Exercise

Databases searched were AMED, EMBASE, MEDLINE, and PubMed via the Ovid platform and CINAHL via EBSCO.

Search keywords were oncology, chemotherapy, radiotherapy, strength training, aerobic exercise, walking program, physical activity, and fatigue.

Studies were included if they reported 

• An acute or rehab hospital setting
• A controlled trial
• An outcome measure of fatigue
• Sufficient exercise intensity to have a physiologic effect.

Studies were excluded if they reported additional diversional interventions.

Initially, 2,954 studies were retrieved. After exclusions, there was a final set of five studies. The PEDro scale was applied for evaluation of study quality.

• The final five trials included 269 patients with various cancer types.
• Sample sizes ranged from 22 to 104 patients.

• Overall study quality was low, with scores being an average of 4.6 out of 10 possible points.
• Four trials were included in the meta-analysis. Findings for fatigue showed a standardized mean difference of -0.22 (95% confidence interval [-0.62, 0.08]; p = 0.13).
• The most common fatigue measures were the Brief Fatigue Inventory (BFI) and visual analog scale (VAS).
• All interventions involved aerobic exercise.
• There were no between-group effects seen for other symptoms analyzed.

This review showed no significant effect of aerobic exercise interventions for fatigue outcomes in hospitalized patients with cancer. As this study only included hospitalized patients, the findings may not be applicable in other patient groups.

The study was limited by the small number of included trials, with most having small sample sizes.

Effectiveness of exercise for fatigue may vary greatly depending on the phase of care and time in the cancer disease trajectory at which the intervention is provided. Lack of significant positive findings here may be related to the timing of the intervention with all patients in acute or rehabilitation hospitals.

To evaluate the effect of types of exercise on cancer-related fatigue.

Only randomized, controlled trials studying the outcome variable of cancer-related fatigue were included.

Seven thousand two hundred forty-five articles met the initial selection criteria. A final sample of 44 studies was included. Two independent raters collected data, and the intensity of exercise was estimated using metabolic equivalent units (METs).  MET values for a given exercise were coded from the Compendium of Physical Activity.

• The total number of participants across all studies was 3,245.
• Twenty-five studies exclusively reported breast cancer survivors.
• Mean age was 53.8 years.
• Forty-six percent of patients were undergoing active cancer treatment.

Characteristics of the Interventions

• Average length of exercise was 11.5 weeks (standard deviation [SD] = 5.2 weeks), and average intensity was 5.6 MET.
• Twenty-four studies included only aerobic exercise, six included only resistance exercise, 11 included a combination of resistance and aerobics, and six used neuromuscular exercise, such as yoga or tai chi.
• Ten studies used a theoretical base:  transtheoretical model of behavior change, self-efficacy, Roy adaptation model, Payne adaptation model, and the Levine conservation model.

Fatigue Measurement

• Fatigue was measured in 30% of patients with the Functional Assessment of Cancer Therapy (FACT) questionnaire, 20% with the Piper Fatigue Scale, 13% with the Profile of Mood States (POMS), 11% with the Brief Fatigue Inventory (BFI), 11% with the European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QOL-C30), and 4% with the linear analog scale.

Regression analysis was used to identify factors that were related to the degree of fatigue modulation.  Significant factors were

• Adherence to a theoretical model (p < 0.001)
• Sample of older cancer survivors (p = 0.04)
• Moderate intensity resistance exercise use (3–6 MET) (p = 0.01).

Session length and number of exercise sessions were not significantly related to effects on fatigue.

Overall effect size of fatigue modulation was 0.31 (95% confidence interval [0.22, 0.4]).  Effect size was 0.39 among survivors of breast cancer and 0.42 among survivors of prostate cancer.  In other cancer types, there were few studies and very small effects, but analysis demonstrated a consistent effect in favor of exercise.

Resistance exercise of moderate intensity appears to be the most effective in reducing cancer-related fatigue. This finding can be useful in planning exercise interventions as well as further research. The report stated a dose response effect on fatigue with exercise; however, the number and length of sessions was not a predictor of the degree of change in fatigue. These two findings seem to be contradictory. This aspect was not discussed by the authors.

The finding that resistance exercise interventions of moderate intensity were more effective than low-intensity or aerobic exercise is contrary to current National Comprehensive Cancer Network (NCCN) and American Cancer Society (ACS) guidelines, which do not mention resistance exercise and emphasize aerobic exercise. Moderate resistance exercise, such as weight machines, resistance bands, or free weights, may be a type that patients can maintain more easily. Use of theoretical models that incorporate issues of exercise behavior and behavior change may be more effective in providing support for the psychological components of adhering to an exercise program.

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

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

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.                                                        

• 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: Active anti-tumor treatment

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.

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.

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.

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.

STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in children and adolescents with cancer

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, CINAHL, PsycINFO, Ovid, MEDLINE, ProQuest Dissertations and Theses, the Electronic Theses and Dissertations System, the Index to Taiwan Periodical Literature, Electronic Thesis and Dissertation System (Chinese)

KEYWORDS: experimental study, random study, quasi-experimental study, children, adolescents, pediatric, cancer, oncology, nonpharmacological interventions, massage, exercise, fitness, physical activity, cognitive-behavioral, stress management, energy conservation, sleep therapy, relaxation, distraction, psychoeducation, fatigue, cancer-related fatigue, loss of energy, levels of tiredness, tired, side effect, symptoms

INCLUSION CRITERIA: RCT or quasi-experimental studies; 1–18 years of age, experiencing cancer-related fatigue; maintenance stage or survivor stage; hospitalized or home; acute lymphoblastic leukemia (ALL)/acute myeloid leukemia (AML)/lymphoma/solid tumor; interventions with descriptions of length, frequency setting, and provider, and including activity enhancement, psychosocial interventions, cognitive behavioral therapy, stress management, relaxation, nutrition consultation, massage, or educational interventions; use of validated scales for cancer-related fatigue in outcomes

EXCLUSION CRITERIA: Written in languages other than English or Chinese

TOTAL REFERENCES RETRIEVED = 76

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Retrieved papers reviewed by two independent reviewers with a third for disagreements about methodologic validity

• FINAL NUMBER STUDIES INCLUDED =  6, 3 in meta-analysis
• SAMPLE RANGE ACROSS STUDIES: 9–60
• TOTAL PATIENTS INCLUDED IN REVIEW = 149
• KEY SAMPLE CHARACTERISTICS: Outpatient and hospitalized children; ALL, solid tumor, AML, and lymphoma; ALL most common; varied disease stage; range from first cycle of chemo to survivor; five studies in the United States, one in Taiwan; home, community, and hospital setting; interventions of exercise-training, physical activity, massage, health education, and exercise training

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Pediatrics

Two studies showed no significance in decreasing total fatigue with exercise. Two studies suggested exercise reduced general fatigue (p < .01). No significance was found for sleep/rest fatigue or cognitive fatigue. Study of massage showed no effect on fatigue. Final study used nurse education session on fatigue versus UC with reports that interventions were “effective.”

No study reduced total fatigue in any population. General fatigue was the only fatigue measure with significant improvement in some studies.

The phases of care, tumor type, and age varied. Children may not have had an ability to differentiate fatigue and relaxation, making fatigue perhaps difficult to measure.

Exercise may be a safe intervention for improving general fatigue in children and adolescents experiencing cancer-related fatigue.

Databases searched were MEDLINE, CANCERLIT, Cochrane Central Register of Controlled Trials (CENTRAL), Dissertation Abstracts, PsycINFO, SPORTDiscus, HealthSTAR, Clinical Evidence, and CINAHL through 2002. The authors also searched the National Institutes of Health (NIH) database of funded studies from 1986 through 2002 and conducted hand searches of selected journals.

Thirty primary study reports (24 in the published literature and the remainder in unpublished dissertations and presentation papers) contained sufficient information to be included in the quantitative analysis. Thirteen studies were designed as single-group pre/post research; the remainder compared at least two groups of patients. Only one two-group study did not randomly assign patients to study arms. Comparisons groups were most often described as having received usual care. Outcomes were quality of life, physical functional ability, fatigue, symptoms other than fatigue, mood, body composition, and exercise behavior. 

Twenty-one of 30 studies tested supervised exercise interventions rather than home-based exercise. Supervised exercise was most often scheduled three times per week, and in 16 of the 21 studies of supervised exercise, the exercise program lasted longer than 10 weeks. Supervised exercise generally included aerobic activity (e.g., walking and cycling) and less often included resistance or flexibility exercise. Mixed types of aerobic exercise were used in several studies. The exercise intervention in most studies was of moderate intensity to achieve approximately 30% to 70% of maximum oxygen consumption.

• In 13 studies, the sample was comprised exclusively of women with breast cancer, and, in five other studies, women with breast cancer comprised more than half of the patients.
• Patients with other cancers were included less commonly, and few studies included patients with more advanced cancer, older patients, or minority patients.
• Sample sizes ranged from five to 155 patients.
• Age ranged from 31 to 71 years.

The effect size estimate for the outcome of fatigue in the two-group comparisons was small and not statistically significant (standardized mean difference [SMD] = 0.11). However, the effect size estimate for the outcome of fatigue in the single group comparisons of pre- and posttest was larger (SMD = 0.27) and remained statistically significant under both the assumption that there was no correlation between participants’ pre- and posttest scores and that pre- and posttest scores were strongly correlated (r = 0.80).

Effect sizes among only control group participants were very small but negative; this observation may lend some support to the validity of meta-analytic findings from single-group designs.

The small, nonsignificant effect size for exercise on the outcome of fatigue may have occurred due to heterogeneity in the exercise characteristics and intervention dose, varied samples, diverse measures of outcomes, and variable outcome assessment timing.

Databases searched were MEDLINE, CANCERLIT, CINAHL, HERACLES, PsycINFO, and SPORTDiscus through 1997. Studies restricted solely to movement therapy and/or stretching/flexibility exercises for rehabilitation of range of motion were excluded. Studies were also excluded if they presented insufficient detail to allow for critical review.

Eighteen intervention studies (10 quasiexperimental and eight experimental designs) of physical exercise designed to improve cardiovascular and/or muscular fitness were included.

Outcomes were fatigue, health-related quality of life, symptom distress, immune function, physical exercise capacity (maximal oxygen consumption), and other physical performance measures.

Treatment evaluated cycle ergometer (eight studies), walking either alone or in combination with some other exercise mode (six studies), resistance training (one study), and unspecified (three studies).

Length of the intervention was 12 weeks or less in 14 studies, between four and six months in three studies, and one year in one study. Exercise was supervised (13 studies), unsupervised home-based (three studies), and partially supervised (two studies).

• The sample sizes ranged from eight to 70 participants.
• Most of the studies were conducted in patients with or survivors of breast cancer or those who were predominantly stage I and II.
• A few studies evaluated exercise in patients with leukemia following allogeneic stem cell transplantation and in patients with solid tumors following autologous stem cell transplantation.
• Single studies were found for survivors of head and neck, colorectal, and childhood cancer.

The reviewed studies indicated promising effects on both physiological and psychological outcomes. Three studies reported a significant reduction in fatigue. Although effect sizes could not be summarized across studies due to the diversity of outcomes with small numbers of effect sizes, the effects appeared to be robust and clinically significant.

• Small convenience samples were used.
• The study design lacked appropriate control groups.
• The range of cancer sites was restricted. 
• The intervention period was short (the exercise treatment lasted 12 weeks or less in most studies).

Additional studies are needed to examine the effect of exercise, specifically on the endpoint of fatigue.

STUDY PURPOSE: To evaluate the effects of exercise on patients with colorectal cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 5 studies, 2 in meta-analysis 
• TOTAL PATIENTS INCLUDED IN REVIEW = 238
• SAMPLE RANGE ACROSS STUDIES: 18–102
• KEY SAMPLE CHARACTERISTICS: All had colorectal cancer.

PHASE OF CARE: Not specified or not applicable

Meta-analysis of three studies showed no significant overall effect of exercise on fatigue or quality of life. Exercise was associated with improved physical fitness (p = 0.0006).

Exercise was shown to be effective in improving physical fitness; however, physical fitness did not have a significant effect on fatigue in patients with colorectal cancer in this study.

• Limited number of studies included
• High heterogeneity
• Low sample sizes

Exercise has been shown to improve fatigue in multiple patient groups. This review was limited by the small number of studies limiting samples to patients with colorectal cancer.

To evaluate the effect of exercise on cancer-related fatigue during and after cancer treatment. This was an update of a study from 2008. A secondary objective, subject to available data, was to explore the effect of exercise in different types of cancer populations.

Databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), CINAHL (1982 to March 2011), British Nursing Index (January 1984 to March 2011), AMED (1985 to March 2011), SIGLE (1980 to March 2011), and Dissertation Abstracts International (1861 to March 2011).  The authors also searched references of all articles; hand searched the following journals up to April 2011: Cancer, Journal of Clinical Oncology, Psycho-Oncology, Cancer Practice, Oncology Nursing Forum; and searched unpublished literature through searches of conference proceedings up to June 2011.

Appendix 1 details the keywords searched, including expanded neoplasms, leukemia, lymphoma radiation therapy, bone marrow transplantation, exercise, movement, and fatigue.

Studies were included in the review if 

• They evaluated and reported the effect of physical exercise on cancer-related fatigue
• They compared exercise with no exercise, a usual care group (i.e., no specific exercise program prescribed), or an alternative treatment or exercise regime for fatigue associated with cancer
• The intervention took place in any setting and was delivered to a group or individual participant
• Any type of physical exercise, including aerobic exercise, strength training, and flexibility exercises, was performed
• They investigated an exercise program accompanied by attempts to promote participant engagement.

Studies were excluded if they explored multidimensional programs in which the effects of exercise alone could not be determined and if a specific exercise program was not described and participants were only given advice or education about the potential benefits of exercise.

Fifty-eight new references plus 28 from the original review were retrieved.

Two independent reviewers reached 100% consensus; they assessed the methodological quality of the studies from the previous review.

• Fifty-six total studies were included in the final review (28 new plus 28 from the original review).
• The sample sizes ranged from 10 to 242 participants; the total number of participants was 4,068.
• Participants had various cancer diagnoses and various timing since diagnosis.
• The majority of participants had breast cancer.
• There was a mix of female and male patients; however, 29 of 56 studies included only females.
• Mean age ranged from 39 to 70 years (mostly in the 50s).

Patients were undergoing multiple phases of care.

Statistically significant improvements in fatigue were identified following an exercise program performed either during cancer therapy (standardized mean difference [SMD] = -0.23; 95% confidence interval [CI] [-0.23, -0.33]) or following cancer therapy (SMD = -0.44; 95% CI [-0.79, -0.09]). Statistically significant beneficial effects were identified specific to breast cancer (n = 672) and prostate cancer (n = 239) populations, but not for those with hematological malignancies (n = 114). Statistically beneficial effects were identified following aerobic training but not following resistance training or low-intensity mind-body interventions.

Sufficient evidence exists to support the recommendation of aerobic exercise during and after treatment for patients with breast or prostate cancer. Insufficient evidence exists to support the recommendation of hematological malignancies or other solid tumors. Exercise modalities other than aerobic exercise do not have sufficient evidence to support their recommendation.

Most studies

• Had small sample sizes
• Did not blind the intervention
• Provided little information about those who refused to participate
• Included self-reports
• Had exercise programs that did not reach the current recommended amounts for adults.

Aerobic exercise is recommended for appropriate patients during and after treatment for breast or prostate cancer. Consider recommending exercise for other solid tumors. Research is needed for various cancer types and stages, including palliative care and for types and duration of exercise.

Databases searched were the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL, British Nursing Index, AMED, SIGLE, and Dissertation Abstracts International through July 2007.

Twenty-eight published randomized, controlled trials investigating the effect of exercise on cancer-related fatigue in adults were identified.

Outcomes

Fatigue was assessed using various self-report measures, including the Functional Assessment of Cancer Therapy-Fatigue (FACT-F), fatigue subscale of the POMS, the Piper Fatigue Scale, and the Brief Fatigue Inventory (BFI). Only three studies incorporated more than one fatigue outcome measure.

Treatment Evaluated

Mode, intensity, and timing of exercise differed across studies. Thirteen studies investigated home-based/unsupervised exercise programs, whereas 16 studies investigated supervised, institutionally-based exercise programs. Some studies investigating supervised exercise programs encouraged participants to undertake additional home-based exercise. The mode of aerobic exercise included walking, stationary cycling, or a range of modalities. Three studies included strength training as a component of the exercise program, and two studies investigated the outcomes of resistance training in isolation. Two studies included flexibility training as a component of the exercise program, although several studies incorporated routine stretching as part of the warm-up, cool-down, or both. Yoga was investigated in two trials and seated exercise in one. The intensity of exercise varied greatly across studies, with the comparison complicated by differences in the methods (e.g., heart rate monitoring, predicted oxygen uptake, and patient perceived effort) used to monitor intensity in each study. The length of the intervention also varied greatly, ranging from three to 32 weeks; the largest proportion of studies had an exercise intervention duration of 12 weeks.

• There were 2,083 participants. 
• Participants had various cancer diagnoses, although the majority of studies investigated breast cancer only.
• Nineteen of the 28 studies investigated participants with a specific cancer diagnosis and nine investigated participants with a range of diagnoses.
• The time since diagnosis and stage of treatment (active versus posttreatment) varied widely between studies and, in some cases, within studies.

Using posttest means and mean change scores from the pre- posttests, exercise was found to be statistically significantly more effective than the control intervention in the management of fatigue. In separate analyses, dividing studies based on whether the intervention was performed during or following cancer treatment, exercise was consistently statistically significantly found to be more effective for fatigue than the control intervention. Similarly, positive results concerning the effects of exercise for fatigue were also found when only those studies performed in women with breast cancer were examined. Quantitative comparison of fatigue intervention outcomes in other disease-specific groupings was not possible due to limitations in the available data. However, two studies of the effects of exercise on fatigue in prostate cancer populations reported mixed results. A four-week, home-based walking program had no significant effect on fatigue, whereas a 12-week supervised resistance training program produced a statistically significant improvement in the exercise group compared to the control group. No statistically significant improvements in fatigue were observed in patients with colorectal cancer who were prescribed a 16-week, home-based cardiovascular and flexibility program; in patients with lymphoma attending a weekly supervised yoga session; or in patients with multiple myeloma receiving an individualized 32-week, home-based strength and aerobic training program.  Follow-up assessment of long-term outcomes was limited, with 18 of 28 studies failing to assess outcomes beyond the end of the intervention period. From the remaining ten studies that included a follow-up assessment, three did not present the follow-up data in the original publication.

Methodologic quality of the studies was modest (the majority of the studies assigned an Oxford Quality Score of 2 or 3 on the 0–5 scale, with higher scores indicating better methodologic quality).

• All studies lost points in the scoring of methodologic quality due to the failure of the design to conceal group allocation of study participants to the exercise intervention.
• The authors also noted that observer blinding was rarely reported in the included studies.
• Several studies had methodologic flaws, such as providing incomplete descriptions of dropouts or inadequate descriptions of the methods of randomization.
• Although 20 of the 28 studies provided some data on adherence to the exercise interventions, methods for reporting adherence varied between studies, making it difficult to control for adherence when comparing results across studies.

• Study Design: Both randomized and nonrandomized studies were considered to acquire a complete understanding of the topic area. The key inclusion criterion was that all studies, regardless of design, had to include some form of physical exercise training for patients surgically treated for NSCLC. This review intended to include quantitative, qualitative, and mixed-method study designs.
• Participants: Studies that included participants diagnosed with resectable NSCLC were included in this review. Exercise interventions were defined as supervised or unsupervised inpatient, outpatient, community- or home-based interventions that included any type of exercise training applied to patients surgically treated for NSCLC. Some studies included additional components. Four studies included education, four included smoking cessation, and three used phone calls.
• Outcome measures: All outcomes measured were recorded in this review. 

• Study Design: All poster abstracts and non-English full-text articles were excluded.  
• Participants: Studies with < 65% of the patient population were excluded to ensure a consistent sample.

PHASE OF CARE: Multiple phases of care

• Fatigue increase was noted in studies presurgery to immediately postsurgery, yet the authors did not cite which studies.  
• Fatigue reduction was found from baseline to postintervention in three out of five studies. The authors note that in two studies, fatigue severity from baseline to postintervention was not reduced and that each of these studies were of a different type of exercise (resistance) with different intervention timing (preoperative).
• Fatigue reduction was noted to be sustained in two participants who did not receive adjuvant therapy as compared to those who underwent adjuvant treatment.

Preliminary findings from the review suggest that intervention via exercise compared with usual care pre- and postsurgery may reduce fatigue. The results from the systematic review show the infancy of this particular field of study with very few studies included for analysis, with the majority of studies being of observational methodology. In addition, studies included a wide range of exercise prescriptions.

The field of treatment for fatigue in the surgical NSCLC population is in its infancy. In one study of the reviewer’s expertise, it is noted that the article was labeled as an unsupervised intervention when the article discusses the actual supervision of subjects participating in the exercise intervention.

Additional study of the best exercise prescription for fatigue management is needed related to patients undergoing surgery. The best timing for such interventions is not clear.

STUDY PURPOSE: To evaluate if a dose response effect of exercise on inflammation and fatigue in cancer survivors exists

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED =  31 included in meta-regression 
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,816
• SAMPLE RANGE ACROSS STUDIES: 16–500
• KEY SAMPLE CHARACTERISTICS: Participants had various tumor types, and the study included individuals in and post active treatment with chemotherapy and/or radiotherapy and/or surgery.

PHASE OF CARE: Multiple phases of care

Exercise interventions included aerobic, resistance, flexibility, and combinations of these. Interventions included supervised, unsupervised, home-based, hospital- or other setting–based, and group or individual exercise sessions. Moderate quality evidence that exercise had a positive effect on fatigue compared to usual care existed (standard mean deviation = 0.32, 95% confidence interval [0.13, 0.52]). A combination of aerobic and resistance provided the largest treatment effect. Aerobic intensity was negatively related to treatment effect. No relationships existed between resistance exercise and treatment effect.

Exercise has a beneficial effect on fatigue. Moderate intensity exercise appears to be most beneficial.

Varied study quality and sample sizes

This analysis adds to the body of evidence that exercise has a beneficial effect on fatigue among patients with cancer. This study suggests that moderate level aerobic exercise is more beneficial than more intense exercise. This information can be used to guide patient counseling and teaching to incorporate moderate exercise into daily routines.

STUDY PURPOSE: To examine the effects of behavioral techniques (e.g., behavioral therapy, cognitive therapy, mind-body and relaxation techniques, counseling, social support, hypnosis, biofeedback, exercise, physical exercise (PhysEx), aerobic exercise, physical activity, motor activity) on psychosocial functioning outcome measures, such as fatigue, depression, anxiety, body image, and stress, and on health-related quality of life

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED =  56 studies: 39 studies of behavioral techniques; 14 studies of physical exercise; 3 studies of both 
• TOTAL PATIENTS INCLUDED IN REVIEW = Not reported. This meta-analysis reported the number of patients by each randomized, controlled trial: 5,462 (behavioral intervention patients), 1,457 (PhysEx patients), 6,919 (total)
• SAMPLE RANGE ACROSS STUDIES: 28–558 (behavioral intervention), 22–242 (PhysEx)
• KEY SAMPLE CHARACTERISTICS: 33 studies of patients with nonmetastatic cancer, 4 studies of patients with metastatic cancer, 5 studies with a mix of patients

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Elder care, palliative care

Behavioral techniques affect specific aspects of psychosocial functioning but have a minor, insignificant effect on health-related quality of life. PhysEx has a positive effect on health-related quality of life. Behavioral techniques demonstrated a moderately significant effect on anxiety and depression and showed a significant but small effect on fatigue. PhysEx was effective for fatigue and showed a positive effect for depression.

• No quality evaluation
• High heterogeneity
• The variety of behavioral interventions made it challenging to select which was more effective than others (e.g., telephone counseling, telephone support, education, body-mind social support self-help, therapeutic groups by telephone, nurse self-efficacy).
• Studies were included only through 2008—more recent evidence has shown some different findings.
• High heterogeneity in behavioral technique analysis
• The studies used a wide range of different measurements and interventions.

A range of behavioral techniques may be effective for patients with breast cancer and fatigue, depression, and depressed body image. PhysEx was shown to improve health-related quality of life, fatigue, anxiety, and depression. Recognizing the symptoms of patients with breast cancer was emphasized as having positive effects (e.g., feeling relieved, hearing helpful strategies addressing quality of life and psychosocial problems).

• FINAL NUMBER STUDIES INCLUDED = 15
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,077
• KEY SAMPLE CHARACTERISTICS: Six studies addressed RE during treatment, and four were conducted during androgen deprivation therapy, one during chemotherapy, and two during radiation therapy. The remaining nine studies focused on RE in participants following the completion of active cancer treatment with a curative intent. This included participants with BRCA (n = 6), prostate cancer (n = 4), head and neck cancer (n = 3), lung cancer (n = 1), and a mixed group (n = 1).

Pertaining to fatigue outcomes, two randomized, controlled design studies showed insignificant changes in fatigue with BRCA survivors. One nonrandomized trial showed insignificant change in patients with prostate cancer. Two randomized, controlled studies showed moderate to large effect sizes in patients with BRCA and prostate cancer patients over time after three and six months. Large effects were seen in the Schmidt study with BRCA survivors. A moderate effect was seen in the Segal study of patients with prostate cancer receiving androgen deprivation therapy. Small effect sizes were seen in BRCA patients undergoing chemotherapy at a midpoint and post-treatment.

The results of this study suggested that RE may improve fatigue in patients with BRCA undergoing chemotherapy, patients with prostate cancer undergoing androgen deprivation therapy, and in BRCA survivors.

Although methodologic quality was good overall, an increase of intent-to-treat analyses of future randomized, controlled trials is needed.

Few studies examined this type of exercise, and additional study is indicated.

STUDY PURPOSE: To evaluate the evidence regarding the effects of physical activity in cancer survivors

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 54 in qualitative review and 34 in meta-analysis
• SAMPLE RANGE ACROSS STUDIES: Median sample size was 93 patients
• KEY SAMPLE CHARACTERISTICS: Various tumor types with the most common being breast, colorectal, and endometrial; mean age was 55 years (range = 39–74 years)

PHASE OF CARE: Late effects and survivorship

The median duration of the exercise intervention was 13 weeks (range = 3–60). A meta-analysis of results for body mass index, body weight, and other physiologic measures was reported. A meta-analysis was completed for three studies regarding effect on fatigue, and slightly reduced fatigue was demonstrated using the Piper Fatigue Scale (p = 0.03). However, sample sizes were small in these studies. A meta-analysis of effects on depression included four studies and showed reduced depression using the Beck Depression Inventory (p < 0.01). Three of the four studies had relatively small sample sizes. Quality of life outcomes showed improved Short Form-36 physical functioning scores (p = 0.01) and mental health scores (p = 0.01). The authors noted substantially different results based on the measurement scales used in the included studies.

This analysis supports the effectiveness of exercise in general on cancer-related fatigue and depression.

It was suggested that the intensity of the exercise could affect results, and intensity was not consistently reported in the studies included. The mean duration of the intervention was as high as 13 weeks and as low as three weeks. The relatively short duration limits the ability to assess long-term outcomes. Most studies were completed in patients with breast cancer. There were very few studies in the analysis, and it was surprising that more studies were not found for inclusion. The studies of fatigue and depression included in this meta-analysis had relatively small sample sizes.

This report adds to the already large body of evidence demonstrating that exercise can improve fatigue and depression outcomes in cancer survivors. Current evidence, however, involves relatively short-term interventions and assessments. For long-term benefits, it is generally believed that physical activity needs to be incorporated into everyday life. Nursing interventions and future research should consider the examination of approaches to address this need for ongoing behavior change. Most exercise studies continue to involve women with breast cancer. Although there is some evidence in other groups, it is limited. Continued research to examine exercise's effects in more varied patients would be beneficial.

STUDY PURPOSE: To assess the effects of aerobic and resistance exercise on treatment-related side effects during adjuvant treatment for breast cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 32 in review, 26 in meta-analysis
• TOTAL PATIENTS INCLUDED IN REVIEW = 2,626
• SAMPLE RANGE ACROSS STUDIES: 20–242 patients
• KEY SAMPLE CHARACTERISTICS: All were receiving adjuvant treatment for breast cancer

PHASE OF CARE: Active antitumor treatment

• Fatigue: SMD for in favor of exercise was –0.28 (95% confidence interval [CI] [–0.41, –0.16]) with moderate quality evidence (19 studies including 1,698 women).
• Depression: The difference with exercise was not significant, and evidence quality was moderate (5 studies including 674 women).
• Cognitive function assessed with Trail Making Test: MD –11.55 (95% CI [–22.06, –1.05]) with low quality evidence (2 studies including 213 women)
• Anxiety: Three studies assessed anxiety. A meta-analysis of two studies found no significant difference with exercise.
• A variety of other outcomes were assessed and reported, such as physical fitness, quality of life, and mood.

The findings show a moderate effect of exercise on fatigue among women receiving adjuvant treatment for breast cancer. No significant effects were seen for depression or anxiety. A statistically significant effect for cognitive function was found; however, the evidence was deemed to be of low quality.

• High heterogeneity
• The authors reported lack of sufficient information in reports to make clear judgments about potential bias.

Exercise probably reduces fatigue and improves physical fitness among women during treatment for breast cancer. Adherence to exercise can be a challenge, and implementation of exercise recommendations or programs will need to address factors to foster exercise participation to be successful.

The MEDLINE database was searched through June 2004 to identify experimental and quasiexperimental studies of exercise (cardiovascular and/or resistance training) during and following cancer treatment.

Twenty-six published studies, reflecting 18 experimental or quasiexperimental trials of exercise during cancer treatment and eight studies of exercise after cancer treatment, were identified. Of the 18 trials during treatment, 14 used some type of cardiovascular training; two used mixed training with cardiovascular, resistance, and flexibility exercise; and two applied a structured resistance training program. Of the eight trials of exercise after cancer treatment, all used cardiovascular or cardiovascular plus resistance training. The duration of the intervention ranged from two to 28 weeks, and the frequency of the exercise intervention ranged from daily to two times per week.

Outcomes were fatigue, health-related quality of life, symptom distress, psychological distress, body composition, physical exercise capacity (maximal oxygen consumption), immunologic parameters, and muscle strength. Treatment evaluated cardiovascular and/or resistance exercise.

• Most of the studies were conducted in women with breast cancer or in samples with mixed solid tumors; single studies in patients with prostate cancer, colorectal cancer, and hematologic malignancies were noted.
• Sample sizes ranged from five to 155 participants.
• Average participant age ranged from 19 to 77 years.

Five of 18 studies of exercise during cancer treatment specifically found improvements in fatigue, and most of these studies were in women with breast cancer. Of note, a trial of resistance training three times per week in men with prostate cancer undergoing androgen depletion therapy showed improvements in fatigue after a 12-week program. Of the eight studies of exercise following cancer treatment, none reported statistically significant improvements in fatigue, but there were improvements in functional status, quality of life, psychological distress, strength, and capacity.

Although recent evidence supports the use of resistance exercise during cancer management as an exercise mode to counteract adverse effects of the disease and treatment, most of the studies were conducted using cardiovascular training. Promising results in terms of fatigue and other outcomes of a short-term resistance exercise program on patients diagnosed with prostate cancer and undertaking androgen-depletion therapy have been reported.

Databases searched were PsycINFO, MEDLINE, and CINAHL through November 2005.

Seventeen randomized, controlled trials of activity-based interventions were included in the meta-analysis. Activity-based interventions included professionally supervised programs and unsupervised, home-based programs designed to promote exercise activity. To be included, a trial must have included a controlled comparison arm with either a no treatment or placebo condition, must have been a study of an activity-based intervention in adults diagnosed with cancer, one of the study outcomes must have been fatigue or the related constructs of vitality or vigor, and the reported results must have included significant testing of differences between an intervention condition and a control condition.

In all 17 studies in which fatigue, vitality, or vigor was assessed as an outcome, more than three-quarters of the studies measured the construct of fatigue. Fatigue, vitality, or vigor was a primary outcome in slightly more than half of all the studies of activity-based interventions, and it was a secondary outcome in the remainder. Activity-based interventions included professionally supervised programs and unsupervised, home-based programs designed to promote exercise activity. There were numerous differences across these studies in the type of exercise (e.g., aerobic or resistance), mode (e.g., walking or cycle ergometer), and intensity of exercise.

Sixteen of the 17 studies used no intervention control groups or wait-list control groups, and one study used a placebo control condition that involved stretching exercises. Sixty-one percent of the studies provided a home-based exercise intervention and 39% provided supervised exercise programs. No study specified the levels of fatigue, vigor, or vitality used as the eligibility criterion.

• Ten of the 17 trials were in patients with breast cancer only.
• Eleven studies included patients undergoing or about to start chemotherapy and/or radiotherapy, and five included only patients who had completed treatment.
• With regard to disease severity, 10 studies included only patients with nonmetastatic disease, and the remaining studies either did not specify metastatic status or were not restricted in terms of metastatic status.
• The total sample size for each activity-based intervention study ranged from 14 to 155 patients (median = 50 patients).

The effect size for activity-based interventions was not statistically significant (d_w = 0.05; 95% confidence interval [CI] [-0.08, -0.19]), and there were no differences in effect sizes as a function of cancer type (breast cancer:  d_w = 0.12; 95% CI [-0.15, -0.30]) or for all other types (d_w = 0.06; 95% CI [-0.11, -0.24]) or intervention modality (home-based:  d_w = 0.04; 95% CI [-0.13, -0.22]; supervised:  d_w = 0.16; 95% CI [-0.09, -0.41]).

• As with all meta-analyses of exercise that pool results across studies, there was variability in the type, mode, and intensity of exercise, as well as variation in the duration of the intervention and whether the intervention was supervised or home-based.
• Few studies provided an analysis of adherence effects in the intervention group, and no study reviewed by the authors required study participants to have a clinically significant level of fatigue. As a result, the possibility exists that many participants were experiencing little or no fatigue at the time of study entry, thus limiting the ability of these study designs to detect intervention effects.

The current results conflict with the results and conclusions made by other authors who conducted narrative systematic reviews of single studies, with meta-analyses that included both randomized and nonrandomized trials, and with the results of another meta-analysis published more recently. Close comparison of the studies reviewed by the current authors with those reviewed by Cramp and Daniel suggest that the conclusions were different in part because different randomized, controlled trials were examined. Six randomized, controlled trials of activity-based interventions with favorable effects on the outcome of cancer-related fatigue were published after the current authors completed their electronic database searches. In addition, the search strategies used by the current authors excluded two randomized, controlled trials that reported activity interventions (Galantino 2003; Dimeo 2004) that met the criteria for inclusion in their meta-analysis. Moreover, a meta-analysis published in April 2008 by the Cochrane Collaboration that included these more recently published trials together with the two trials that were inadvertently excluded by the current authors concluded that there was a small but statistically significant effect for exercise (standardized mean difference = -0.23; 95% CI [-0.33, -0.13]).

STUDY PURPOSE: To conduct a systematic review and meta-analysis on nonpharmacologic interventions (psychosocial and exercise) for cancer-related fatigue (CRF)

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 57 RCTs included in the meta-analysis, 116 published articles for systematic review
• TOTAL PATIENTS INCLUDED IN REVIEW = 4,621 in meta-analysis
• SAMPLE RANGE ACROSS STUDIES: Not reported
• KEY SAMPLE CHARACTERISTICS: Of the patients, 33%–45% had breast cancer and were in a mix of stages and treatment statuses.

PHASE OF CARE: Multiple phases of care

Both psychosocial interventions and exercise showed benefit in CRF. Psychosocial interventions had a small to moderate effect on fatigue; exercise had a moderate effect. No significant differences existed in the effect of exercise on CRF between psychosocial interventions and exercise. Exercise showed a stronger effect during treatment than post-treatment, whereas psychosocial interventions showed a stronger effect post-treatment.

Both psychosocial interventions and exercise are beneficial in ameliorating CRF. A multimodal approach across all phases of treatment is best.

• Limited search
• High heterogeneity
• Somewhat dated review; latest published article included was 2006

Provides additional support for psychosocial interventions and exercise for CRF. Because of the heterogeneity of interventions, supporting one type of psychosocial intervention or exercise regime over another is difficult. Nurses can incorporate interventions acceptable to patients.

To systematically review the literature for benefits of exercise in patients with prostate cancer.

Databases searched were PubMed, CINAHL, and Google Scholar.

Search keywords were exercise, physical activity, prostate cancer, and training and all word derivatives.

Studies were included if they 

• Were full, published articles
• Included patients with prostate cancer
• Involved an exercise intervention of at least four weeks duration
• Reported changes in body composition, fitness, quality of life (QOL), and/or fatigue.

The total volume of studies retrieved and excluded was not provided. An adaptation of methods reported by Sackett was used to evaluate methodological rigor, involving six criteria. How the criteria were applied by investigators was not described.

• A sample of 12 studies was included, involving a total of 360 patients.
• Study sample sizes ranged from 10 to 82 patients.
• All patients had prostate cancer.
• Demographics were not reported in all studies used; however, most patients were said to be Caucasian, married, and between ages 66 and 72 years.

Seven studies reported group-based exercise. The authors reported that most of these patients showed significant improvement in some QOL measures and fatigue.  Five studies reported home-based exercise. These showed no significant increase in QOL, and two of these reported significant reduction in fatigue.  Resistance, aerobic, and combined types of exercise appeared to be similarly effective. The timing of exercise interventions related to cancer treatment were not described. Comparative findings regarding changes in muscle strength and endurance were provided.

There is relatively strong to strong evidence that exercise performed a minimum of two to three days per week can significantly improve physical fitness, functional performance, and QOL and reduce fatigue in patients with prostate cancer.

The context in which the exercise was performed and type of exercise (aerobic, resistance, or combined) may mediate the magnitude of benefit derived.  Group-based exercise appeared to offer greater benefit than home-based programs in the studies included.

Findings suggested that exercise recommendations should be a part of care for survivors of prostate cancer for fitness, QOL, and fatigue benefits. Group-based activity may have greater benefit than individual home-based exercise recommendations.

Databases searched were MEDLINE, CINAHL, Cochrane Library, CANCERLIT, and PEDro through June 2004 to identify randomized, controlled trials and controlled trials (those with a comparison group but without explicit use of randomization for purposes of group allocation).

To be included in the review, the trials had to have examined the effects of physical exercise after surgery or during or after chemotherapy, radiotherapy, and/or hormonal therapy. Only exercise interventions designed to improve endurance or muscular strength were included.

Studies of relaxing exercises (e.g., yoga or tai-chi) were excluded.

The methodologic quality (using the Delphi criteria list—a set of nine criteria for quality assessment of clinical trials) and substantive results of 34 randomized, controlled trials and controlled trials was examined. Of the 34 studies examined, 22 examined the effectiveness of physical exercise during medical treatment, whereas 12 focused on the period after medical treatment.

Outcomes were fatigue, health-related quality of life, symptom distress, psychological distress, body composition, physical exercise capacity (maximal oxygen consumption [VO₂] max), self-reported exercise/physical activity level, and other physical performance measures, such as walk time. Various physical exercise modalities were used, differing in type (walking, cycling, swimming, resistive exercises, or combined exercises), intensity (with most programs at 50% to 90% of the estimated VO₂ maximum heart rate), frequency (ranging from two times per week to up to two times daily), and duration (ranging from two weeks up to one year). In some studies, the experimental group was compared with a group that received some form of training of a lesser intensity, frequency, and/or duration (e.g., stretching, self-directed exercises, strength exercises, aerobic exercise of a lesser intensity, swimming, behavioral therapy). In other studies, the comparison group did not receive any exercise program or advice, was on a waiting list, or participated in a cross-over trial.

The studies during medical treatment were divided into three subcategories: (1) exercise during breast cancer treatment, (2) exercise during bone marrow and peripheral blood stem cell transplantation, and (3) exercise during medical treatment for mixed solid tumors. The studies after medical treatment were divided into those involving exercise after breast cancer treatment and exercise after medical treatment for other solid tumors. The authors used this strategy to reflect not only differences in cancer diagnosis and the timing of physical exercise programs, but also possible differences in motivation, safety, feasibility and efficacy of exercise. The sample sizes for the intervention groups ranged from 12 to 188 participants.

A clinically significant or statistically significant positive effect of physical activity specifically on fatigue was noted during breast cancer treatment  (three studies) or after breast cancer treatment (two studies), and during treatment (three studies) or after treatment (one study) in a mixed solid tumor population. The median quality criteria score on the Delphi list (range 1–7) was four for studies of exercise during and after cancer treatment. Twenty-five of the trials satisfied more than three criteria on the Delphi criteria list. The most commonly observed methodologic problems were with concealment of treatment allocation, blinding of the outcome assessor, and failure to use an intention-to-treat data analysis strategy.

Overall, the authors concluded that the included trials were of moderate methodologic quality, with a trend toward more methodologic rigor in more recent studies.

To determine if patients receiving treatment for cancer experienced less treatment-related fatigue if they participated in a regular committed exercise regimen, compared to those who did not exercise regularly.

Databases searched were CINAHL, MEDLINE, Ovid, and ProQuest between January 2000 and October 2006.

Search keywords were fatigue, cancer, and exercise.

Studies were included in the review if

• The date range was January 2000 to October 2006
• The participants were 18 years or older
• They were written in the English language
• They were published in peer-reviewed nursing and healthcare journals
• They were quantitative or qualitative studies.

Two unpublished doctoral dissertations were also included.

Initially, 400 articles addressing the topics of fatigue, cancer, and exercise were found. When the inclusion criteria were applied, 10 studies were included. Levels of evidence presented were established using the Priority Symptom Management (PRISM) system developed by the Oncology Nursing Society.  No meta-analysis was performed due to differing definitions and methods of measurement of fatigue across studies.  All studies demonstrated strong levels of evidence of PRISM level I or II. Brief summaries of study design, exercise regimen, outcomes, limitations, level of evidence, and study recommendations were provided. Studies were identified within two major categories: home-based exercise interventions and out-of-home exercise interventions.

• There were 523 total participants across 10 studies.
• Sample sizes of studies ranged from 12 to 108 participants.

The majority of studies (eight of 10) used home-based exercise interventions.

Eight of the studies had findings that supported exercise during treatment to reduce fatigue.  In the two studies that did not show differences in fatigue, one had a very small sample size and one showed poor patient adherence to the exercise regimen.

Exercise was generally well tolerated by participants, and there were no adverse events associated with exercise.

Components of the regimens that were found to be beneficial were

• Ease of treatment (home-based, use of own equipment, etc.)
• Interest in treatment (allowing patients to choose an aerobic activity of interest to them, such as biking, walking, swimming, etc.)
• Inclusion of a daily diary to record frequency and intensity of exercise, as well as other symptoms
• Design of a program based upon a physician’s assessment of individual abilities
• Participation in a group exercise program provided support and increased motivation.

Theoretical foundations of studies were reviewed. These included

• Transtheoretical Model
• Roy’s Adaptation Theory
• Adherence
• Multidimensional conceptual framework interrelating psychosocial and physiologic dimensions of fatigue.

The evidence suggested that an individualized exercise program should be included in the treatment of patients receiving chemotherapy and/or radiation therapy. Studies have not shown any adverse effects, such as increased fatigue or falls, as a result of exercise. Studies retrieved were limited to four types of cancer: multiple myeloma, breast, lung, and prostate. Studies reviewed encompassed both early and late stages of disease.

Common limitations found among the studies reviewed included

• Lack of a universal definition of fatigue
• Lack of a universal instrument or method to measure fatigue and evaluate the effectiveness of interventions.

Use of common definitions and methods of measurement of outcome variables is needed to further advance this area of study. Evidence supports the inclusion of scheduled exercise in the care plan of patients undergoing cancer treatment. It was noted that approximately 50% of healthy Americans have been shown to have difficulty initiating and maintaining an exercise program for more than three months. This suggests that individuals with cancer are likely to need professional support to begin and maintain an exercise program. Nurses’ awareness of the role of exercise can enable better education that benefits patients.

PubMed was searched to identify English or French language reports of randomized or controlled studies and meta-analyses concerning the benefits of physical activity in patients receiving cancer treatment. The dates encompassed by the search process were not specified.

Eleven randomized or controlled studies that had evaluated the effects of physical exercise on cancer-related fatigue as one of their primary or secondary objectives were identified for analysis. Varied patient-reported outcome measures were used to evaluate fatigue, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Piper Fatigue Scale, Functional Assessment of Cancer Therapy-Fatigue (FACT-F), or the Profile of Mood States (POMS) Fatigue-Inertia subscale. Studies evaluated aerobic exercise, strength training, or a combination of both. Supervised and home-based exercise interventions were studied, and the duration of exercise treatment ranged from only the duration of hospitalization to several months.

• The groups represented in these studies included survivors of breast cancer and individuals with prostate cancer, multiple myeloma, mixed solid tumors, lymphomas, breast cancer, and colon cancer.
• In total, 718 patients were represented across these studies, most without metastases.
• Age ranged from 18 to 77 years.
• Participants were either undergoing active cancer therapy or had completed therapy.
• Most study samples were small, with less than 50 participants.

Of the seven studies of exercise during active cancer therapy, five studies (all with less than 25 patients) found no significant differences in fatigue across the treatment period. A sixth study in a highly selected population of patients hospitalized for stem cell transplant noted that fatigue increased significantly in the control group but remained steady in the exercise group. The seventh study of men with prostate adenocarcinoma on hormone therapy and receiving strength training noted a statistically significant improvement in fatigue in patients receiving the strength training intervention.

In the posttreatment setting, three studies with small samples suggested that exercise (aerobic exercise of low or moderate intensity) or a motivational counseling intervention to increase home-based exercise and a small study in patients with breast and colon cancer who were three to 15 months posttreatment showed significant improvement in fatigue as a result of either low- or moderate-intensity exercise, compared to controls. An additional study in patients who had completed chemotherapy or surgery within the past month showed an improvement in aerobic fitness in the intervention group but a statistically significant increase in fatigue.

Taken together, these results suggested that there is no clear evidence that exercise during active treatment improves fatigue outcomes, although it may have a favorable effect on cardiorespiratory conditioning. The results of this review point to the possibility that a minimum of rest or mild activity is needed to promote some initial recovery from treatment-related fatigue before residual fatigue is addressed, but current studies provide no guidance on how long the interval should be between the end of chemotherapy and the start of exercise for therapeutic purposes.

STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in men with prostate cancer

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: PubMed, PsycINFO, CINAHL, Cochrane Central Trials Register and Embase, PsychExtra, SIGLE, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, World Health Organisation International Clinical Trials Registry Platform, EU Clinical Trials Register, MedNar, and reference lists of articles included in review

KEYWORDS: key concepts of prostate cancer, fatigue, non-pharmacological and nursing management, and various interventions; detailed search for PubMed included as appendix

INCLUSION CRITERIA: Adult men older than 18 years with prostate cancer at any stage of treatment; non-pharmacologic interventions including exercise, exercise with diet and lifestyle modification, education, and cognitive behavioral therapy; comparison to other non-pharmacologic interventions or usual care; experimental studies; fatigue as primary outcome of interest using existing validated tools to measure

EXCLUSION CRITERIA: Not stated

TOTAL REFERENCES RETRIEVED = 1,480

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two independent reviewers appraised studies; validity assessed with Johanna Briggs Institute Critical Appraisal Checklist for Randomised and Pseudo-Randomised Studies

• FINAL NUMBER STUDIES INCLUDED = 8
• SAMPLE RANGE ACROSS STUDIES: 21–240
• TOTAL PATIENTS INCLUDED IN REVIEW = 600
• KEY SAMPLE CHARACTERISTICS: Undergoing treatment for prostate cancer or completed treatment within past 12 months; age range 46–86 years

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Elder care

All studies were of high methodologic quality. Four out of five studies measuring physical activity found statistically significant fatigue reduction; the other study showed a trend toward fatigue reduction. Two studies concluded that cognitive behavioral therapy was effective in managing cancer-related fatigue. Two studies looking at education had mixed results. Brief nursing education was not significant in reducing fatigue, but intensive prostate-specific education was significant.

This report supports physical activity for managing cancer-related fatigue. Cognitive behavioral therapy and intensive focused education are also likely to be effective.

• Only eight studies included
• Variety in delivery of interventions and measurement of fatigue

Nurses should continue to recommend physical activity for management of cancer-related fatigue. Cognitive behavioral therapy and intensive education may be considered.

Databases searched were Cochrane Breast Cancer Specialised Register, MEDLINE, EMBASE, CINAHL, SPORTDiscus, PsycINFO, SIGLE, ProQuest Digital Dissertations, and Conference Papers Index through July 2004.

Treatment evaluated aerobic (walking or cycle ergometer interval training) or resistance exercise, or a combination of both. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually, or in groups.

To be included in this meta-analysis, the exercise intervention had to be of at least six weeks' duration and had to coincide with the adjuvant treatment regimen rather than follow it. Trials in which the exercise intervention was part of a complex intervention (e.g., complete decongestive lymphatic therapy) and trials restricted to local muscular endurance (e.g., training of shoulders, back, or legs only) instead of including all major muscle groups or restricted to stretching exercises were also excluded.

Seven randomized trials and two nonrandomized, controlled trials involving 452 participants met the inclusion criteria. Five trials, involving 317 participants, were used in the meta-analysis specifically for the outcome of fatigue.

• Sample size was common among included trials, with only two trials having more than 30 participants.  Median sample size was 42 patients.
• Women were undergoing adjuvant (including neoadjuvant) treatment (including chemotherapy, hormonal therapy, or radiotherapy, sequentially or concurrently) for stage I, II, and III breast cancer.

Outcomes were physical fitness, psychological distress, symptoms (pain and fatigue), quality of life, body weight or lean body mass, and immune function. Fatigue was evaluated predominantly using the Piper Fatigue Scale. Meta-analysis of the trials in which fatigue was included as an outcome did not identify a statistically significant improvement in fatigue for participants in the exercise intervention groups compared to the control (nonexercising) groups. Statistically significant improvements for cardiorespiratory fitness, anxiety, sleep disturbance, and nausea relief were found.

The methodologic quality of the studies was overall moderate.

• The absence of blinding of the outcome assessor was the most prominent methodologic flaw.
• The conclusions that can be drawn from this review are limited based on the inclusion of only a small number of trials, together with a considerable degree of clinical heterogeneity regarding adjuvant cancer treatments and exercise interventions.

To determine if exercise interventions can effectively mitigate cancer-related fatigue (CRF)

DATABASES USED: PubMed, CINAHL, PsycINFO, ProQuest, SPORTDiscus

KEYWORDS: exercise, physical activity, exercise therapy, exercise training, aerobic exercise, resistance exercise, physical training, exercise prescription, cancer, oncology, malignancy, neoplasm cancer treatment, chemotherapy, radiotherapy, hormonal therapy, fatigue, CRF, QOL, depression

INCLUSION CRITERIA:

• Experimental, quasi-experimental, or pre-post design
• Data reported and available for meta-analysis
• Inclusion of exercise intervention to measure effects on CRF
• Control groups received care as usual with no prescribed physical activity

EXCLUSION CRITERIA:

• Interventions and measures focusing only on range of motion

TOTAL REFERENCES RETRIEVED = 948 articles initially identified

EVALUATION METHOD: No quality scoring of retrieved studies was described.

FINAL NUMBER STUDIES INCLUDED = 16 studies included in meta-analysis

SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Study sample sizes ranged from 22–242; 1,426 patients in treatment and control groups

KEY SAMPLE CHARACTERISTICS: Subjects were at various phases in cancer treatment, with some in active treatment of various modes and others post-treatment. Eight trials were in patients with breast cancer. Other studies included prostate cancer, mixed disease types, and acute myelogenous leukemia.

Overall effect of exercise on CRF showed a small but significant effect size with overall reduction in CRF ( SMD = 0.28, 95% CI 0.17–0.38, p <.001).

Subgroup analysis of exercise mode:

• Aerobic exercise had a small but significant positive effect (SMD = 0.25, 95% CI 0.12–0.38, p < .001)
• Resistance training had a small and insignificant effect (SMD =1.66, 95% CI 0.41–3.73, p > .05)
• Mixed aerobic and resistance exercise had a small and insignificant positive effect (SMD = 0.22, p > .05)

Interventions provided in a supervised setting (15 trials) significantly reduced CRF (SMD = 0.29, 95% CI 0.17–0.46, p < .001).

Unsupervised exercise showed a positive trend but no significant difference with exercise.

Effects in phase of treatment:

• Exercise caused a moderate and significant reduction in CRF when provided after completion of treatment (SMD = .31, 95% CI 0.6–14.03, p < .001).
• Exercise during treatment also resulted in reduced CRF (SMD = 0.24, 95% CI .12–.36, p < .001).

Effects in patients with cancer other than breast cancer:

• Subgroup analysis in trials with those patients with cancer other than breast cancer (four trials) showed that exercise significantly reduced CRF (SMD = 0.17, 95% CI .01–0.34, p < .05).

Exercise intervention produced improvement in aerobic fitness and musculoskeletal fitness (p < .001).

Findings from meta-analysis provide strong support for the positive effect of exercise on CRF. Effect sizes are small.

Findings suggest that various modes of exercise show a trend toward a positive impact on CRF in patients with breast cancer, as well as patients with other types of cancer.

There may be differences in effect based on mode of exercise.

Findings suggest positive effects in supervised and unsupervised exercise programs, but only those that were supervised demonstrated statistical significance in this study. It is unclear if this represents a real difference in effectiveness, or the fact that there were only four studies of unsupervised exercise included.

Findings support the use of exercise to reduce CRF during and after completion of cancer treatment. Subgroup analyses in this study begin to provide additional useful information regarding the modes and types of exercise interventions that may be most effective. Further research comparing effectiveness of various approaches is warranted.

Effect sizes of exercise are small, suggesting that studies that include patients with very low fatigue or interventions to prevent fatigue may not readily show significant changes.

Databases seached were MEDLINE, CINAHL, EMBASE, PsycINFO, CANCERLIT, Cochrane Library, PEDro, and SPORTDiscus through March 2005.

Fourteen randomized trials were included. Nonrandomized trials, pilot studies, and studies reported only in abstract form were excluded. Therapeutic exercise regimens addressing only specific impairments to shoulder and arm were not included. Studies with an additional treatment arm or combined intervention (e.g., exercise with diet modification) were included only if the effects of exercise could be isolated. Studies were required to have quality of life, cardiorespiratory fitness, or physical functioning as a primary outcome. Secondary outcomes of interest included symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention. Methodologic quality of each included study was evaluated using eight quality criteria specified a priori.

Outcomes were quality of life, cardiorespiratory fitness, physical functioning, symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention.

There was wide variability in the exercise interventions evaluated. Interventions included Tai Chi Chuan, aerobic exercise (walking, cycle ergometer, and arm ergometer), resistance training (weights and resistance bands), and mixed aerobic and resistance exercise. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually or in groups. Overall, study reports provided too little detail concerning the frequency, intensity, time, and type of exercise to allow for determination for an exercise dose-response. Similarly, limited detail about the adherence to the exercise program was provided, and few studies had been designed to include monitoring of activity in the comparison group, so that potential contamination could be gauged.

• A total of 717 participants were included, with sample sizes for individual studies ranging from 16 to 123 participants.
• Participants in the included studies were women with early to later stage (stage 0–III) breast cancer or who had undergone breast cancer surgery with or without adjuvant cancer therapy.
• Clinical heterogeneity in treatment (e.g., chemotherapy, radiation therapy, and hormonal therapy) was evident, particularly in trials of exercise during adjuvant treatment for breast cancer.

Six studies involving 319 patients assessed the effect of exercise on symptoms of fatigue. Although all of the studies showed improvements in symptoms of fatigue with exercise, only two reported statistically significant improvements. These two studies were also the only studies performed following breast cancer treatment. The pooled results from all six studies showed that exercise significantly improved symptoms of fatigue (standardized mean difference [SMD] = 0.46; 95% confidence interval [CI] [0.23, 0.70]). The pooled results from the four studies performed during adjuvant cancer treatment showed a nonsignificant effect on fatigue (SMD = 0.28; 95% CI [-0.02, 0.57]). Four studies reported adverse events; in one study, two of 23 participants reported that participation in the home-based exercise program (self-monitored walking program) resulted in worsening of fatigue.

• Of the 14 studies included in this review, the median score for methodologic quality was 3 (range 0–8). Only four of the 14 studies were considered high quality.
• The most common methodologic shortcomings included failure or inadequate blinding of outcome assessor and inadequate participant concealment of study group allocation.

• FINAL NUMBER STUDIES INCLUDED = 9 
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,156
• KEY SAMPLE CHARACTERISTICS: Of the trials, 67% were conducted during active treatment. The mean age was 55.2 years, and the studies were mainly of non-Hispanic Caucasians.

PHASE OF CARE: Multiple phases of care

All trials included aerobic training, and six included resistance training. The average duration of training was 21 weeks, and the average sessions per week was 2.5. Supervised aerobic exercise was more effective than usual care in improving fatigue (SMD = –0.51, 95% confidence interval [CI] [–0.81, –0.21]). SMD for resistance training was –0.41 (95% CI [–0.76, –0.05]). No dose response for training intensity was seen. Studies conducted during active treatment showed a significant benefit in reducing fatigue (SMD = –0.66, p < 0.05). In four studies conducted after cancer treatment, the effects of exercise on fatigue were not significant. Exercise improved physical well-being, but no significant effects were observed for social and emotional domains.

Supervised aerobic training during cancer treatment was associated with a significant improvement in fatigue.

• High heterogeneity among the studies
• The analysis was limited to the use of supervised exercise compared to only usual care.
• The number of studies reporting emotional and psychosocial outcomes was small.

Exercise during cancer treatment has been shown to reduce fatigue. This study suggests that the results may be best with aerobic exercise. The optimum intensity and “dosage” of exercise at various time points in cancer treatment remain unclear.

• Randomized, controlled trials
• Participants: Patients with any type of cancer without restriction to a particular stage of diagnosis or treatment
• Intervention: Supervised physical activity interventions (i.e., aerobic, resistance, stretching)
• Outcome measures: Cancer-related fatigue (primary outcome), physical wellbeing, and functional wellbeing
• Comparisons: Supervised physical activity versus conventional care

PHASE OF CARE: Active

The interventions had a mean duration of 17 weeks (SD = 12) with an average of three sessions (SD = 1) per week. The mean session duration was 45 minutes (SD = 29). The interventions included aerobic exercise (i.e., walking, stationary cycling) in all trials, resistance training in six trials (55%), and stretching/flexibility exercises in four trials (36%). Training intensity varied considerably among studies, ranging from 50%–90% of maximum heart rates. All studies reported pre-exercise screening before high intensity physical training. The overall meta-analysis showed that supervised physical activity had a favorable effect on cancer-related fatigue when compared to conventional care. The final analysis of the results revealed that supervised physical activity interventions were effective in the management of cancer-related fatigue for all types of cancer. The favorable effect was no longer significant at the six-month follow-up. However, more participants in the intervention group continued to exercise.

This study provides additional support for exercise in management of cancer-related fatigue during active treatment, in this case supervised activity. It reinforces the role of physiotherapy in the management of cancer-related fatigue.

Publication bias may have been present, but it was not possible to test for it because of the small number of included studies. Heterogeneity was present in most of the meta-analyses. This may be because of the range of sample sizes, the diverse exercise regimens (in terms of length, duration, and intensity) evaluated, and the wide variety in outcome measurement tools used in the included studies

Nurses can continue to recommend exercise as an intervention for cancer-related fatigue. However, additional research is still needed on the type, frequency, intensity, and duration of exercise.

• FINAL NUMBER STUDIES INCLUDED = 9
• TOTAL PATIENTS INCLUDED IN REVIEW = 788 
• SAMPLE RANGE ACROSS STUDIES = 22–235 patients
• KEY SAMPLE CHARACTERISTICS: Age ranged from 46–60 years with a mean of 55.5 years; 54.2% were female and were receiving treatment; most common treatment was chemotherapy; average months since diagnosis was 8.2 months; most common diagnoses were breast and prostate cancers

PHASE OF CARE: Active antitumor treatment
 
APPLICATIONS: Palliative care

Supervised multimodal exercise programs resulted in an overall reduction of fatigue in cancer survivors (SMD = –0.23, p = 0.001) with low statistical heterogeneity. Slight evidence of publication bias was noted. Length (weeks of training), frequency (sessions/week), and duration (minutes/session) were linearly associated with overall improvement in CRF (Tau squared = 0.04, p = 0.04). Aerobic exercise, resistance training, and stretching were implemented in seven of the nine studies, and the pooled effect estimate showed significant reductions in CRF (SMD = –0.35, p = 0.01). Two studies used resistance training, and the pooled effect estimate showed no significant reductions in CRF (SMD = –0.17, p = 0.3). Reported adverse events occurred infrequently (n = 7 events, one requiring hospitalization). Most studies were conducted during treatment (chemotherapy) and resulted in significant reductions of CRF (SMD = –0.23, p < 0.0001). No significant reductions in CRF were reported after anticancer treatment (p = 0.1).

Supervised multimodal exercise programs implemented during treatment are supported as an intervention for reducing CRF.

• Considerable statistical heterogeneity in effect estimates existed.
• Risk of bias was evaluated by a single investigator.

Supervised multimodal exercise programs are safe and beneficial for patients receiving anticancer therapy. Referrals to exercise professionals to plan a personalized exercise program for patients with cancer is recommended.

To conduct a meta-analysis of the effectiveness of exercise interventions on health-related quality of life (HRQoL) and domains (e.g., physical, psychological, economic, social, and spiritual well-being) of HRQoL among adult cancer survivors posttreatment.

Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro, LILACS, SIGLE, SPORTDiscus, OTSeeker, Sociological Abstracts, Web of Science, and Scopus.

Search keywords (selected from appendices) were exercise, quality of life, health-related quality of life, pain, and cancer.

Studies were included in the review if they

• Were randomized, controlled trials (RCTs) and controlled clinical trials that compared exercise interventions with either usual care or no exercise
• Evaluated the impact on overall HRQoL or at least one domain of HRQoL in cancer survivors posttreatment
• Reported cancer survivors diagnosed as adults (18 years and older).

Studies were excluded if they reported patients with terminal cancer or in hospice care who were receiving active treatment for primary or recurrent cancer.

A total of 1,795 relevant references were retrieved.  A total of 1,636 articles were excluded based on the title and abstract.  After further review of the abstract, 82 were excluded because they did not meet the inclusion criteria. An additional 13 were excluded from qualitative synthesis because they were ongoing studies.

• The review included a final number of 40 trials in qualitative synthesis and 33 in quantitative (meta-analysis of findings).
• A total of 3,694 participants were randomized to an exercise (n = 1,927) or control (n = 1,764) group.
• Of the 40 studies, 38 were RCTs, three used variation of an RCT, and two used a quasiexperimental design. All but four trials were randomized to an exercise group or a control group.
• Studies included various cancer types, including breast, colorectal, head and neck, and others. Twenty-two trials were focused on breast cancer only.
• The time frame included 30 studies completed with treatment and 10 completed during and after cancer treatment. Only posttreatment data were included. The range of treatment time was immediate completion of treatment to up to 15 years after completion.
• The majority of trials reported females only; 15 used mixed gender samples.
• Participant age ranged from 39 to 68 years.
• Of those reporting socioeconomic status, the majority of participants had at least a high school education.
• Fifteen trials reported past exercise use, with types of exercise including strength and resistance training, walking, cycling, yoga, qigong, and tai chi.

The review has clinical applicability for late effects and survivorship.

Exercise had a positive effect on change in HRQoL scores at 12 weeks and six months of evaluation, and it improved cancer-specific HRQoL in breast cancer concerns. The effect on HRQoL remained after exclusion of patients who were receiving active treatment. For cancer-specific HRQoL, there was significant improvement in exercise groups compared with controls for breast cancer concerns at baseline to 12 weeks and six months. There was a significant decrease in anxiety in the exercise group compared to controls at 12 weeks only (standardized mean difference [SMD] = -0.26; 95% confidence interval [CI] [-0.44, -0.07]) but not in breast cancer-only analysis. There was a high risk of bias in most of these studies, and when these were removed, the results were not significant. Significant differences were noted in body image at follow-up (12 weeks to six months and beyond) using the Rosenberg Self-Esteem Scale. Significant change scores were noted for cancers other than breast for improving depression scores (SMD = -0.46; 95% CI [-0.72, -0.19]). Significant improvements were noted in emotional well being (12 weeks) and fatigue (12 weeks and 6 months) (SMD = -0.42; 95% CI [-0.83, -0.02]). No effects after six months were seen for fatigue, and effects were not significant when studies involving patients during treatment were excluded. Improvement in pain using follow-up scores (12 weeks) was seen (SMD = -0.29; 95% CI [-0.55, -0.04]), but this was from a single trial. Positive effects were noted in sexuality scores at six months and sleep disturbance at 12 weeks (sleep SMD = -0.46; 95% CI [-0.72, -0.20]). Significant improvements were noted in change scores for social functioning (12 weeks and six months). No significant changes were noted in cognitive function, general health perspective, role function, and spirituality in exercise trials.

Exercise interventions showed beneficial effects on HRQoL and some HRQoL domains, including breast cancer concerns, body image, emotional well being, sexuality, sleep disturbances, social functioning, anxiety, fatigue, and pain at various follow-up time points.

• Studies included used exercise programs of various types, intensity levels, and lengths.
• Significant effects found tended to be in subgroups of patients or at only one time point, limiting the confidence in observed effects.
• Measures of HRQoL varied, creating heterogeneity among the studies in how HRQoL was quantified.
• There was a high risk of bias in the trials reviewed. In many cases, no significant effects were seen when analyzing changes in symptoms from baseline to follow-up time points, and significant findings were seen in comparing only follow-up scores between various comparison groups. Results should be used with caution for these reasons.

Findings supported the general benefit of exercise for patients with cancer; however, there is further need for research to verify the positive effects of exercise on symptoms of cancer in various patient groups and at various phases of cancer care. These future research studies should determine how to produce larger effect sizes over time and delineate predictors of that effect, such as type of exercise, intensity of the program, timing, and type of cancer and treatment in order to maximize the effect on QoL. It will be important to note that certain questionnaires can affect the outcomes, and consistency would improve this body of research.

PURPOSE: To evaluate the effectiveness of exercise interventions on several domains of health-related quality of life

• FINAL NUMBER STUDIES INCLUDED = 40 in systematic review (33 in meta-analysis)
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,694
• SAMPLE RANGE ACROSS STUDIES: 7–271 patients
• KEY SAMPLE CHARACTERISTICS: Multiple tumor types

PHASE OF CARE: Late effects and survivorship

Studies included those with interventions such as yoga, tai chi, and qigong, as well as more traditional exercises. Moderate to vigorous exercise was associated with positive effects on quality of life (SMD = 0.29, 95% CI = 0, 0.58), but no effect was seen for mild to moderate level exercise. These findings did not differ by type of cancer. Anxiety was reduced in all studies by 12 weeks, but this was not observed at longer follow-up periods. At 12 weeks, more vigorous exercise showed no overall effect on anxiety with pooled data. However, a significant effect was seen with mild to moderate exercise (SMD = -0.26, 95% CI = -0.02,-0.51). For fatigue, there were significant positive effects at 12 weeks and between three and six months, but not at six months

The findings of this review show the benefits of various types of exercise on anxiety, fatigue, and quality of life among cancer survivors. Results varied by exercise intensity and at various time points in patient follow-up. This suggests that benefits exist mainly in the short-term up to six months.

Most studies showed a moderate to high risk of bias. All types of exercise were combined with various mind/body interventions, which would affect the results of the meta-analysis. It is not clear that these various types of interventions are truly equivalent types of interventions. The methods of measurement for the studies included were not provided, and differences in measurement would affect the meta-analysis. The search result volumes differed in two areas of this report. The differences reported by exercise intensity are confusing. It is not clear how more vigorous exercise improved quality of life while less vigorous exercise only affected anxiety.

Overall findings confirm other findings that exercise is beneficial for patients with cancer at various phases of care. This particular analysis was aimed at cancer survivors who completed initial treatment. It is of interest that the benefits of interventions appear to wane around the six-month timeframe. It is not clear if the interventions were done in a group setting for some time period or if social interaction could have influenced the findings that long-term effects were not generally seen if group exercise activity had ceased. Future research in this area should incorporate data to facilitate our understanding of the longevity of effects and mechanisms to maintain improvements long-term.

Databases searched were PubMed, PsycINFO, CANCERLIT, and Cochrane Library through May 2003.

Twelve randomized trials were included. Nonrandomized trials, pilot studies, and studies in which exercise was combined with other therapies, such as cognitive therapy or diet, were excluded.  Outcomes were fatigue, health-related quality of life, physical exercise capacity (maximal oxygen consumption), and other physical performance measures.  Treatment evaluated aerobic exercise training (10 studies) and resistance exercise (two studies).

• Sample sizes ranged from 21 to 155 patients.
• Nine studies included breast cancer patients, most of whom were stages I or II. The remaining studies included samples with mixed diagnoses, prostate cancer, and acute leukemia.
• In 10 of 12 studies, the intervention was conducted when patients were undergoing radiation therapy and/or chemotherapy treatment; two trials implemented exercise after the treatment was finished.
• Eleven of 12 studies were performed in patients receiving treatment with curative intent, and one study included a mix of patients receiving treatment with either curative or palliative intent.

Three studies reported a significant reduction in fatigue. One study observed a significant reduction in fatigue, although this did not reach statistical significance. In another study, no statistical analyses were performed to examine between-group differences.

The reviewed studies indicated promising effects on both physiological and psychological outcomes. However, the reviewed studies differed widely in the length of the exercise program, its intensity, content, and frequency, and the timing of the interventions in relation to the patient’s disease and treatment.

• In many of the studies reporting data on quality of life, too many outcomes were listed (range 2–12), and only four of the trials defined which variables were the primary endpoints.
• Randomized clinical studies are few, small in scope, and focus mainly on patients with breast cancer.
• Complete knowledge about the type of physical exercise most beneficial for patients at different stages of disease is lacking.

Future exercise intervention studies should also identify fewer and more specific endpoints.

• FINAL NUMBER STUDIES INCLUDED = 10
• TOTAL PATIENTS INCLUDED IN REVIEW = 192
• SAMPLE RANGE ACROSS STUDIES = 1–45 patients
• KEY SAMPLE CHARACTERISTICS: Adults with lung cancer

• PHASE OF CARE: All phases
• APPLICATIONS: Elder care, palliative care

Three of the 10 studies showed a significant reduction in fatigue with exercise, one using aerobic exercise, one using chest physiotherapy, and one using pulmonary rehab. The other studies showed improvement but did not reach statistical significance. All studies were level 4 or 5 evidence (low). Studies with significant results, however, were not similar in their exercise intervention. Exercise was safe and feasible for adults with lung cancer. All studies provided exercise under supervision, and most included aerobic and interval training

\"This current review shows that exercise is beneficial and safe in lung cancer-related fatigue; however, the studies are small and, without any control groups, are lacking clinically significant effects. Thus, exercises could be used in the management of cancer-related fatigue in lung cancer in view of the available evidence in other cancer cohorts with due caution. There is an urgent need of further research with adequate sample size, preferably randomized controlled trials, to evaluate the effect of exercise in this cancer cohort” (p. 10).

• Small number of studies
• Small sample sizes
• Most studies without randomization or control groups
• Studies retrieved and reviewed by one student and advisor

In light of studies on the effects of exercise in other diseases, exercise can be considered for the management of fatigue in patients with lung cancer with attention to performance status. Patients perhaps should undergo individual testing and exercise prescription. Additional research is needed.

To determine the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews. This overview does not attempt to rereview the literature or provide information on outcomes not reported within the included Cochrane reviews.

The database searched was Cochrane Database of Systematic Reviews.

No keyword or subject heading was searched because it would be unreliable due to the diverse range of interventions and illnesses under review. The authors hand searched the Cochrane Database of Systematic Reviews by title for all reviews that might assess the effect of an intervention on fatigue and/or unintentional weight loss in adults with advanced progressive illness.

Studies were included if they reported interventions with fatigue and/or unintentional weight loss as the primary treatment intent.

Studies were excluded if the treatment of fatigue and/or unintentional weight loss was not a primary indication for the intervention, they were systematic reviews published outside the Cochrane Library, or if they only included children.
 

Twenty-seven systematic reviews were retrieved. Assessment of Multiple SysTemAtic Reviews (AMSTAR) was used to assess the methodological quality of each systematic review.

• The final number of systematic reviews included was 27.
• The total sample size included 302 studies with 31,833 participants.
• Adults 18 years or older with an advanced progressive illness known to have clinically significant fatigue and/or weight loss in the latter stages of illness were included. These conditions included degenerative neurological conditions, such as multiple sclerosis, Parkinson’s disease, dementia, irreversible organ failure, cancer with distant metastasis, and acquired immune deficiency syndrome (AIDS).
• The pharmacological interventions were eicosapentaenoic acid (EPA) and any drug therapy for the management of cancer-related fatigue. The nonpharmacological interventions were exercise, interventions by breast care nurses, and psychosocial interventions.

• Patients were undergoing the end of life phase of care.
• The study has clinical applicability for palliative care.

The review looked for the following outcomes:

1. Clinically significant improvements in fatigue and/or unintentional weight loss
2. Improvements in quality of life of people who have fatigue and/or unintentional weight loss
3. Withdrawals due to adverse events.

Results relative to fatigue in patients with cancer included identification of five systematic reviews (116 studies with 17,342 participants). 

Nonpharmacologic Interventions

The evidence provided some insight into interventions that may prove beneficial, such as exercise. However, recommendations could not be made for specific exercise interventions that might best manage fatigue. In a systematic review, Cruickshank et al. (2008) reviewed the effect of breast care management strategies on fatigue in women with breast cancer at any stage of their illness. No included study assessed fatigue as an independent outcome, and no conclusions could be drawn. In 2009, Goedendorp reported that for patients undergoing cancer treatment at any disease stage, there was insufficient evidence that psychosocial interventions were beneficial for fatigue management. 

Pharmacologic Interventions

Sufficient evidence was not provided for the use of EPA over placebo in patients with advanced cancer. A small but significant improvement with fatigue was found with the use of methylphenidate in 51 studies with 10,296 participants. Use of erythropoietin and darbepoetin showed evidence of an effect over standard of care or placebo for the treatment of cancer-related fatigue. However, increased safety concerns mean they are no longer recommended in practice for this use, especially if the person’s hemoglobin concentration is greater than 12 g/dL. No benefits over placebo were seen for fatigue with the use of antidepressant drug paroxetine, nor with progestational steroids.

There was a lack of robust evidence for interventions for fatigue management in the advanced stage of progressive illness related to cancer.

Extraction of data was limited to Cochrane reviews. Fatigue as an outcome indicator was not always sufficiently reported.

Exercise interventions can lead to an improvement in fatigue in patients with cancer; however, this beneficial effect requires further research for those in the advanced stage.

STUDY PURPOSE: To evaluate the effectiveness of exercise interventions compared with usual care on physical fitness, fatigue, and quality of life in patients treated with hematopoietic stem cell transplantation (HSCT)

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 9
• TOTAL PATIENTS INCLUDED IN REVIEW = 472
• SAMPLE RANGE ACROSS STUDIES: 19-105
• KEY SAMPLE CHARACTERISTICS: All had HSCT. Mean ages ranged from 29.1-55 years.

PHASE OF CARE: Active antitumor treatment

Six studies showed a positive effect on cardiorespiratory fitness (effect size [ES] = 0.53, 95% confidence interval [CI] [0.13, 0.94]) compared to usual care. Positive effects were seen in muscle strength. Five studies showed positive effects on quality of life (QOL) in global QOL (ES = 0.41, p = 0.0005), cognitive functioning (ES = 0.36, 95% CI [0.13, 0.59], p = 0.002) from the European Organization of Research on Treatment and Cancer (EORTC) self-report instrument. Compared to usual care, exercise had a moderate and significant positive effect on fatigue (ES = 0.53, 95% CI [0.27, 0.79], p < 0.0001).

Exercise interventions were shown to have a positive effect on cardiorespiratory fitness and fatigue, and might show some benefit in terms of several aspects of health-related quality of life for patients undergoing HSCT.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• Low sample sizes
• Single-item scale data were used for outcome measurement in areas of cognitive function and quality of life, and in two of those related to fatigue.
• High variability in the content, timing, and duration of interventions

This review adds to the body of evidence showing the effectiveness of exercise interventions for fatigue among various types of patients with cancer. Exercise may also have an impact on various aspects of health-related quality of life; however, the evidence in this area is weak, and additional research is needed to determine efficacy in this area.

• Cancer patients currently undergoing treatment
• Randomization to either exercise training or a nonexercise comparison
• A cancer-related fatigue outcome measured before and during and/or after exercise training.

In total, 434 records were screened, and 325 were excluded.  One hundred nine RCTs were screened further, with 23 excluded due to no primary data being available.  Eighty-six studies were assessed for eligibility, and 16 were excluded. 

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Authors extracted data independently and resolved discrepancies via consensus judgment.

• The final number of studies included was 70.
• In total, 4881 patients were included; 3235 were undergoing treatment and 1646 were posttreatment.
• Key sample characteristics varied because results were captured during and after treatment investigations.

Patients were undergoing multiple phases of care.

Exercise significantly reduced cancer-related fatigue during and after treatment.  During treatment, patients with lower baseline fatigue scores and higher exercise adherence achieved the greatest improvements.  Following treatment, cancer-related fatigue improvement was largest in trials with longer durations between treatment completion and exercise initiation, trials with shorter exercise program lengths, and trials with wait-list comparisons.

Exercise reduces cancer-related fatigue in patients during and after cancer treatment. Exercise is palliative in patients during treatment and recuperative posttreatment.

• Many studies did not report adequate information about the exercise intervention or appropriateness of comparisons and underreported adherence levels, medication use, and cancer sites.  
• The authors did not use a validated cancer-related fatigue outcome measure in 10% of the trials.

The study provided evidence for prescribing exercise during and following cancer treatment and recognized the differential effects of exercise on cancer-related fatigue when prescribing exercise.

The database searched was MEDLINE through February 2005 to identify intervention studies designed to increase physical activity in adults. Only those studies with a concurrent comparison group with results presented separately for treatment and comparison groups were included.

The quality of 32 studies was assessed using prespecified criteria for internal validity. Twenty-two of 32 studies were rated as being of high methodologic quality and were retained for qualitative and quantitative analysis. The outcomes of physical activity interventions in patients receiving active treatment were analyzed separately from the studies of physical activity after treatment was concluded.

Outcomes were fatigue, health-related quality of life, symptom distress, immune function, hematocrit, body composition, physical exercise capacity (maximal oxygen consumption), and other physical performance measures.

Treatment evaluated aerobic physical activity of moderate to vigorous intensity three to five times per week for 20 to 30 minutes per session. The majority of the interventions lasted between five weeks and three months, with no follow-up at the end of the intervention. The majority of the studies used a control group in which no physical activity or other treatment was prescribed, although a few studies provided an intervention for the comparison group.

• Average sample size for the intervention group was 28 participants.
• The most common diagnosis included in the studies was breast cancer.
• The majority of the studies focused on the time period during or immediately following active cancer therapy. No study focused on palliation.

Although a consistent positive effect of physical activity on fatigue was noted using qualitative study review techniques, effect size calculations revealed no effect of physical activity on fatigue during treatment (weighted mean effect size = 0.13; 95% confidence interval [CI] [-0.06, 0.33]; p = 0.18) or after treatment (weighted mean effect size = 0.16; 95% CI [-0.23, 0.54]; p = 0.43) or on vigor/vitality during treatment (weighted mean effect size = 0.43; 95% CI [-0.07, 0.94]; p = 0.09). A large positive effect of exercise on vigor/vitality posttreatment was noted (weighted mean effect size = 0.82; 95% CI [0.05, 1.6]; p = 0.04). When fatigue and vigor/vitality were combined into one category (under the assumption that fatigue and vitality are the same attribute) and all studies were combined across treatment timing, the weighted mean effect size was still small (weighted mean effect size = 0.19; p = 0.03).

The results supported the conclusion that physical activity has a large positive effect on vigor/vitality after treatment is complete. There is some support from qualitative analysis of a consistent effect of physical activity on fatigue, although the magnitude of this effect may be too small to be clinically meaningful. The study findings also supported a preliminary conclusion that physical activity is generally well tolerated during and after cancer treatment, although the available literature does not allow conclusions to be drawn regarding adverse events from participation.

• The reviewed studies used small, self-selected samples.
• The reviewed studies were heterogeneous in terms of the outcome measures and interventions.
• The reviewed studies had gaps in the level of detail reported about individual study procedures and results.

• FINAL NUMBER STUDIES INCLUDED = 102 (However, data from 82 studies were abstracted, WMES were calculated from 66 high quality studies, and a systematic level of evidence criteria was applied to evaluate 60 outcomes.)
• TOTAL PATIENTS INCLUDED IN REVIEW = 41 (control), 42 (intervention)
• SAMPLE RANGE ACROSS STUDIES: 4–322 patients
• KEY SAMPLE CHARACTERISTICS: 40% during treatment, 60% after treatment, 83% breast cancer, 90% randomized controlled trials, 80% aerobic (either alone or combined with another modality), 76% did not adequately describe their sample, and 57% described the intervention

PHASE OF CARE: Multiple phases of care

The majority of studies demonstrated a positive effect on upper and lower body strength and self-esteem with physical activity during treatment. The majority of studies also demonstrated a positive effect on aerobic fitness, lower body flexibility, lean body mass, quality of life, trial outcome index, breast cancer subscale, vigor and vitality, fatigue, immune parameters, pain, symptoms, and side effects post-treatment. Twenty-nine of 36 studies reporting on aerobic exercises reported no side effects from physical activity. Significant WMES were found post-treatment for fatigue (-0.54, p = 0.003).

In general, physical activity is well-tolerated during and after cancer treatment. More studies are needed on specific kinds of exercise and the structure of delivery. Physical activity studies with fatigue as an outcome have increased from five to 14 since 2005 for post-treatment interventions with 93% of studies showing positive results and 50% of them being statistically significant.

• Most of the studies involved patients with breast cancer.
• Considerations for the difficulty of making recommendations based on variations in dose response, cancer diagnosis, and stage of treatment during the intervention were acknowledged.

Patients can be educated that physical activity after a cancer diagnosis can be safe with modifications as necessary.

Databases searched were MEDLINE, EMBASE, Cochrane Controlled Trials Register, CANCERLIT, CINAHL, PsycINFO, and SPORTDiscus through December 2003.

Thirty-three studies (25 randomized trials and eight nonrandomized studies) reported in 40 articles were included in the review. Data were pooled for 10 trials that assessed physical functioning and 12 trials that assessed fatigue.

Trials were included if they tested interventions involving regular exercise of any type (e.g., aerobic, resistance, and flexibility). Exercise could be the sole intervention or could be combined with other interventions (e.g., diet counseling).  Only prospective trials with a control arm were included.  Based on an a priori decision, both nonrandomized and randomized trials were included.  There were no restrictions on the outcomes assessed in trials. Nineteen studies tested aerobic exercise interventions, of which eight used cycle ergometers and eight used walking programs.  Three trials tested resistive exercise, 10 had combined aerobic and resistive programs, and one was based on team sport activities. Most trials compared an exercise intervention with no intervention; six that did not used information training, psychological therapies, stretching, or tai chi as comparison arms.

Trials of single exercise sessions that measured acute effects were excluded, as were trials that only investigated the effects of physiotherapy.  Control arms could not comprise an intervention (e.g., usual care), an alternative intervention (e.g., counseling, relaxation), or a different type of exercise (e.g., aerobic versus flexibility exercises). Trials with healthy or historical control groups were excluded. 

Exercise interventions lasted for 10 weeks or longer in 17 trials and two weeks or less in four studies. The longest intervention period of any trial was 26 weeks. Trial quality was assessed by recording whether the following features were incorporated in the study design:  randomization, allocation concealment, blinding of the main outcome assessment, and intention-to-treat analysis.

• Thirteen trials included patients with breast cancer during or after adjuvant therapy.
• Eleven trials involved adult patients with any cancer, and one involved pediatric cancer survivors.
• The remaining trials included patients undergoing treatment for prostate, lung, colorectal, or stomach cancers; multiple myeloma; or leukemia.

Reductions in cancer-related fatigue were reported in 10 studies, although statistical significance was not reached or not tested for in three of them.  No differences between groups were reported for fatigue in six trials immediately after the intervention or several months later.  Pooling the data from the 12 trials that assessed fatigue suggested that there was no overall effect of exercise on symptoms of fatigue (standardized mean difference [standard deviation (SD)] in fatigue = -0.15 [-0.38, 0.09]).  Heterogeneity between studies was not related to randomization, allocation concealment, intention-to-treat analysis, or choice of control.  However, the effect appeared to vary by population type.  Some evidence existed that no effect was found of exercise on fatigue symptoms in trials that recruited patients with any type of cancer and that those that recruited patients with breast cancer found a modest reduction in symptoms of fatigue among those allocated to exercise (standardized mean difference [SD] = -0.52 [-0.95,-0.09]).  There was no strong evidence of small study bias in this meta-analysis by the Beggs and Egger tests.

The authors generally concluded that there were methodologic limitations associated with many of the studies and that these limitations may have contributed to the inconsistencies among the results.

Limitations included

• Lack of a randomized allocation
• Failure to conceal allocation
• Failure to specify the primary outcome measures
• Small sample sizes
• Multiple statistical testing without adjustment of significance values.

Two studies may have included participants in the control group who had declined to undertake the intervention; in five other studies, it was unclear whether eligibility (including willingness to participate) was determined prior to group allocation or whether the control group may have solely or partly consisted of those who declined to be allocated to exercise.

STUDY PURPOSE: The purpose of this article was to review published literature on impact resistance training (RT) in adults with cancer.

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE

KEYWORDS: cancer, resistance training, muscle function, muscle strength, body mass, fatigue

INCLUSION CRITERIA: RCT comparing RT with an exercise or non-exercise control group in adult patients with cancer. Evaluation and report on strength, body composition, or fatigue comparing RT to no exercise, usual care, or alternative treatment.

EXCLUSION CRITERIA: Single RT intervention, intervention less than six weeks, recommendation of interventions with no further detail, indirectly or poorly documented RT, clinical co-intervention not applied to control, concomitant aerobic endurance training not applied to control

TOTAL REFERENCES RETRIEVED = 261

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Assessed by Jadad score (randomization, double-blinding, follow-up, intention to treat). Scores higher than two considered.

• FINAL NUMBER STUDIES INCLUDED = 14
• SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Total patients = 1,323 (594 RT and 555 control, 174 aerobic endurance not included in meta-analysis); studies collecting fatigue = 437
• KEY SAMPLE CHARACTERISTICS: 72% women, 57% breast cancer, 21% prostate cancer, 7% head and neck cancer, 14% any cancer. Six studies during cancer treatment, eight after completion. Mean age range = 47–75 years. Nine studies recruited only women.

PHASE OF CARE: Multiple phases of care

Four studies provided FACT-fatigue data. Improvement was seen in pooled fatigue scores (p = .05; WMD 1.86; CI -.03–3.75). Individually, two studies showed significant improvement. The therapeutic dose necessary to reduce fatigue was unable to be determined. No significant difference was seen in participant characteristics. No significant side effects were reported.

Low-to-moderate intensity RT may improve cancer-related fatigue described as muscle fatigue within 15–20 repetitions.

• Heterogeneity between treatment stage, cancer type, and type of RT intervention
• Not all studies measure fatigue data
• Limited to English-only and three databases

RT may have benefits for fatigue with a certain subset of patients with cancer with low risk for side effects. Further studies are needed to establish dose and to validate improvement for certain populations.

Databases searched were MEDLINE, CINAHL, and Database of Abstracts of Reviews of Effects (DARE) through October 2003.  Proceedings of the annual meetings of the American Society of Clinical Oncology, American College of Sports Medicine, and Oncology Nursing Society were also searched.

Twenty experimental studies (nine randomized, clinical trials and 11 quasiexperimental studies) were included.  The outcome was fatigue. Treatment evaluated physical activity or group or individual exercise.

• Sample sizes ranged from nine to 11 participants.
• Participants were adults.
• Participants had breast cancer, mixed solid tumors, or hematologic malignancies; were receiving active treatment, including stem cell transplantation, radiation, or chemotherapy; were receiving or palliative care; or were long-term survivors.

There is strong evidence to support the effectiveness of home-based exercise programs performed by middle-aged women undergoing adjuvant chemotherapy or radiation therapy for nonmetastatic breast cancer and some evidence that exercise may be equally beneficial in other cancer populations, including individuals with solid tumors and hematologic malignancies and cancer survivors.  Based on current evidence, low-intensity exercise individualized to patient comfort is the only type of exercise that can be considered safe for patients in palliative care settings. Evidence supports the efficacy of aerobic laboratory-based interval training in individuals receiving peripheral blood stem cell transplantation.

All studies had some design limitations, including

• Small sample sizes
• No random assignment
• No control groups
• Failure to control for anemia levels, intensity of chemotherapy, and the timing of the fatigue measurement in relationship to chemotherapy treatments.

Databases searched were MEDLINE, PubMed, EMBASE, Allied and Complementary Medicine (AMED), and PsycINFO. The dates encompassed by the search process were not specified by the authors.

Trials that provided data on the outcomes of physical activity in survivors of prostate cancer were identified. Studies that did not disentangle the effects of physical activity from a package of multiple interventions (e.g., physical activity combined with diet, counseling, etc.) were excluded. Studies that included survivors of prostate cancer among other cancer survivors without presenting separate results for survivors of prostate cancer were also excluded.

Six studies that examined the effects of physical activity in survivors of prostate cancer were identified. Of these studies, the physical activity interventions were performed during radiotherapy in one study and during androgen depletion therapy in five.  Four studies were randomized trials, whereas two were uncontrolled trials.

Outcomes were physical functioning, body composition, fatigue, and quality of life.

Four studies examined the effects of supervised exercise programs, whereas two investigated the effects of home-based exercise programs. Three studies tested a resistance exercise program; one tested a home-based walking program; one tested a group-based lifestyle program designed to increase physical activity; and one used a home-based intervention with walking, stretching, and resistance activities with biweekly supervised group-based booster sessions. The length of the exercise programs ranged from four weeks to six months, with a median of 12 weeks.

Sample sizes ranged from nine to 155 participants (median sample size = 48).

In four of the six studies in which fatigue was measured and reported, statistically significant improvements in fatigue were noted.  All studies demonstrated that physical activity was safe and feasible for survivors of prostate cancer receiving treatment.

• FINAL NUMBER STUDIES INCLUDED = 26
• TOTAL PATIENTS INCLUDED IN REVIEW = 2,830
• SAMPLE RANGE ACROSS STUDIES: 10 of 26 had a sample size less than 30
• KEY SAMPLE CHARACTERISTICS: 13 studies of breast, 3 of prostate, 2 of colorectal, 2 of nasopharyngeal, 2 of hematological, 1 of gynecologic, and 3 of various types of cancer. The mean age ranged from 40–70.6 years. Twelve studies reported cancer stage from mostly I to III. Eight studies included patients who had completed active treatment.

PHASE OF CARE: Active antitumor treatment

Exercise was supervised or home-based, 15–50 minutes in length, two to five times per week for 6–24 weeks. Overall aerobic exercise had a small but significant effect (p = 0.01). Studies with patients past active treatment had a moderate effect on fatigue compared to usual care (p < 0.01). Professionally led exercise led to significant improvements in fatigue (p = 0.02). Professionally led exercises lasted 20–30 (p < 0.01) or 50 minutes (p < 0.02), two to three (p < 0.01, p = 0.01) times per week for eight weeks (p < 0.01). No significant difference by exercise type existed.

Structured exercise can have a positive effect on CRF. The effect may be greater when activity is professionally led and after active treatment.

• The majority of patients had breast cancer, limiting generalizability.
• Other potential contributing factors to CRF were not reported in these studies.

Consistent physical activity should be discussed with patients with cancer to lessen the effects of CRF.

• FINAL NUMBER STUDIES INCLUDED = 72
• TOTAL PATIENTS INCLUDED IN REVIEW = 5,367 (2,740 in intervention, 2,627 control groups)
• KEY SAMPLE CHARACTERISTICS: 19% aerobic, 26% walking, 12.5% yoga, 31% mixed-exercise, 63% supervised, 36% home-based, 63% mixed malignancy, 26% solid tumor, 11% hematologic; and most patients off treatment

PHASE OF CARE: Multiple phases of care

There was a moderate effect on fatigue, sleep disturbance, and depression with exercise in the intervention groups (p < 0.001) compared to the control group. The benefits of exercise did not differ by type of exercise intervention (P = 0.85 for interaction). However, the effect of exercise on fatigue reduction may differ by underlying malignancy type with a stronger effect in solid tumors versus hematologic and mixed-malignancy types (P = 0.01 for interaction). There was a stronger effect on depression in females (p = 0.03). Patients with solid tumors seemed to experience a greater benefit.

Exercise can have an effect on fatigue despite the type of exercise and phase of care when delivered.

The clinical effect of what is considered a significant reduction in Functional Assessment of Cancer Therapy - Fatigue was questioned. The terms physical activity and exercise were used interchangeably, and the meaning of structured exercise was not well-explained.

Patients may be given several options for kinds of exercise to improve fatigue based on their preference while still receiving the benefit of improved fatigue.

STUDY PURPOSE: To summarize and analyze the evidence provided by randomized, controlled trials (RCTs) on physical exercise interventions among patients with cancer undergoing HSCT

TYPE OF STUDY: Systematic review and meta-analysis

TOTAL REFERENCES RETRIEVED: 232 originally retrieved; 180 excluded by title and abstract

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane collaborative tool for assessing for risk of bias used for bias; two of the authors scored articles. If a disagreement occurred, a third author reviewed.

• FINAL NUMBER STUDIES INCLUDED = 11 (14 articles met criteria; three were reports of the same study looking at different outcomes and, therefore, excluded) used in qualitative systematic review; three studies used in the meta-analysis; for outcome of fatigue, six studies examined effect of exercise on fatigue and two of these were included in meta-analysis
• TOTAL PATIENTS INCLUDED IN REVIEW = 734; for meta-analysis, 148; for fatigue meta-analysis, 115
• SAMPLE RANGE ACROSS STUDIES: 18–135 for total, 33–81 for meta-analysis, and 34–81 for fatigue meta-analysis
• KEY SAMPLE CHARACTERISTICS: Several countries; allogeneic or autologous HSCT; multiple myeloma, any type of leukemia or lymphoma. No other demographic data provided

• PHASE OF CARE: Active treatment, post HSCT; intervention initiated either during hospitalization or after discharge
• APPLICATIONS: Elder care

Only six of the studies examined the effect of exercise on fatigue. In meta-analysis of 115 patients (two studies), exercise significantly reduced fatigue at discharge (n = 115; SMD = 0.53; 95% CI [0.16, 0.91], p = .005). The meta-analysis indicated that training during hospitalization has a positive effect on fatigue in patients receiving an allogeneic HSCT.

Results of meta-analysis could not be confirmed through individual review of the other four studies, as only two showed statistically significant effect for fatigue in favor of the exercise group.

Physical functioning could not be evaluated by meta-analysis due to differences in study design and outcomes, but the majority of the studies did suggest a positive effect of exercise on functioning.

Exercise intervention during hospitalization can have a positive effect on fatigue at discharge for patients undergoing HSCT.

• Literature search limited to English
• Heterogeneity of type and timing of exercise intervention

Best outcomes were seen at discharge, suggesting that starting interventions before or just after transplantation are most effective. Further research into the optimal exercise program is needed.

STUDY PURPOSE: To investigate the effects of exercise on physical and psychosocial dimensions of fatigue during adjuvant treatment for breast cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 5 
• TOTAL PATIENTS INCLUDED IN REVIEW = 714
• SAMPLE RANGE ACROSS STUDIES: 70–206
• KEY SAMPLE CHARACTERISTICS: All had breast cancer and were receiving adjuvant chemotherapy. In two trials, women were also receiving radiation therapy and/or hormonal therapy.

PHASE OF CARE: Active antitumor treatment

Analysis showed that exercise had significant benefit for general fatigue (ES = –0.22), physical fatigue (ES = –0.35), reduced activity (ES = –0.22), and reduced motivation (ES = –0.18) (p = 0.05) but no effect on cognitive or affective dimensions of fatigue. Five studies included resistance exercises. Two studies compared resistance and aerobic exercise.

Exercise was shown to have beneficial effects on the physical dimensions of fatigue with low to moderate effect sizes. No apparent effects on emotional and cognitive components of fatigue were observed.

Limited number of studies included

This analysis adds to the large body of evidence showing the beneficial effects of exercise on fatigue. In this study, only the physical aspects of fatigue were affected. Additional interventions may be needed to address the psychosocial dimensions of fatigue.

To evaluate short- and long-term effects of different exercise parameters during adjuvant treatment on cancer-related fatigue.

Databases searched were CINAHL, EMBASE, MEDLINE, Scopus, PEDro, and Cochrane Library to 2008. Hand searching was performed using reference lists from articles obtained.

Search keywords were cancer (and related terms), chemotherapy, radiotherapy, hormone*, exercise, cycle, train*, walk, and fatigue.

Studies were included in the review if 

• They were randomized, controlled trials
• They studied effects of exercise on cancer-related fatigue in adults receiving adjuvant therapy
• There was overlap of 50% or more of the exercise intervention with the cancer treatment period
• The study compared exercise with a no exercise usual care group
• Patient-reported fatigue was the outcome.

No exclusion criteria were specified.

Initally, 1,097 articles were identified. A final set of 18 articles met the inclusion criteria. The PEDro scale was used to rate the methodological quality of the research. Fifteen studies were considered to be of high quality, with a score 4 or greater (range 2–8).

• The final sample of 18 studies involved 1,109 patients.
• Study sample sizes ranged from 14 to 174 patients.
• Twelve of the 18 studies were performed in patients with breast cancer.

Overall Findings in Breast Cancer

• Pooled results in patients with breast cancer (n = 654) showed a small significant reduction in fatigue with exercise (standardized mean difference [SMD] = 0.22; 95% confidence interval [CI] [0.06, 0.37]; Z = 2.46; p = 0.01).

Home-Based Exercise

Exercise was home-based and self-monitored in seven studies. Interventions consisted of walking for 10 to 45 minutes per week and for three to six times per week. In one study, the participants also performed resistance exercises. Cancer treatments and timing of the programs varied. Adherence ranged from 70% to 100%.

• Pooled results of 2 high-quality studies (n = 128) showed a small nonsignificant reduction in fatigue (SMD = 0.10; 95% CI [-0.25, 0.45]).

Supervised Exercise Programs

Supervised programs were used in five studies. Three involved aerobic exercises, and the others included groups with stretching and/or resistance exercises. Most were performed for 10 to 30 minutes three times per week. Programs were completed by 39% to 100% of partcipants.

• Pooled analysis of three high-quality studies (n = 340) showed a medium significant reduction in fatigue with exercise (SMD = 0.30; 95% CI [0.09, 0.51]).

Overall Findings in Prostate Cancer

Four studies were performed in patients with prostate cancer; three were supervised and one was home-based.

• Pooled results in these five studies showed a medium significant reduction in fatigue with exercise (SMD = 0.32; 95% CI [0.05, 0.59]).
• Subgroup analysis of home-based and supervised programs showed small nonsignificant effects, with these approaches analyzed individually.

Findings in Multiple Myeloma and Acute Myeloid Leukemia

One study was performed in each of these patient groups. One was of low quality. Both had nonsignificant reductions in fatigue.

Only short-term effects could be analyzed because only one study described any longer-term effects of physical exercise. No significant adverse effects overall were seen. Supervised aerobic exercise programs were more effective in reducing fatigue than home-based programs. There were significant positive effects during breast cancer treatment, with small to moderate effect sizes. The most effective frequency intensity or duration of exercise could not be determined. Reported adherence to the exercise program varied widely.

• There was an overall beneficial effect of exercise in patients with prostate cancer when all findings were pooled; however, the effectiveness of home-based and supervised programs could not be demonstrated separately.
• The limited number of studies and available data in this area may have influenced these results.
• The clinical relevance of findings could not be determined due to the wide range of measurement instruments used in the research and the lack of associated data that establish clinically important differences.

Findings showed that exercise had at least a small beneficial effect in reducing fatigue for patients during adjuvant treatment. Supervised programs may be more effective than self-managed home-based programs. More research on the effects of resistance exercise, home-based exercise, and most effective exercise parameters are needed. Longer-term outcomes and patient adherence need to be examined further. Research on the effects of exercise in other patient types is also needed.

To review the literature on nonpharmacologic supportive strategies to enhance quality of life (QOL) among patients with breast cancer experiencing cancer-related fatigue.

Databases searched were MEDLINE and CINAHL (2000–2010).

Search keywords were breast cancer patient, oncology patient, fatigue, cancer-related fatigue, quality of life, health-related quality of life, physical activity, and exercise.

Studies were included in the review if they 

• Were randomized, controlled trials or quasiexperimental designs
• Investigated nonpharmacological supportive strategies
• Had cancer-related fatigue and/or QOL as an outcome measure.

Eighty-nine articles were identified, of which 28 met the inclusion criteria. No method of quality rating of the studies was described.

• Twenty-eight studies including 2,164 patients were included.
• Sample sizes among studies ranged from 11 to 377 patients.
• All studies were performed in patients with breast cancer at various phases of care and receiving various types of treatment or after treatment.

Supervised exercise was used in eight studies.  Four of these showed that exercise significantly improved QOL and reduced fatigue.  Two studies showed that supervised exercise improved QOL but not fatigue; they had noted study limitations and intervention contamination. One large multi-site study showed that supervised aerobic exercise improved self-esteem, fitness, etc., but had no significant effect on QOL, depression, anxiety, or fatigue

Home-based exercise was used in six studies.  All of these confirmed a positive effect of participation in exercise on fatigue.  Fatigue levels either decreased, or those who exercised had significantly less increase in fatigue over time.

Telephone-based encouragement in activity was used in one study (25 patients).  At 12 weeks, there were significant increases in activity, QOL, and fatigue.

One study used print materials and step pedometers along with physical activity recommendations.  Those who received all three of these strategies had improved QOL and fatigue.

Education and counseling was used in five studies. Mixed results were seen across studies, with a positive effect on fatigue that was significant in three of these studies. 

Sleep therapy was examined in three studies.  Two of these demonstrated a significant positive effect on fatigue with cognitive behavioral therapy and insomnia treatment.  One large study using cognitive behavioral therapy showed improvement in sleep quality but no effect on fatigue.

Other interventions were yoga in one study, tai chi in one study, and physical therapy in one study.  Yoga was associated with an improvement in fatigue, and physical therapy was also associated with improvement, although this was only studied in 11 patients.

This review generally showed that supervised exercise and supervised exercise and other strategies to promote exercise can reduce cancer-related fatigue and improve QOL in women with breast cancer.  Findings were limited by several studies with small sample sizes and variations in the phases of care in which the interventions were provided. There was insufficient evidence to draw conclusions about the complementary therapies included.

• Studies of supervised education demonstrated mixed results.
• Several studies had small samples or other limitations.
• Application should be used cautiously.

Based on current evidence, exercise, educational counseling, and sleep therapy appear to be helpful methods to improve QOL and reduce fatigue. Because of methodological limitations of many of these previous studies, further well-designed research is needed to confirm these conclusions.

• FINAL NUMBER STUDIES INCLUDED = 12
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,014
• SAMPLE RANGE ACROSS STUDIES: 15–201 patients
• KEY SAMPLE CHARACTERISTICS: Four studies were of Asian women, eight studies were of Caucasian women, and all patients were receiving chemotherapy for breast cancer.

PHASE OF CARE: Active

The Revised Piper Fatigue Scale (RPFS) scores for patients with breast cancer were significantly lower in the intervention group than the control group. However, there was no significant difference in the Functional Assessment of Chronic Illness Treatment Fatigue (FACIT-F) scale scores between the intervention and control groups. A subgroup analysis by ethnicity indicated that there were significant differences in RPFS and FACIT-F scores between the intervention and control groups among Asian populations.

This study provided additional support for aerobic exercise as an intervention for CRF in women receiving chemotherapy for breast cancer, especially Asian women. However, it did not help determine the frequency, intensity, or duration of aerobic exercise that is most beneficial for CRF.

• Relatively small sample sizes
• Retrospective study, which may result in recall or selection bias
• Lack of access to original data

Nurses can continue to recommend aerobic exercise for women receiving chemotherapy for breast cancer. However, additional research is needed regarding the frequency, intensity, and duration of exercise.

To determine if a multimodal exercise program for patients during induction chemotherapy is feasible, safe, and beneficial for fatigue, quality of life, and fitness

Patients were randomized to the exercise or usual care groups. Usual care generally included suggestions to walk on a regular basis, without further instruction. Those in the exercise group were approached 4–5 days per week during hospital admission to participate in light-to-moderate–intensity exercise for 30–60 minutes. Exercise sessions included combined aerobic, resistance, and flexibility training. Aerobic intensity was encouraged at an exertion equivalent to 50%–75% of heart-rate reserve. The resistance exercises targeted large muscle groups using resistance bands and free weights. Flexibility was incorporated into each session via static stretching. Exercise sessions were directly supervised by a certified exercise physiologist. Study assessments were completed at baseline, post induction, and within two weeks of discharge, post cycle 2 (4–6 weeks post discharge).

• N = 70 post induction; 63 completed post-consolidation measures.
• MEAN AGE = 57 years (SD = 14.7)
• MALES: 54.3%, FEMALES: 45.7%
• KEY DISEASE CHARACTERISTICS: Patients with acute myeloid leukemia (AML) or relapsed AML receiving induction chemotherapy who were medically cleared for participation
• OTHER KEY SAMPLE CHARACTERISTICS: Participants in the exercise group were slightly older.

• SITE: Single site  
• SETTING TYPE: Inpatient    
• LOCATION: Canada

• PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• European Organization of Research and Treatment of Cancer Core Quality of Life (EORTC QLC-C30)
• Functional Assessment of Cancer Therapy-Fatigue (FACT-F) subscale/BMI
• Maximal oxygen consumption test (VO₂ max test)
• Six-minute walk test (6MWT)
• Grip strength
• Daily exercise diary for control patients

Exercise group participants completed 514.2 minutes of exercise on average during an average admission of 36.5 days. The most common reported reason for not exercising was fatigue. Adherence to exercise sessions was 54%. Control group patients exercised an average of 510.4 minutes over 35.8 days. Participants in both groups demonstrated an improvement in global quality of life. Fatigue scores improved only in the exercise group, with a between group difference of 3.6 points, which was not statistically significant. The six-minute walk improved in both groups but improved significantly more in the exercise group (p = 0.005). No significant adverse event occurred. During over 1,000 patient days of observation, four musculoskeletal events were reported. No differences existed between groups in length of stay or other resource utilization.

This study demonstrated that the provision of an exercise program is feasible for patients during induction chemotherapy and may help manage fatigue in these patients. Patients who participated in the multimodal exercise program demonstrated improved physical fitness.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Given the comparison of mean hours of exercise between study groups, the total amount of physical activity did not appear substantially different between groups, which may have affected the lack of substantial differences in fatigue.

Participation in an exercise program of moderate intensity was shown to be feasible for patients who were hospitalized and receiving induction chemotherapy for AML.

To examine the feasibility (recruitment, retention, and adherence), preliminary efficacy, and safety of a 12-week, home-based exercise program for middle-aged and older acute myeloid leukemia (AML) survivors

• N = 40  
• AVERAGE AGE = 56 years
• MALES: 45%, FEMALES: 55%
• KEY DISEASE CHARACTERISTICS: Acute myeloid leukemia; the average time from diagnosis to study enrollment for all participants was approximately two years.
• OTHER KEY SAMPLE CHARACTERISTICS: Participants were mostly white. The mean body mass index (BMI) 28.25%. Patients had undergone posthematopoietic stem cell transplant.

• SITE: Single-site    
• SETTING TYPE: Multiple settings    
• LOCATION: Home and “health care” gym

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Elder care  

Phase II randomized controlled trial with an exercise group and a wait-list control group that could cross over to the exercise group at week 12.

• Primary outcome measures included both global quality of life (QOL) and fatigue.
• QOL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).  
• Functional Assessment of Cancer Therapy–Fatigue (FACT-F)
• Secondary outcome measures included the Edmonton Symptom Assessment Scale (ESAS).

Recruitment and retention rates were 31% and 91%, respectively. The adherence rate was 28%. The analyses did not suggest statistically significant or clinically important benefits in QOL, fatigue, or physical fitness between groups. There were no adverse events.

Successful recruitment with low adherence and limited effects on clinical outcomes including fatigue.

• Small sample (< 100)
• Risk of bias (no blinding)
• Measurement/methods not well described
• Other limitations/explanation: The description of the cross-over of patients from the control group is confusing and inconsistently described from the actual protocol.

Further study is needed in this population including how to enhance exercise adherence.

To determine the feasibility of an exercise intervention among women receiving treatment for breast cancer and to examine the effects of exercise on hemoglobin (Hb) and maximum oxygen volume (VO2MAX) and their association with changes in cancer-related fatigue (CRF) and quality of life (QOL) while investigating changes in selected inflammatory markers

The intervention consisted of a supervised, progressive treadmill exercise program two to three times times per week delivered in a rehabilitation center for the duration of chemotherapy (9–12 weeks).

• N = 14  
• AGE = Aged 21 years and greater
• FEMALE: 100%
• KEY DISEASE CHARACTERISTICS: Stages I–II breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: No history of depression, arthritis, or joint pain in the prior three months; engaged in regular exercise for five days per week in past three months; other uncontrolled conditions 

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: Southern California and Virginia

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care  

Random assignment with repeated measures

• Feasibility: Measured by recruitment, retention, adherence to exercise protocol, tolerance of exercise testing, and the completion of data collection
• Efficacy: Measured by Hb concentration (venous blood), VO2MAX (using the Trackmaster TM500/S^® by JAS Fitness Systems in Carrollton, TX), CRF (Piper Fatigue Scale [PFS]), QOL (Functional Assessment of Cancer Treatment - Breast [FACT-Breast]), and inflammatory markers (IL6, IL10, cortisol, and myeloperoxidase) using laboratory kits

Feasibility: The recruitment rate was 45.7%, the retention rate was 87.5%, the adherence rate was 95%–97%, and the tolerance rate was 93%.  

Efficacy: There were no differences in VO2MAX at baseline between the groups. The exercise group maintained pretreatment VO2MAX levels throughout chemotherapy, and the usual-care group showed a significant decline of as much as 6.3 ml/kg per minute that continued three to four weeks after treatment. CRF outcomes favored the exercise group, and QOL, physical well-being, and functional well-being declined significantly in both the experimental and usual-care groups.

Recruitment to exercise interventions is difficult. The type of exercise, location, and the choice of a self-lead or a supervised intervention may influence the decision to participate. Retention may be influenced by flexibility in scheduling and the allowance of make-up sessions. Exercise did not have a significant effect on CRF or QOL. Changes in the inflammatory markers favored the exercise group. Exercise may protect against a decline in VO2MAX but not Hb concentrations.

• Small sample (< 30)
• Risk of bias (no blinding)
• Risk of bias(sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results 
• Findings not generalizable
• Intervention expensive, impractical, or training needs

This study addressed exercise dose in terms of intensity, duration, and frequency when prescribing exercise as an intervention. The inclusion of inflammatory markers is a potential benefit that future research could use to quantify the effects of an exercise intervention.

To explore the interdependence of changes in oxygen uptake, quality of life (QOL), and cancer-related fatigue (CRF) during a four-month exercise intervention

Aerobic exercise capacity was determined by a physician-supervised cardiopulmonary exercise test on an electrically braked cycle ergometer. An initial watt load of 0 watts was increased by 25 watts every three minutes until exhaustion. The results were used at an initial exercise counseling session to individualize exercise plans (i.e., frequency of three to five times per week, intensity, type of exercise, opportunity to participate in a Nordic walking training session once per week). Subjects attended a second counseling session four weeks into the intervention to adjust home-based exercises to fit their conditions. An exercise counselor was available by phone, via email, or in person at any time during the intervention. Assessments were repeated at the end of 16–20 weeks. Self-reported measures of adherence to exercise plans were obtained by diaries.

• N = 101  
• AGE RANGE = 32–85 years
• MALES: 40%, FEMALES: 60%
• KEY DISEASE CHARACTERISTICS: Confirmed cancer diagnosis (any site and stage) within the past three years; during adjuvant, palliative, or postadjuvant therapy (finished within the past 12 months); performance status of 0–II (as ranked by the Eastern Cooperative Oncology Group); exclusion criteria included brain or bone metastasis, uncontrolled hypertension, hemoglobin counts < 8 g/dl, and any condition precluding exercise

• SITE: Multi-site    
• SETTING TYPE: Multiple settings    
• LOCATION: Germany

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care 

Repeated measures pre- and postintervention

• Aerobic exercise capacity measured by a cardiopulmonary exercise test (CPET) and the peak oxygen consumption (VO2PEAK) 
• QOL measured by the European Organisation for Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 v.3.0)

Subjects were active (i.e., hiking, biking, walking, bicycling) three to six times per week for 60–300 minutes at 60%–100% of individual anaerobic thresholds. At baseline, the groups differed in QOL scores but not CRF or VO2PEAK scores. Subjects with complete data sets had a significant increase in VO2PEAK and QOL scores, and their fatigue decreased significantly over the course of the intervention. No significant effect for diagnosis or time since diagnoses occurred.

A relationship between exercise capacity enhancement, QOL improvement, and fatigue symptom reduction exists during and shortly after cancer treatment.

• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Findings not generalizable
• Questionable protocol fidelity

The data in this study support the role of individualized exercise planning based on baseline exercise capacity with respect to frequency, time, and intensity as well as the importance of patient choice in the type of exercise in which to participate.

To examine the effects of a home-based walking program on quality of life and fatigue.

Women were randomized to the usual care, wait list control, or intervention groups. Those in the intervention group received a 30 minute in-person counseling session and follow-up telephone counseling calls in weeks 1, 2, 4, 7, and 10. Counseling calls applied constructs of social cognitive therapy, discussing specific behavior change principles that could be used to increase walking, using a semi-structured script. Walking plans were designed for gradual increases in frequency, duration, and intensity. Women in the usual care group were asked to maintain their usual activity levels. Those in the intervention group were asked to keep daily activity logs and were given pedometers.

• N = 32  
• MEAN AGE = 55 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer, stages I–III. All had completed adjuvant treatment within the last 12 months.

• SITE: Single site  
• SETTING TYPE: Home  
• LOCATION: South Carolina

• PHASE OF CARE: Transition phase after active treatment

• RCT

• SF-36^®
• Physical activity logs
• Pedometer
• International Breast Cancer Study Group QOL Core Questionnaire
• