanged estimate (adjusted mean difference HBE–CBE −0.56 mL·kg^-1·min^-1, 95% CI −2.39 to 1.27; p=0.545).

Maximal workload also improved in both groups, with no between-group difference (adjusted mean difference 2.05 W, 95% CI −9.20 to 13.30, p=0.721).

On average, patients in the HBE group performed 28.8 training sessions (adherence: 80.1%, range 17–40), while the CBE group attended an average of 28.0 supervised sessions in 12 weeks (adherence: 77.9%, range 11–36).

Effects on Other Outcomes

The key secondary HRQL outcome (SF-36 Physical Functioning) showed no between-group difference at 12 weeks (adjusted mean difference 1.69 points, 95% CI −3.37 to 6.74, p=0.512). Other outcomes (additional SF-36 domains, body composition, and handgrip strength) were analyzed as exploratory and are reported in the Supplementary Table S1. Program satisfaction was high in both groups: 67.6% of respondents in the HBE group (23/34) and 60.0% in the CBE group (21/35) rated satisfaction as 4–5 on the 5-point Likert scale (Supplementary Table S2).

Costs

The total cost per participant was CZK 24,900 in the CBE group compared with CZK 13,032 in the HBE group, representing a 48% lower per-participant expenditure for HBE (Supplementary Table S3). Major cost drivers in the CBE group included facility fees, on-site monitoring, and gymnasium use, whereas the HBE group incurred higher technology and communication costs. Assessment costs were identical between groups, and patient travel expenses were substantially higher in the CBE group. Using the adjusted between-group difference in pVO₂ and per-participant costs, the exploratory ICER for CBE compared with HBE was CZK 19,780 per 1 mL·kg^-1·min^-1 additional pVO₂ gained at 12 weeks. Because the effect difference was small and statistically uncertain, this estimate should be interpreted cautiously alongside the broader cost comparison.

Discussion

The present manuscript reports the prespecified short-term 12-week outcomes of this randomized controlled trial comparing HBE with CBE in lymphoma survivors entering CORE. Three main findings emerge. First, both delivery models were associated with clinically meaningful improvements in cardiorespiratory fitness, with no statistically significant between-group difference in baseline-adjusted pVO₂ at 12 weeks. Second, adherence, safety, and patient satisfaction were favorable in both groups, supporting the feasibility of both rehabilitation strategies. Third, HBE was associated with substantially lower per-participant costs than CBE. Together, these findings suggest that telehealth-supported HBE can serve as a pragmatic lower-cost delivery model for selected lymphoma survivors entering CORE. Longer-term 12-month outcomes are reported separately in a companion manuscript.²⁴

The absence of a between-group difference in pVO₂ should not be interpreted as a lack of benefit; rather, it suggests that a telehealth-supported home model can achieve short-term gains comparable to those of supervised center-based delivery when exercise prescription, monitoring, and feedback are structured. Among participants with observed post-intervention CPET data, pVO₂ increased in both groups, consistent with prior exercise rehabilitation studies in oncology populations.^36-38 These improvements are clinically relevant because cardiorespiratory fitness is a strong prognostic marker in cancer survivorship and is closely linked to functional capacity and cardiovascular risk.^17,18,39 The comparable results across delivery modes may reflect the use of individualized exercise prescription, objective heart-rate monitoring, weekly coaching, and feedback-driven progression in both study arms.

These findings are particularly relevant in the context of underutilization of rehabilitation services in both cancer¹⁶ and cardiovascular care.¹⁵ Traditional center-based programs remain limited by travel burden, scheduling demands, work and family commitments, and uneven availability of specialized cardio-oncology services. Telehealth-supported HBE has the potential to reduce these barriers while preserving key therapeutic elements of rehabilitation, including individualized prescription, regular contact with a physiotherapist, behavioural support, and objective monitoring.²³ From a clinical standpoint, this model may be particularly useful for survivors who are clinically stable but face practical obstacles to repeated on-site attendance.

We also observed improvements in physical functioning and several exploratory HRQL domains in both groups, with no clear between-group differences. This pattern is consistent with recent studies of telehealth-supported exercise in cancer populations, in which both remote and supervised delivery models improve patient-reported outcomes while between-group contrasts remain modest.^40-44 One plausible explanation is that the study population entered rehabilitation in remission and with relatively preserved baseline functioning, which may have limited the magnitude of detectable between-group separation over 12 weeks. Similarly, body composition and handgrip outcomes changed modestly in both groups, suggesting that short-term rehabilitation may influence fitness and functional measures more readily than body composition.^45-47

High adherence in both groups further supports the feasibility of the interventions. Participants in the HBE arm completed slightly more sessions on average than those in the CBE arm, indicating that remote delivery can be successfully integrated into daily routines when supported by telemonitoring and regular feedback. Satisfaction was high in both groups, suggesting that participants regarded both delivery models as acceptable. No adverse events were reported, which is reassuring and consistent with previous reports showing that structured exercise interventions for cancer survivors are generally safe when tailored to clinical status and accompanied by appropriate monitoring.¹⁰

