Exercise

Exercise

PEP Topic 
Depression
Description 

Exercise is physical activity that involves repetitive bodily movement to improve or maintain one or more of the components of physical fitness: cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, flexibility, and body composition (Centers for Disease Control and Prevention, n.d.). Exercise interventions in patients with cancer have been provided as home-based programs, programs self-managed by patients, and supervised and unsupervised individual or group sessions of varying duration and frequency. Interventions can include combinations of aerobic and resistance activities. Studies have evaluated the effectiveness of exercise in alleviating the anxiety, CINV, depression, hot flashes, lymphedema, sleep-wake disturbance, pain, and fatigue of patients with cancer. Review intervention details in study summaries carefully: Exercise interventions and their timing in the trajectory of cancer care vary. These differences can influence effectiveness.

Centers for Disease Control and Prevention. Glossary of terms. Retrieved November 28, 2007, from http://www.cdc.gov

Likely to Be Effective

Research Evidence Summaries

Berglund, G., Petersson, L-M., Eriksson, K.C., Wallenius, I., Roshanai, A. Nordin, K.M., . . . Häggman, M. (2007). “Between Men”: A psychosocial rehabilitation programme for men with prostate cancer. Acta Oncological, 46, 83–89.

doi: 10.1080/02841860600857326
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Study Purpose:

To evaluate the effect of psychosocial rehabilitation on patients newly diagnosed with prostate cancer

Intervention Characteristics/Basic Study Process:

Patients enrolled in the “Between Men” program were randomized to one of four groups. Each intervention group met for seven sessions. The group that received physical training participated in 60-minute sessions of light physical training that included movement, fitness training, relaxation, and breathing exercises. The group that received informationattended a 60-minute session about prostate cancer, treatment, side effects, etc. The "combination" group participated in exercise and received information, for a total of 135 minutes. The control group received standard care. Investigators asked four research questions, including whether physical training reduces depression among men with prostate cancer.

Sample Characteristics:

The sample included 158 patients who had been newly diagnosed with prostate cancer.

Setting:

  • Single site
  • Uppsala, Sweden

Study Design:

Randomized controlled trial (RCT)

Measurement Instruments/Methods:

  • Hospital and Anxiety Depression Scale (HADS)
  • EORTC Cancer Core Quality of Life (EORTC QLQ-C30) questionnaire
  • A cancer-specific multidimensional tool with subscales of functioning and symptoms

Results:

This RCT did not find any differences in depression or anxiety symptoms among participants at the preintervention, 6-month, or 12-month assessment. The group that received physical training appeared to have experienced the most improvement in symptoms of depression. This improvement occurred between baseline and 12 months, but the confidence intervals overlapped too much for the improvement to be conclusive.

Limitations:

  • Possibly ineffective intervention diminished control over activity and information in the control group.
  • Of all participants, 20% dropped out after 12 months.
  • The sample lacked heterogeneity among participants, and the size of each group was small; therefore, the study has limited generalizability.

Cantarero-Villanueva, I., Fernández-Lao, C., Cuesta-Vargas, A. I., Del Moral-Avila, R., Fernández-de-Las-Peñas, C., & Arroyo-Morales, M. (2013). The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 221–230.

doi: 10.1016/j.apmr.2012.09.008
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Study Purpose:

To examine the effectiveness of an eight-week aquatic exercise program on cancer-related fatigue and physical and psychological outcomes in patients with breast cancer.

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to exercise groups or usual care control groups. The intervention consisted of an eight-week program of water-based exercises, three times per week, in a heated deep swimming pool. Sessions lasted 60 minutes each and included a warm-up and cool-down. Exercise intensity was maintained according to recommendations for moderate exercise as stated by the American College of Sports Medicine and American Heart Association. Groups of 10 to 12 women participated in the exercise program. Data were collected at baseline, eight weeks, and six months.

Sample Characteristics:

  • The sample was comprised of 61 participants.
  • Mean participant age was 48 years.
  • All participants were female.
  • All participants had breast cancer. 
  • The majority had undergone radiation and chemotherapy after surgery. 
  • All had completed treatment other than ongoing hormone therapy.
  • Of the participants, slightly more than 60% were married and 70% to 75% were postmenopausal.
  • At baseline, all patients reported 32 to 38 minutes of activity per day. 
  • All had completed treatment within the previous 18 months.

Setting:

  • Single site
  • Outpatient
  • Spain

Phase of Care and Clinical Applications:

Patients were undergoing the transition phase after active treatment.

Study Design:

This was a single-blind, randomized, controlled trial.

Measurement Instruments/Methods:

  • Piper Fatigue Scale
  • Profile of Mood States (POMS)
  • Multiple sit-to-stand test
  • Trunk curl static endurance test

Results:

  • ANOVA showed a significant difference in all dimensions of fatigue and overall fatigue over time, between groups, with greater improvement in fatigue in the aquatic exercise group (p < 0.001). The overall effect size for total fatigue was d = 1.51 (95% confidence interval [CI] [1.13, 1.90]) at eight weeks. The overall effect size for severity of fatigue was d = 0.68 (95% CI [1.14, 1.22]). The intergroup effect size for total fatigue at six months was d = 0.87 (95% CI [0.48, 1.26]).
  • Leg and abdominal muscle endurance for the sit-to-stand and abdominal curl tests was significantly higher in patients in the exercise group (p < 0.001).
  • Groups showed a significant difference over time in favor of exercise (p = 0.029).
  • The six-month follow-up revealed no effect of exercise on depression.

Conclusions:

Deep-water exercise reduced fatigue, provided a short-term improvement in leg and abdominal muscle endurance, and resulted in some short-term reduction in depression. Effects on muscle endurance and depression declined after the eight-week program. Apparent effects on fatigue lasted six months.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • The study had a risk of bias due to lacking an appropriate attentional control condition.
  • Unintended interventions or applicable interventions not described would influence results.
  • The authors either did not know the components of patients' ongoing physical activities or did not describe them.
  • The authors provided no information about adherence to the exercise program.
  • The authors did not present an intention-to-treat analysis.
  • The sample was very homogeneous, which limited the generalizability of the study.
  • The authors did not address whether the exercise itself or involvement in group activity affected depression. 

Nursing Implications:

The study adds to the large body of evidence showing the effectiveness of various types of exercise in the treatment of fatigue in patients with breast cancer. Nurses can recommend various types of exercise for their patients.

