Nakano, J., Hashizume, K., Fukushima, T., Ueno, K., Matsuura, E., Ikio, Y., . . . Kusuba, Y. (2018). Effects of aerobic and resistance exercises on physical symptoms in cancer patients: A meta-analysis. Integrative Cancer Therapies, 17, 1048–1058.

• STUDY PURPOSE: To conduct a meta-analysis to establish the effect of exercise interventions on multiple physical symptoms, including fatigue, nausea/vomiting, pain, dyspnea, insomnia, loss of appetite, constipation, and diarrhea in patients with cancer
• TYPE OF STUDY: Systematic review

• DATABASES USED: Cochrane Library, the Center for Reviews and Dissemination, PubMed/MEDLINE, CINAHL, Scopus, PEDro, Health and Medical Collection, Psychology Database
• YEARS INCLUDED: Articles published before April 2017
• SEARCH TERMS: MeSH terms of cancer, tumor, randomized controlled trial, training, rehabilitation, and exercise, as well as outcome of physical symptoms
• INCLUSION CRITERIA: Included RCTs that evaluated the effects of exercise intervention by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 or the C15-PAL
• EXCLUSION CRITERIA: Excludes systematic reviews, editorials, cross-sectional studies, case reports, case series, and interventions that were not of high enough intensity (yoga, stretching, Pilates, and education). Also excluded shoulder exercise studies for breast patients and pelvic floor muscle training in gynecologic patients, as well was any trial that did not have a control group that received no major exercise intervention.

• TOTAL REFERENCES RETRIEVED: 743 (only 45 reviewed full-text after exclusion for study design)
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Studies were evaluated for study design (RCT) and for data form, methodologic quality was evaluated with the PEDro scale

• FINAL NUMBER STUDIES INCLUDED: 10
• TOTAL PATIENTS INCLUDED IN REVIEW: 893 (434 in intervention groups)
• SAMPLE RANGE ACROSS STUDIES: Lists patients as having hematological malignancies (largest group), breast, prostate, and mixed cancer. Phases of care were heterogenous, although listed as “mainly postsurgery, posttransplantation (heme), and during chemotherapy
• KEY SAMPLE CHARACTERISTICS: Heme malignancy was most prevalent, states that the largest number of patients with lung cancer was 46 “at most”--total breakdown of cancer types was not provided.

• PHASE OF CARE: Varied
• APPLICATIONS:  Palliative care 

Results showed exercise positively affected the symptoms of fatigue (p = 0.0004), pain (p = 0.02), insomnia (p < 0.0001), dyspnea (p = 0.001), and no significant effect on nausea/vomiting, loss of appetite, constipation, or diarrhea. For dyspnea specifically, only within the mixed exercise program subgroup (as opposed to resistance alone or aerobic exercise alone) was an improvement effect in favor of the intervention group found.

This study concluded that it had confirmed that exercise interventions improve fatigue, pain, and insomnia in cancer, and that it had a novel finding of a benefit of exercise on dyspnea, but showed no effect on nausea/vomiting, loss of appetite, or constipation/diarrhea. The analysis did show significant results in the areas listed previously, although it is difficult to determine generalizability given the unknown sample characteristics. The effect of exercise on dyspnea was only seen with the mixed exercise groups, and it is difficult to understand who was included in that subgroup of patients; unclear, in particular, with cancer type and phase of case. The mechanism of dyspnea in a heme malignancy patient is very different, for example, than for a solid tumor patient, and there was a highly limited number of patients with lung cancer in this study. Not knowing phase of care also limits the ability to understand who this could be applied to. More exploration of the effect of exercise on dyspnea should be undertaken to reach solid conclusions, but this analysis does suggest that the exploration is warranted.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• It can be argued, also, that the search process itself had limitations by using only studies that measured outcomes from the two tools they chose and would limit a  number of high-quality studies using other tools.

With regard to dyspnea specifically, the nurse should be aware that there is a possibility that exercise may have an impact on dyspnea for some patients. It is unclear who these patients are, or what exercise regimens are most affected, so no clear recommendation can be provided to patients at this time based on this particular study.