The economic findings strengthen the practical relevance of the study. Per-participant costs were nearly half as high in the HBE group as in the CBE group, with major savings driven by lower facility and on-site monitoring costs. This is consistent with the broader telerehabilitation literature, where initial technology costs may be offset by lower operational costs and greater scalability over time.^48,49 In an exploratory analysis, the ICER for CBE compared with HBE was CZK 19,780 per 1 mL·kg^-1·min^-1 additional pVO₂ gained at 12 weeks. Because the estimated effect difference in pVO₂ was small and statistically uncertain, this ICER should be interpreted cautiously. Accordingly, the economic results of the present short-term report are best understood primarily as a cost comparison with exploratory cost-effectiveness context, rather than as a definitive trial-based cost-utility evaluation.

Clinically, our findings support a flexible CORE model in which telehealth-supported HBE can complement, rather than simply replace, center-based rehabilitation. Stable lymphoma survivors who do not require frequent on-site supervision may benefit from a home-based pathway that preserves rehabilitation access, whereas center-based delivery may remain preferable for patients with greater complexity, lower confidence with self-management, or a need for closer direct supervision. Such stratified implementation may help expand the reach of cardio-oncology rehabilitation without proportionally increasing service burden.

Limitations

Several limitations should be acknowledged. First, this was a single-center trial with a relatively modest sample size, and the present manuscript reports short-term 12-week outcomes only. Second, because the mode of delivery was visible, participants and treating physiotherapists could not be blinded. Third, although randomization was used, baseline imbalance remained in BMI categories and, to a lesser extent, lymphoma subtype. However, a post hoc baseline BMI-adjusted sensitivity analysis yielded materially unchanged results for the primary endpoint. Fourth, missing 12-week outcomes were handled using multiple imputation under a missing-at-random assumption; although our post hoc assessment supported the plausibility of this assumption, a missing-not-at-random mechanism cannot be fully excluded. Fifth, detailed reasons for incomplete adherence or barriers encountered during home training were not systematically captured. Finally, the economic evaluation in this short-term report did not constitute a full protocol-specified cost-utility analysis with long-term patient-level utility and healthcare-use data, and therefore the ICER should be regarded as exploratory.

Conclusions

In conclusion, telehealth-supported HBE produced short-term improvements in cardiorespiratory fitness and physical functioning that were comparable to those achieved with supervised CBE in lymphoma survivors entering CORE. Both delivery models were associated with high adherence and no reported adverse events, while HBE required substantially lower per-participant costs. Telehealth-supported HBE may therefore represent a practical option to broaden access to cardio-oncology rehabilitation in clinically stable lymphoma survivors. Larger and longer-term studies are warranted to define which patients benefit most from each delivery model and to confirm longer-term clinical and economic outcomes.

Supplemental Material

Supplemental Material _ Effects of Home-Based Exercise With Telehealth Guidance in Lymphoma Survivors Entering Cardio-Oncology Rehabilitation: A Randomized Controlled Trial

Supplemental Material for Effects of Home-Based Exercise With Telehealth Guidance in Lymphoma Survivors Entering Cardio-Oncology Rehabilitation: A Randomized Controlled Trial by Katerina Chamradova, Ladislav Batali, Petr Winnige, Filip Dosbaba, Martin Hartman, Marian Felsoci, Garyfallia Pepera, Jing Jing Su in Cancer Control.

Footnotes

Acknowledgements

The authors acknowledge clinicians for their support in this work.

ORCID iDs

Ladislav Batalik

Jing Su

Ethical Considerations

The study was approved by the Multicentric Ethics Committee of University Hospital Brno, Czech Republic (approval no. 05-080622/EK; project no. 93/22; approved 8 June 2022) and was conducted in accordance with the Declaration of Helsinki of 1975, as revised in 2024.

Consent to Participate

Written informed consent was obtained from all participants prior to enrollment.

Authors’ contributions

All authors contributed equally to the manuscript and read and approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Ministry of Health, Czech Republic; conceptual development of research organization (FNBr, 65269705). This work was also supported by the Ministry of Health of the Czech Republic, grant no. NU23-09-00048. The funders had no role in the design of the study; collection, analysis, or interpretation of data; writing of the manuscript; or the decision to submit the article for publication.

Declaration of Conflicting Interests

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

Data Availability Statement

The datasets analyzed during the current study are available from the corresponding author on reasonable request.*

Trial Registration

ClinicalTrials.gov, NCT05779605

Use of Artificial Intelligence

Generative artificial intelligence was used for language polishing and editorial improvement of the manuscript text. All scientific content, interpretation, and conclusions are the sole responsibility of the authors, who reviewed and verified the final manuscript.

Supplemental Material

Supplemental material for this article is available online.

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