Ergun, M., Eyigor, S., Karaca, B., Kisim, A., & Uslu, R. (2013). Effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in breast cancer patients. European Journal of Cancer Care, 22, 626–637.

doi: 10.1111/ecc.12068
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Study Purpose:

Evaluate moderate intensity exercise programs for patients with breast cancer and their effect on several immune indicators as well as on fatigue, depression, and quality of life

Intervention Characteristics/Basic Study Process:

Lab was obtained at week 0 and 12 and analyzed. Quality of life, fatigue, and depression were evaluated before and after the exercise program using tools mentioned. Patients were assigned to one of three groups. All were provided education. Group one did supervised exercise consisting of 45 minutes per day three times per week and brisk walking for 30 minutes per day three times per week. Group two did brisk walking for 30 minutes per day three times per week. Group three received education only. Patients wrote down their progress, and groups two and three were interviewed over the phone once a week. Arm circumference was measured to control for lymphedema at zero, one, two, and three months.

Sample Characteristics:

  • N = 58
  • AGE: 18–65 years
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer, completed surgery, radiation, chemotherapy, post-menopausal, had not smoked in past year, absence of physical condition that would hinder exercise, cognitive capacity
  • OTHER KEY SAMPLE CHARACTERISTICS: Patient demographics, age at diagnosis, type of operation, time after diagnosis, axillary dissection, sentinel lymph node biopsy, operation side, number of chemotherapy cycles, number of radiation treatments, body mass index

Setting:

  • SITE: Single site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Outpatient clinic for oncology and support unit of Ege University Tulay Aktas Oncology Hospital

Phase of Care and Clinical Applications:

PHASE OF CARE: Transition phase after active treatment

Study Design:

Prospective, randomized controlled study

Measurement Instruments/Methods:

  • European Organisation for Research and Treatment of Cancer Quality of Life C30
  • Brief Fatigue Inventory (BFI)
  • Beck Depression Inventory (BDI)

Results:

Demographics were similar among the three groups. Exercise groups had a statistically significant decrease in some of the biomarkers, while the education group had a statistically significant increase in monocyte chemoattractant protein 1 levels. Functional score and global health score in both exercise groups increased.  Depression score was reduced in the supervised exercise group (p < .05). However, no significant differences were seen between groups after the intervention.

Conclusions:

Significant changes in biomarkers were found at the end of 12 weeks, and improvements were seen in quality of life and depression in the supervised  and unsupervised exercise groups.

Limitations:

  • Small sample (< 100)
  • Findings not generalizable
  • Intervention expensive, impractical, or training needs
  • 12-week exercise program often is difficult for individuals
  • Unclear if the home walking group adhered to the exercise program

Nursing Implications:

Nurses encouraging patients with breast cancer to stay physically active and adopt a moderate exercise program is important to improve quality of life and help with symptoms of depression.

Eyigor, S., Karapolat, H., Yesil, H., Uslu, R., & Durmaz, B. (2010). Effects of Pilates exercises on functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer patients: a randomized controlled study. European Journal of Physical and Rehabilitation Medicine, 46, 481–487.

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Study Purpose:

To investigate the impact of Pilates exercise on physical parameters, as well as on fatigue, depression and quality of life among women with breast cancer.

Intervention Characteristics/Basic Study Process:

Patients selected for participation were randomly assigned to a home exercise program or to the hospital exercise program. Those in the hospital program performed Pilates exercise for one hour per day three times a week for eight weeks. All patients were given an instructional booklet showing pictures of the exercise program as well as information about lymphedema prevention and activities of daily living. All patients were instructed to perform these exercises once daily at home and to walking 20 to 30 minutes per day, three days a week. Assessments were performed prior to the intervention and eight weeks after the exercise program.

Sample Characteristics:

  • The sample was comprised of 42 participants.
  • Mean age was 49.13 years.
  • All participants were female.
  • Of the participants, 98% had a total mastectomy.
  • There was an average of 38 months since diagnosis of breast cancer.
  • All patients had completed treatment.
  • Forty percent had adjuvant treatment.

 

Setting:

  • Single site
  • Outpatient
  • Turkey

Phase of Care and Clinical Applications:

The phase of care was late effects and survivorship.

Study Design:

This was a prospective, randomized two-group, pre-/post study.

Measurement Instruments/Methods:

  • Six-minute walk test
  • Modified sit-and-reach test (for flexibility)
  • Brief Fatigue Inventory (BFI)
  • Beck Depression Inventory (BDI)
  • European Organization for Research and Treatment of Cancer QOL scale (EORTC) quality of life QOL scale
     

Results:

  • Almost 50% of the initial sample assigned to home exercise failed to complete the study due to lack of interest, difficulty commuting to the hospital, or medical problems.
  • The hospital exercise group showed significant improvement in the six-minute walk test (p = 0.00), depression scores (p = 0.01), and functional aspects on the QOL scale (p = 0.04).
  • The only difference between groups was seen in the six-minute walk test, with hospital exercise patients showing improvement and others showing a decline.

Conclusions:

Supervised Pilates exercise appears to have positive effects on depression and physical functioning. There was no effect seen on fatigue. A substantial number of those on a home exercise program failed to complete the study, and findings and comparisons are limited by the small sample size.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • Baseline sample/group differences were of import.
  • The study had risks of bias due to no control group, no blinding, no appropriate attentional control condition, and the sample characteristics.
  • The intervention was expensive, impractical, and required training.
  • Only women with breast cancer were studied, so findings may not apply to other types of patients. The home exercise intervention was not well described, and apparently consisted of just the booklet and a recommendation to do exercises. The fact that so many patients in the home exercise did not complete the study raises the question of the practicality and ability to maintain patient interest in this approach. Patients in the hospital exercise group had higher baseline fatigue and depression scores and may have had greater opportunity for improvement. Patients in the hospital exercise group did this in a group setting; related social support may have influenced results.

Nursing Implications:

This study provides some evidence that exercise can be of benefit to patients in managing depression. The study has multiple limitations.

Hanna, L.R., Avila, P.F., Meteer, J.D., Nicholas, D.R. & Kaminsky, L.A. (2008). The effects of a comprehensive exercise program on physical function, fatigue, and mood in patients with various types of cancer. Oncology Nursing Forum, 35(3), 461–469.

doi: 10.1188/08.ONF.461-469
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Intervention Characteristics/Basic Study Process:

The Cancer Exercise Program (CEP) is based on exercise, education, and support. Patients attended CEP sessions twice a week as able until they completed 16 sessions. Exercise mode was based on patients’ fitness level; individualized heart rate target ranges were supplied. The education component focused on symptom management, coping, survivorship, resources, spirituality, stress management, treatment, and other topics. Education was an optional but encouraged component of the CEP. Peer support was encouraged. The exercise specialist also provided support.

Sample Characteristics:

  • The sample was composed of 39 participants.
  • The sample included 13 cancers.
  • Most patients had finished cancer treatment within six months of beginning the program.

Setting:

  • Single site
  • 350-bed teaching hospital
  • Midwestern city, United States

Study Design:

Nonrandomized retrospective analysis of archived data

Measurement Instruments/Methods:

  • The Revised Piper Fatigue Scale measured fatigue.
  • Profile of Mood States questionnaire measured mood.
  • Investigators measured fatigue and mood before the first exercise session and after all the sessions. Investigators also measured physical function.

Results:

  • Patients reported a significant decrease in total mood disturbance after CEP participation, compared to before CEP.
  • Of all participants, 80% improved; the total mood disturbance of 20% of patients stayed the same or worsened.
  • Fatigue and physical function improved.

Limitations:

  • The fact that this study was a retrospective analysis was a limitation.
  • The study had a very small sample size, and it lacked a control group. Patients were compared to themselves only.
  • The study included patients with various types of cancer.
  • Educational sessions were optional.
  • The number of sessions attended or the topics covered during sessions attended may have affected outcome.

Jacobsen, P.B., Phillips, K.M., Jim, H.S., Small, B.J., Faul, L.A., Meade, C.D., . . . Wilson, R.W. (2013). Effects of self-directed stress management training and home-based exercise on quality of life in cancer patients receiving chemotherapy: A randomized controlled trial. Psycho-Oncology, 22, 1229–1235.

doi: 10.1002/pon.3122
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Study Purpose:

Evaluate the effects of stress management training and exercise, alone or in combination, on well-being, depression, and anxiety among patients during chemotherapy treatment

Intervention Characteristics/Basic Study Process:

Patients were stratified by gender, physical activity level, treatment schedule, and whether they also were receiving radiation therapy. They then were randomly assigned to one of four groups: usual care only (UCO), exercise (EX), stress management training (SM), or exercise plus stress management training (SMEX). The SM group met with an interventionist before the first chemotherapy infusion and was provided with a 15-minute video, a booklet, and an audio recording that provided information and instructions for paced breathing, progressive muscle relaxation with guided imagery, and coping statements to manage stress. Patients were instructed on how to learn and use the techniques during chemotherapy. The EX group met with the interventionis before the first infusion and was given a video and booklet providing instructions on use of regular exercise during treatment, with an emphasis on walking. These patients also were provided with pedometers. Patients were advised to exercise for 20–30 minutes three to five times per week and were provided with heart rate targets and shown how to use pulse rate to monitor exercise intensity. The SMEX group was provided with exercise and stress management resources. All patients had the same usual care access to the full range of psychological services provided to all patients and were given information about chemotherapy with written materials. Assessments were done at baseline (T1), six weeks (T2), and 12 weeks (T3). Exercise was self-directed and home-based.

Sample Characteristics:

  • N = 286  
  • MEAN AGE: 57.5 years
  • MALES: 34%, FEMALES: 66%
  • KEY DISEASE CHARACTERISTICS: Multiple tumor types. The majority were not receiving concomitant radiation therapy.
  • OTHER KEY SAMPLE CHARACTERISTICS: More than one-third were college graduates and were married or partnered. All were adults.

Setting:

  • SITE: Single site   
  • SETTING TYPE: Home   
  • LOCATION: Florida

Phase of Care and Clinical Applications:

PHASE OF CARE: Active anti-tumor treatment

Study Design:

  • Randomized, controlled trial
  • Four groups

Measurement Instruments/Methods:

  • MOS–SF36
  • Center for Epidemiological Studies Depression Scale (CESD)
  • Beck Anxiety Inventory (BAI)
  • Godin Leisure-Time Exercise Questionnaire

Results:

The SMEX group had a significant reduction in depressive symptoms compared to the UCO group (p = .048). All groups except for the UCO group showed a decrease in depressive symptoms over time. The effect size was small at its maximum (d = 0.25). BAI scores showed a positive effect in the SMEX group compared to the UCO group (p = .049). In the SMEX group, this decline occurred mainly between baseline and the first follow-up at six weeks, and then anxiety scores increased. The maximum effect size was small (d = .22). No significant differences were seen between the UCO and EX or SM groups in anxiety or depression over time. Exercise and stress management activities increased only in the SMEX group.

Conclusions:

The combination of exercise and stress management training reduced anxiety and depressive symptoms during chemotherapy treatment. Exercise alone and stress management training alone did no show positive results. The size of the effect of SMEX was small.

Limitations:

  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10%
  • By the first follow-up, about one-third of the patients withdrew. By the investigator's calculations, the study was underpowered.

Nursing Implications:

Findings suggest that the combination of stress management training, using approaches such as progressive muscle relaxation and guided imagery with home-based exercise delivered via video and written guidelines, had a small effect on improving anxiety and depressive symptoms among patients receiving chemotherapy.  This combination was more effective than relaxation training and exercise alone. This suggests that nurses can educate patients to use both of these approaches to manage these symptoms. Effect sizes seen here were small, and the intervention consisted of a single instructional face-to-face meeting and then patient self-directed activity using resources provided. More personal time and follow-up support and encouragement during treatment sessions may increase the magnitude of the effects. Provision of videos and written materials as used here can provide a practical approach to patient education in these areas.

Kwiatkowski, F., Mouret-Reynier, M.A., Duclos, M., Leger-Enreille, A., Bridon, F., Hahn, T., . . . Bignon, Y.J. (2013). Long term improved quality of life by a 2-week group physical and educational intervention shortly after breast cancer chemotherapy completion. Results of the 'Programme of Accompanying women after breast Cancer treatment completion in Thermal resorts' (PACThe) randomised clinical trial of 251 patients. European Journal of Cancer, 49(7), 1530–1538.

doi: 10.1016/j.ejca.2012.12.021
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Study Purpose:

Determine the effectiveness of an intensive intervention (i.e., two weeks at a SPA centre involving exercise, physiotherapy, and dietary education) on overall quality of life, weight, nutrition, and physical activity in women who recently had completed treatment for non-metastatic breast cancer

Intervention Characteristics/Basic Study Process:

The intervention included a two-week stay at a SPA centre with a daily routine of physical training (i.e., two hours daily under the supervision of a physiotherapist, which included walking, strength training, and aquaexercise), dietary education with cooking lessons and provision of healthy meals, and aesthetic care, massage, etc. Dietary consultations every six months for three years also were incorporated into standard follow-up care.

Sample Characteristics:

  • N = 222
  • MEAN AGE: Intervention group: 51.8 years (SD = 8.7 years), control group: 52.3 years (SD = 10.1 years)
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: The stage of cancer is not reported; it's described only as invasive and non-metastatic. A description of disease characteristics is not reported. Subjects had completed treatment (chemo and/or radiation) for breast cancer less than nine months prior to study enrollment. The majority of patients received chemotherapy and radiation therapy, and more than two-thirds of the sample were on hormonal therapy; a minority (less than 15%) were on trastuzumab as well.
  • OTHER KEY SAMPLE CHARACTERISTICS: No significant differences were seen between the treatment and control group, except for a statistically significant difference in smoking history, in that a greater percentage of the treatment group reported a history of smoking.

Setting:

  • SITE: Not stated/unknown 
  • SETTING TYPE: Other 
  • LOCATION: This is a French study. The intervention occurred at three different SPA centres, also mentioned as “thermal centres.” From where the sample was recruited is not reported.

Phase of Care and Clinical Applications:

PHASE OF CARE: Transition phase after active treatment

Study Design:

Prospective, randomized, repeated measures (baseline, 6, 12, 18, and 24 months after intervention) two-group clinical trial

Measurement Instruments/Methods:

  • Short Form 36 Health Survey (SF-36) as quality-of-life measure
  • Hospital Anxiety and Depression Scale (HADS)
  • Adapted Leeds Sleep Evaluation Questionnaire
  • Ricci & Gagnon questionnaire for physical activity
  • Questionnaire for sitting time and impedancemetry for body composition

Results:

Statistically significant differences were seen between groups on the SF-36 measure at six months, but these differences did not persist in any dimension at year one except for a difference in vitality at one year between groups. Although data were collected on weight/body mass index, diet, and sleep, results for these variables are not reported (except to note no significant differences in sleep between the groups). The plots/trends in quality of life over time (at 6, 12, 18, and 24 months) look very similar for both groups, except for a significant upward trend at six months for the intervention group. The correlation was stronger between HADS depression and SF-36 quality of life. In the SPA group, an overall decrease was seen in anxiety compared to baseline scores (p = 0.0005). No significant difference was seen in the anxiety scores between the SPA and control groups at six months. Depression decreased in both groups but to a greater degree in the SPA group. A significant difference was seen between the SPA group and control group in terms of depression scores. What the “control” or comparison group was or what care was given to them is not clear.

Conclusions:

As reported, patients with non-metastatic breast cancer did not appear to derive significant benefit (improved quality of life as measured by the SF-36) from a two-week SPA intervention in terms of improving quality of life and reducing anxiety and depression.

Limitations:

This unrealistic intervention (two-week SPA stay) does not seem sustainable. Furthermore, if this “intensive” intervention did not demonstrate significant impact on quality of life or anxiety, except for depression, then the “cost” of such an intensive intervention is not worth the benefit. When exactly the intervention occurred is not reported relative to timing of completion of breast cancer treatment except to say “within nine months,” but this is an important variable/covariate because time since treatment completion (and intervention) might impact study results. Importantly, unclear is how subjects were screened or that only a “distressed” group was enrolled. The report that global SF-36 scores at study inclusion were 56 and 54 respectively (treatment and control groups) indicates that this is not a very “stressed” group, as evidenced by SF-36. The higher the scores on the SF-36, the better the quality of life. These scores at study inclusion are right at the midpoint range of 0%–100%; thus, a possible floor effect is at play. Overall, this is not a very well developed or reported study.

Nursing Implications:

No real meaningful nursing implications are drawn from this study. The intervention seems unrealistic and unsustainable and did not impact outcome measures as predicted, except for depression.

Mehnert, A., Veers, S., Howaldt, D., Braumann, K.M., Koch, U., & Schulz, K.H. (2011). Effects of a physical exercise rehabilitation group program on anxiety, depression, body image, and health-related quality of life among breast cancer patients. Onkologie, 34, 248–253.

doi: 10.1159/000327813
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Study Purpose:

To investigate whether an exercise intervention reduces anxiety and depression, and improves quality of life, body image, and physical fitness in women with breast cancer

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to the intervention or a wait list control group after a sports medicine assessment. The intervention group received structured group exercise training twice weekly for 10 weeks. Training sessions lasted 90 minutes, were done in small groups (five patients), and included two main components: (a) warm-up, dance and movement games, physiotherapeutic exercises, and relaxation, and (b) moderate walking and jogging outdoors. Patients wore heart monitors during exercise. Sessions were led by a physio- or sports medicine therapist. Outcome variables were measured at baseline and at the end of the 10-week study period.

Sample Characteristics:

  • The study initially had 63 enrolled participants; 11 completed the 10-week program.
  • Mean participant age was 51.88 ± 8.46.
  • All participants were females diagnosed with breast cancer; 51.7% had stage I disease.
  • Of the sample, 58.9% had breast-conserving surgery, 34.5% had lymphedema, and 1.8% had no surgery. All were entered after at least four weeks post-adjuvant treatment.
  • Half of the sample did regular sports and fitness activities as part of their usual lifestyle, 77.2% were either married or in a relationship, and 26.4% had a college education.

Setting:

  • Single site
  • Outpatient setting
  • Germany

Phase of Care and Clinical Applications:

  • Patients were undergoing the transition phase of care after initial treatment.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
  • Short-Form Health Survey–36 (SF-36)–German version
  • Body Image Questionnaire
  • Symptom Checklist–90–revised (symptom burden measure)

Results:

Anxiety declined over time in all patients (p = 0.08), and ANOVA showed a significant interaction of the intervention (p = 0.03). The effect size in anxiety with the intervention was -0.54 (95% CI -1.06 to -0.02). Depression declined over time in all patients (p = 0.02), but there was no interaction effect with the intervention. Body image improved over time in all patients (p = 0.003), and there was a significant interaction effect of group assignment (p = 0.006); however, body image at baseline was also better in the intervention group. There were no differences between groups in symptom burden or quality of life.

Conclusions:

Participation in this exercise intervention was associated with a significant decline in anxiety.

Limitations:

  • The study did not include an appropriate control group.
  • The study had no attentional control.
  • The final group of patients who completed the intervention and were analyzed was very small, only 11 patients.
  • Authors reported different sample sizes in different tables and figures, suggesting the potential for issues in data analysis, and there is no discussion of reasons for missing data.
  • Authors stated that the intervention was effective for depression, although the ANOVA did not demonstrate a significant group and time interaction effect on this variable, suggesting some investigator bias in discussion of results.
  • Authors stated an intervention adherence rate of about 50%, but there was actually a 63% drop-out rate.

Nursing Implications:

Study findings suggest that group exercise can be helpful in reducing anxiety in patients with breast cancer after completion of adjuvant treatment. These study results should be interpreted with caution given the high drop-out rate and study limitations.

Midtgaard, J., Rorth, M., Stelter, R., Tveteras, A., Andersen, C., Quist, M., & Adamsen, L. (2005). The impact of a multidimensional exercise program on self-reported anxiety and depression in cancer patients undergoing chemotherapy: A phase II study. Palliative and Supportive Care, 3(3), 197–208.

doi: 10.1017/S1478951505050327
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Study Purpose:

To determine the effectiveness of a specific structured exercise intervention on patients undergoing chemotherapy

Intervention Characteristics/Basic Study Process:

Patients with cancer who were undergoing chemotherapy volunteered to participate in the six-week structured exercise program. The total time of all weekly sessions was nine hours per week. Fitness training, relaxation, body awareness training, and high- or low-intensity programs were offered, and safety measures were incorporated. Participants were assessed for depression and anxiety at baseline and after the six-week intervention.

Sample Characteristics:

  • The sample was composed of 91 participants.
  • The participants were men and women receiving chemotherapy for various cancers. Of all participants, 70% were female.
  • Participants self-referred for participation, after seeing posters and pamphlets in clinics.

Setting:

  • Multisite
  • Denmark and Sweden

Study Design:

Prospective pre/post-test one-group design

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression scale, anxiety and depression subscales
  • Maximal oxygen consumption test (VO2 max test), to measure aerobic capacity

Results:

  • Anxiety and depression scores decreased from baseline to six weeks. The decrease of depression scores was more moderate than the decrease of anxiety scores, but both were significant.
  • Most participants had low levels of depression and anxiety at baseline.
  • VO2 max scores significantly increased over time. Improvements in VO2 max scores were associated with improvements in depression but not anxiety.

Limitations:

  • The study had a small sample size. The sample contained a disproportionate number of women. Patients self-referred to the study, and those patients may have been more motivated and psychologically intact than others.
  • The study had a risk of bias due to no control group.
  • Groups contained an unequal number of cancers and different cancer diagnoses.
  • Investigators did not collect information about psychopharmacologic drug use. Such drugs could have influenced results.
  • Levels of anxiety and depression were low at baseline.

Payne, J. K., Held, J., Thorpe, J., & Shaw, H. (2008). Effect of exercise on biomarkers, fatigue, sleep disturbances, and depressive symptoms in older women with breast cancer receiving hormonal therapy. Oncology Nursing Forum, 35, 635–642.

doi: 10.1188/08.ONF.635-642
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Study Purpose:

To determine if a home-based walking program is more effective than usual care in reducing fatigue, sleep disturbances, and symptoms of depression in older women receiving hormone treatment for breast cancer.

Intervention Characteristics/Basic Study Process:

Patients were recruited from breast cancer clinics and randomized to usual care or a prescribed exercise program that focused on walking. Researchers followed patients' progress over a 14-week period. Patients completed study instruments at baseline, two weeks later via mail, 12 weeks after baseline at a clinic visit, and 14 weeks after baseline via mail. Cortisol, serotonin, interleukin-6 (IL-6), and bilirubin were collected at the initial clinic visit and again at three months. At visit 1 and at 12 weeks, patients were asked to wear a sleep-watch actigraph for 72 continuous hours. The walking exercise intervention was a moderate walking activity for 20 minutes, four times a week. Patients were to log the duration and frequency of walking activity.

Sample Characteristics:

  • The sample was comprised of 18 women.
  • Mean age was 65 years (range 56–78).
  • All patients had breast cancer and were being treated, by means of hormone therapy, with tamoxifen, anastrozole, or letrozole.
  • Of the patients, 65% were married, 55% were retired, 90% were Caucasian, and 40% had education at the college level or higher.
  • Inclusion criteria were postmenopausal status and fatigue.

Setting:

  • Single site
  • Outpatient
  • Comprehensive cancer center in the southeastern United States

Study Design:

The study was a longitudinal, repeated-measures, randomized, clinical trial.

Measurement Instruments/Methods:

  • Revised Piper Fatigue Scale (PFS-R)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Center for Epidemiologic Studies Depression Scale (CESD)
  • Sleep measurements collected by means of actigraphy

Results:

Levels of fatigue over time and between groups were not significantly different. PSQI scores decreased significantly over time in the exercise group (p = 0.007) and did not change in the usual care control. Actigraphy analysis after 12 weeks showed a shorter wake time (p = 0.02), sleep time (p = 0.05), and less movement during sleep (p = 0.002) in the exercise group. There was no difference between groups in regard to sleep efficiency, which is the ratio of total sleep time to time in bed. There were no differences in cortisol levels over time or between groups. ANOVA showed a significant difference between groups and across time in serotonin levels, with an intervention effect of exercise (p = 0.009). There were no differences between groups or over time in regard to symptoms of depression.

Conclusions:

A home-based walking intervention appears to be acceptable to older women receiving hormone therapy for breast cancer and an intervention that is feasible for use in that population. Decline in PSQI scores in the exercise group suggest that this type of intervention may help improve sleep quality in this population. Effects of the exercise intervention on biomarkers are unclear.

Limitations:

  • The study had a small sample size, with less than 30 patients.
  • There was no intention-to-treat analysis.
  • The study had a risk of bias due to no appropriate attentional control group.
  • Although significance values were reported, the authors provided no other statistical results regarding significant findings. Such results would enable evaluation of the strength of the relationships.
  • The authors did not report actual adherence to the exercise program, so the use of exercise as prescribed cannot be determined. It is also unknown whether members of the control group exercised on their own.
  • The use of patient self-reporting—in this case, of exercise—is a limitation in itself. Furthermore, the authors did not provide or discuss the patient self-reports or their analysis.

Nursing Implications:

An exercise program involving walking may be helpful to patients receiving hormone treatment for breast cancer, but the actual effects of such a program on fatigue, sleep, and symptoms of depression are unclear.

Saarto, T., Penttinen, H. M., Sievänen, H., Kellokumpu-Lehtinen, P. L., Hakamies-Blomqvist, L., Nikander, R., . . . Luoma, M. L. (2012). Effectiveness of a 12-month exercise program on physical performance and quality of life of breast cancer survivors. Anticancer Research, 32, 3875–3884.

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Study Purpose:

To determine whether physical exercise training improves the quality of life and physical fitness of survivors of breast cancer.

Intervention Characteristics/Basic Study Process:

Patients were randomized to the exercise intervention or control group. The duration of the exercise intervention was 12 months, with the aim of attaining permanent changes in lifestyle. The intervention consisted of both supervised and home training.  Supervised training, delivered to a group of 15 to 20 individuals, included step aerobics and circuit training. Home training consisted of walking, aerobics cued by a video, cycling, or swimming; participants could choose the activity.

Sample Characteristics:

  • The sample was comprised of 573 participants.
  • Participant age ranged from 35 to 68 years.
  • All participants were female.
  • All participants had breast cancer; were pre- or postmenopausal; and had undergone adjuvant chemotherapy within four months, started adjuvant endocrine therapy no fewer than four months previously, or had started a combination of chemotherapy and endocrine therapy no fewer than four months previously.

Setting:

  • Multisite
  • Outpatient
  • Multiple locations in Finland

Phase of Care and Clinical Applications:

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for palliative care.

Study Design:

This was a randomized, controlled trial.

Measurement Instruments/Methods:

  • European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30)
  • EORTC QLQ-BR-23 questionnaire to assess quality of life of patients with breast cancer
  • Functional Assessment of Cancer Therapy-Fatigue (FACT-F)
  • Finnish version of the Beck Depression Inventory (BDI)
  • Two-hour walking test
  • Figure-eight running test

Results:

No significant differences were found between the exercise group and control group in regard to changes in quality of life during the intervention or in regard to depression or fatigue.

Conclusions:

This study did not show that the exercise intervention had an effect on fatigue, depression, or quality of life. Lack of effect may be due to a ceiling effect in both groups because most study participants had relatively high activity levels at baseline.

Limitations:

  • The study had risks of bias due to no blinding, no appropriate attentional control condition, and as a result of sample characteristics. Key sample group differences could have influenced the results.
  • Most participants were physically active before the study. (Only a few patients [0.25%] were sedentary before the study.) Control patients were also motivated to remain active. Actual activity levels of control patients were not analyzed.
  • Findings were not generalizable.
  • One of the physical fitness tests used, two-hour walking test, cannot be generalized to other countries.
  • The main strength of this study was its size.   

Nursing Implications:

The ability of physical exercise, especially group exercise, to improve quality of life and reduce fatigue and depression in patients with breast cancer during and following treatment is generally known. The fact that this study did not support the widely held view may be due to the fact that most participants had a high level of activity at baseline. The study did not clarify whether exercise interventions are needed or effective for individuals who already have an active lifestyle and are motivated to maintain it.

Yang, C. Y., Tsai, J. C., Huang, Y. C., & Lin, C. C. (2011). Effects of a home-based walking program on perceived symptom and mood status in postoperative breast cancer women receiving adjuvant chemotherapy. Journal of Advanced Nursing, 67, 158–168.

doi: 10.1111/j.1365-2648.2010.05492.x
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Study Purpose:

To test the effect of a home-based walking program on symptom distress and mood status in women undergoing breast cancer treatment.

Intervention Characteristics/Basic Study Process:

Women referred by their oncologists were randomly assigned to the exercise or control group. Patients in the control group were instructed to maintain their usual lifestyles. Those in the exercise group were given individualized home-based exercise instructions based on American College of Sports Medicine guidelines. Participants were asked to walk briskly three times per week for 12 weeks during chemotherapy treatment, beginning two to three days after starting each chemotherapy cycle. Exercise sessions included a five-minute warm-up, 30 minutes of walking at  60% to 80% of the age-adjusted maximal heart rate, and a five-minute cool-down. Patients were asked to wear a heart rate monitor during exercise sessions and to monitor their own heart rates during exercise. Investigators read the heart rate monitor data weekly. Outcome data were collected at baseline and at six and 12 weeks. All patients received weekly telephone calls over the 12 weeks to identify any relevant health problems among participants.

Sample Characteristics:

  • The sample was comprised of 40 participants.
  • Mean age was 51.8 years (range 31–67).
  • All participants were female.
  • Most participants had stage I or II breast cancer and were receiving adjuvant chemotherapy.  
  • All participants had undergone surgery, and most had undergone modified radical mastectomy.

Setting:

  • Single site
  • Outpatient
  • Taiwan

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

This was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Seven-day physical-activity recall:  self-reported physical activity and intensity (prior validation and reliability provided)
  • MD Anderson Symptom Inventory (MDASI)
  • Profile of Mood States (POMS), Taiwanese version

Results:

Adherence to the exercise prescription was 77% for the number of sessions and 100% for intensity. Mean physical activity levels from self-reports were not different between the groups at baseline. However, over time, a significant effect developed, for time and group assignment, regarding weekly energy expenditure (p = 0.02). Over time, symptoms declined in both groups, and the authors noted a significant group-by-time interaction on symptom severity (p < 0.01), indicating a greater decline in the exercise group. The authors also noted, compared to baseline in the exercise group, a significantly lower symptom severity overall, lower symptom interference, and less mood disturbance (p < 0.01) at 12 weeks. During the same period, the severity of symptoms increased in the control group. The sample size was determined by power analysis and met the size requirements.

Conclusions:

Findings suggested that an individually prescribed home-based exercise program can reduce symptom severity and mood disturbance in women with breast cancer during adjuvant chemotherapy treatment.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • The authors provided no information regarding medications provided to patients that could have influenced differences in symptoms.
  • Patients had relatively low symptom severity at baseline (<3), and individuals with more advanced disease were excluded from the sample.
  • The authors did not clarify how critical the weekly telephone calls were to patient adherence to the exercise regimen, and the authors did not detail the nature of these calls.
  • This was a single-site study of relatively short duration.

Nursing Implications:

Use of a prescribed individualized exercise regimen consisting mainly of brisk walking, three days per week, was shown to have a positive effect on the symptoms and mood of women with breast cancer during chemotherapy treatments. Although the study did not show the effect on single symptoms, overall symptom severity decreased. This study showed that this type of simple exercise intervention for patients during cancer treatment can have a positive effect for overall well-being.

Systematic Review/Meta-Analysis

Brown, J.C., Huedo-Medina, T.B., Pescatello, L.S., Ryan, S.M., Pescatello, S.M., Moker, E., . . . Johnson, B.T. (2012). The efficacy of exercise in reducing depressive symptoms among cancer survivors: A meta-analysis. PloS One, 7(1), e30955.

10.1371/journal.pone.0030955
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Purpose:

To perform a meta-analysis and systematic review to determine the efficacy of exercise in reducing the symptoms of depression among cancer survivors

Search Strategy:

  • Databases searched were PubMed, PsycINFO, CINAHL Plus, SPORTDiscus, and ProQuest medical databases. In addition, investigators searched reference lists for relevant studies.
  • Search keywords were cancer (and related terms), depression OR anxiety (and similar terms) AND exercise (and associated terms).
  • Included studies were RCTs involving exercise, adults who had survived some form of cancer, and at least one measure of depression.
  • Authors excluded studies involving children.

Literature Evaluated:

  • The sample was composed of 14,702 participants.
  • Except for noting the general method of collecting data, authors did not report the evaluation method.

Sample Characteristics:

  • The number of studies included in the sample was 37; the number of participants was 2,929. Authors did not provide the sample range across studies.
  • The sample included patients with breast, prostate, and colorectal cancers as well as patients with leukemia and lymphoma.

 

Phase of Care and Clinical Applications:

Late effects and survivorship

Results:

  • The intensity of exercise was low to moderate, according to calculations of metabolic equivalent of task (MET).
  • Exercise interventions most often occurred during curative treatment. 
  • Compared to standard care, exercise provided a small reduction in measures of depression symptoms. Subgroup analysis showed this effect among breast cancer patients only (d = –0.19, 95% CI –0.28, –0.09). Moderators of the effect were increases in the amount of aerobic exercise per week: Aerobic exercise reduced depression in dose-response fashion. 
  • Effects were greatest when exercise sessions were supervised.

Conclusions:

Findings support the conclusion that exercise has a small positive effect on symptoms of depression among women with breast cancer.

Limitations:

  • Studies were highly heterogeneous, even just those studies of patients with breast cancer.
  • Authors state that included studies were limited by sample size and quality issues, but they do not describe how they assessed study quality.
  • In most studies, depression symptoms were at a very low level at baseline.
  • Effect sizes were very small.

Nursing Implications:

Findings suggest that supervised aerobic exercise may be helpful in reducing mild symptoms of depression among women with breast cancer. Applicability of the findings to patients with other diagnoses is unclear.

Carayol, M., Bernard, P., Boiche, J., Riou, F., Mercier, B., Cousson-Gelie, F., . . . Ninot, G. (2013). Psychological effect of exercise in women with breast cancer receiving adjuvant therapy: What is the optimal dose needed? Annals of Oncology, 24, 291–300.

doi: 10.1093/annonc/mds342
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Purpose:

To investigate the effects of an exercise prescription on fatigue, anxiety, depression, and quality of life in patients with breast cancer receiving adjuvant therapy and to explore the relationships between the volume of targeted exercise and the effects observed on these psychological outcomes.

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: MEDLINE, PsycINFO, Pascal, PSYarticles, and Cochrane

KEYWORDS: anxiety, breast cancer, depression, exercise, fatigue, and quality of life

INCLUSION CRITERIA: Participants were adult women diagnosed with breast cancer. Studies had a randomized, controlled experimental design. Intervention programs involving physical activity (yoga-based) were included, whereas relaxation-based interventions were not. An intervention program was scheduled during adjuvant cancer therapy (chemotherapy and/or radiotherapy). At least one psychological outcome among fatigue, anxiety, depression, and quality of life was observed. Pre- and post-intervention data were included to calculate standardized mean differences.

EXCLUSION CRITERIA: Not given

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 1,011

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: A quality score based on 10 methodologic criteria specifically chosen for the evaluation of exercise intervention randomized controlled trials and mostly derived from the PEDro scale was calculated for each included study. Targeted exercise volume was estimated using metabolic equivalent for task (MET), where 1 MET accounts for 3.5 ml O2/kg/min. Corresponding MET values for a given exercise intervention were coded from the Compendium of Physical Activity. Five and 3.8 METs were, respectively, assigned to moderate- and low-intensity aerobic physical activity; strength-training physical activity was coded 3.5 METs; warm-up and cool-down were estimated 2.5 METs if no more detail related to their content was provided; yoga and stretching activities were coded 2.5 METs.                                                        

Sample Characteristics:

  • N (studies) = 17
  • TOTAL PATIENTS INCLUDED IN REVIEW: 748 subjects, 632 controls
  • KEY SAMPLE CHARACTERISTICS: The median age of included patients was 50.5 years old. All patients with breast cancer had been diagnosed with nonmetastatic cancer and were undergoing adjuvant therapy (i.e., chemotherapy and/or radiotherapy during exercise intervention).                                                                                                                     

The methodologic quality of the studies had a median score of 7, ranging from 2–9.

Phase of Care and Clinical Applications:

PHASE OF CARE: Active anti-tumor treatment

Results:

Controlled comparisons of pre- and post-intervention indicated that exercise intervention significantly reduced fatigue, anxiety, and depression, but only borderline significance was reached for anxiety (P = 0.06). Moreover, exercise intervention significantly improved quality of life. Findings showed that higher dose and duration of exercise targets had greater effectiveness. Effect sizes were modest. When low-quality studies were eliminated, effects for fatigue no longer were significant.

Conclusions:

Adapted physical activity programs can be expected to decrease fatigue and depressive symptoms and increase quality of life during chemotherapy and/or radiotherapy for patients with early-stage breast cancer. Reduction in anxiety symptoms also was observed, but the evidence still is limited.

Limitations:

A limitation of the study was the estimation of exercise dose. Targeted aerobic exercise intensity frequently was described within a range such as 50%–80% of the maximal heart rate, which did not enable considering it precisely. Except when it was explicitly stated as light or vigorous, intensity was considered moderate for dose calculation. Only targeted exercise doses were estimated instead of achieved exercise doses.

Nursing Implications:

Exercise intervention may improve fatigue, depression, and quality of life in patients with breast cancer receiving adjuvant therapy, with findings suggesting that a prescription of relatively low doses of exercise (less than 12 MET h/week) consisting of about 90–120 minutes of weekly moderate physical exercise seems more efficacious in improving fatigue and quality of life than higher doses.

Chipperfield, K., Brooker, J., Fletcher, J., & Burney, S. (2013). The impact of physical activity on psychosocial outcomes in men receiving androgen deprivation therapy for prostate cancer: A systematic review. Health Psychology.

doi: 10.1037/hea0000006
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Purpose:

To evaluate the effectiveness of physical activity on depression and anxiety symptoms, cognitive function, and quality of life in patients receiving androgen deprivation therapy (ADT) for prostate cancer

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, PsycINFO, EMBASE, Informit, Scopus, Cochrane Library, CINAHL

KEYWORDS: Prostate neoplasm, prostate cancer, prostate carcinoma, prostate adenocarcinoma, androgen deprivation therapy, androgen ablation, androgen suppression, hormone therapy, androgen antagonist, androgen agonist, gonadotropin, luteinizing hormone-releasing hormone, antiandrogen, orchidectomy, surgical castration, chemical castration, physical activity, physical exercise, exercise, sport therapy, sport, endurance, aerobic training, resistance training, cardiac training, aerobic activity, resistance activity, and motor activity

INCLUSION CRITERIA: Physical activity interventions, exercise interventions, and supervised and nonsupervised interventions. Participants who were patients with prostate cancer receiving ADT only (or separate results according to cancer and treatment type). All study designs. Pilot studies (no sample size limitations). Published in English.

EXCLUSION CRITERIA: Studies with the additional interventions of psychotherapy or nutritional consultation. Studies about physical activity behavior or motivation. Studies involving outcomes other than depression, anxiety, quality of life, or cognitive function. Studies involving the impact of physical activity on patients with prostate cancer undergoing forms of treatment other than ADT.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 867

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Reviewed studies for inclusion and exclusion criteria. No appraisal or scoring system used.

Sample Characteristics:

  • N (studies)  =  7
  • TOTAL PATIENTS INCLUDED IN REVIEW: 420 participants with 242 participants receiving physical activity intervention
  • KEY SAMPLE CHARACTERISTICS: Men with prostate carcinoma with any disease stage receiving androgen deprivation therapy at least three months after recruitment or on therapy for two months or expected to receive for six months

Phase of Care and Clinical Applications:

PHASE OF CARE: Mutliple phases of care

Results:

Existing data suggest that physical activity improved quality of life. The existing evidence, however, is not sufficiently robust to determine the adequacy of physical activity as an intervention to improve depression, anxiety, and cognitive function outcomes. One study examined impact on depression and found no significant effect.

Conclusions:

Preliminary findings support physical activity to improve quality of life in men receiving ADT for prostate cancer.

Limitations:

  • Potential for sample selection bias with participants interested in an active lifestyle being more likely to participate
  • Three studies did not report comorbidities.
  • Social support bias and attention effects with structured fitness environment fostering social interaction
  • Very few studies for outcomes of anxiety or depression

Nursing Implications:

Evidence suggests that clinical exercise in the form of resistance and combined aerobic and resistance training programs may be important for the health status and rehabilitation of patients with prostate cancer.

Craft, L. L., Vaniterson, E. H., Helenowski, I. B., Rademaker, A. W., & Courneya, K. S. (2012). Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 21(1), 3-19.

10.1158/1055-9965.EPI-11-0634
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Purpose:

Evaluate the current literature on antidepressant effects of exercise in cancer survivors. Also to explore potential moderating variables related to participant, cancer and exercise characteristics.

TYPE OF STUDY Combined systematic review and meta analysis

Search Strategy:

DATABASES Medline, Medline in Process, Psycinfo, Embase, CINAHL, Cochrane database, Cochrane central register of controlled trials, Allied and Complementary Medicine, Biosis Previews, Sports Discus
   

KEYWORDS  terms related to cancer, exercise, and depression    

INCLUSION CRITERIA Studies were eligible if they were a RCT of adults with cancer, compared exercise program with usual care, exercise program was chronic in nature (at least 4 weeks), reported depression pre and post  intervention, used depression inventory or clinician interview to define depression symptom, English language

EXCLUSION CRITERIA studies that used quality of life or moods scales to measure depression
Study Aims Evaluate the current literature on antidepressant effects of exercise in cancer survivors. Also to explore potential moderating variables related to participant, cancer and exercise characteristics.  
 

Literature Evaluated:

TOTAL REFERENCES RETRIEVED : N =60

METHOD OF STUDY EVALUATION AND COMMENTS ON LITERATURE USED Two investigators independently reviewed articles with discrepancies resolved by consensus.

All studies included aerobic exercise with some also including strength training. Exercise programs were implemented prior to or during treatment in 47% of the studies. Interventions varied from unsupervised home based to supervised facility based with frew having mixed supervision. Intervention length ranged mostly from 4-14 weeks, with the longest being 52 weeks.  
 

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED: N = 14 articles describing 15 RCTS   TOTAL SAMPLE SIZE: N =  1371   SAMPLE RANGE ACROSS STUDIES : 18-209, including exercise and control groups combined

KEY SAMPLE CHARACTERISTICS 60% (9) studies included breast cancer survivors. The average age was 51.6 years. 76.9 of those who reported race/ethnicity were Caucasian. Of those reporting cancer stage, 75% were patients with non-metastatic disease.

Phase of Care and Clinical Applications:

PHASE OF CARE Active Treatment

APPLICATIONS Late Effects and Survivorship
 

Results:

Effect size of -.22(p=0.04) was found comparing exercise group to control groups. Home based exercise had increased depressive symptoms (effect size(ES)e 0.16) compared to exercise location and facilities, laboratories, gyms (ES= -0.45, -0.77, -.014). Supervised exercise had the greatest effect (ES=-0.67) compared to mixed supervision (ES=-0.32) and unsupervised activity showed a small increase in depression (ES=0.25). Duration of greater than 30 minutes had a larger effect (ES=-.57) compared to less than or equal to 30 minutes (ES=0.01)

Conclusions:

Overall, exercise had a small to moderate impact on depression symptoms which varied based on location of exercise, supervision, and duration. 

Nursing Implications:

Exercise at places where patients interact with others had a greater effect size associated with reduction of depression symptoms. It would be important to recognize this when intervening with exercise. Future research should measure the significance of social interaction during exercise and depression symptoms.  Also, more work is necessary to understand if the exercise intervention improves QOL.

Guideline/Expert Opinion

National Health and Medical Research Council (Australia). (2003). Clinical practice guidelines for the psychosocial care of adults with cancer. Retrieved from http://www.nhmrc.gov.au/publications/synopses/cp90syn.htm

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Purpose & Patient Population:

Comprehensive, evidence-based guidelines were developed to assist healthcare professionals in providing optimal psychosocial care. The guidelines are multidisciplinary in focus, with recommendations applicable to diverse treatment settings.

Type of Resource/Evidence-Based Process:

Evidence was presented using levels I, II, III-1, III-2, III-3, and IV rating system with level I representing the gold standard.

Guidelines & Recommendations:

 Clinically relevant recommendations supported by level I and II evidence about depression include the following.

  • Referring high-risk patients to specialized psychological services to minimize the likelihood of developing significant distress (level I)
  • Using a range of psychoeducational interventions to decrease distress (level I)
  • Managing depression by incorporating a combination of supportive psychotherapy, cognitive and behavioral techniques, and pharmacotherapy (levels I, II)
  • There is no evidence that any particular antidepressant is superior to another in the management of depression in people with cancer (level I).
  • Other therapies that may improve depression are art, music, painting, reading, poetry, wellness programs, meditation, hypnosis, acupuncture, relaxation, exercise, prayer, and laughter. (levels I, II, III-3, IV).

Nursing Implications:

The treatment of depression should incorporate psychotherapeutic interventions and the use of medication.

Evidence of the efficacy of antidepressant medication in treating depression in patients with cancer is clear.

No evidence suggests that any particular antidepressant is superior to another.

  • The sedating properties of tricyclics may be beneficial to some patients, as may their potentiation and enhancement of opioid analgesia in those with pain.
  • Their anticholinergic side effects may aggravate stomatitis, exacerbate constipation, and affect cardiac rhythm.
  • Patients with cancer may respond to a lower dose of tricyclic antidepressants.
  • Selective serotonin reuptake inhibitors have been demonstrated to be effective in treating depression in patients with cancer.
  • The long half-life of fluoxetine makes it less desirable in patients with hepatic or renal dysfunction where sertraline or paroxetine is preferable.

Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Jr., Cross, J.T., Jr, Owens, D.K., . . . Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146.

doi: 10.7326/0003-4819-148-2-200801150-00009
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Purpose & Patient Population:

Objectives were to

  • Present evidence that will contribute to the improvement of palliative care at the end of life.
  • Answer questions regarding critical elements.
  • Identify patients who could benefit from palliative approaches.
  • Identify treatment strategies that work for pain, dyspnea, and depression.
  • Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

Type of Resource/Evidence-Based Process:

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

Results Provided in the Reference:

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

  • Pain
    • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
    • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
    • Palliative care teams may be moderately beneficial in providing pain management.
  • Dyspnea
    • Evidence shows a valuable effect of morphine.
    • Nebulized opioids show no additional benefit over oral opioids.
    • Evidence regarding the use of oxygen is equivocal.
    • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
  • Depression
    • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
    • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
    • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

Guidelines & Recommendations:

The following were graded as strong recommendations with moderate quality of evidence.

  • Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
  • For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
  • Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
  • Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
  • Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

Limitations:

  • Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
  • Financial support for this guideline was entirely from the American College of Physicians.

Nursing Implications:

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.


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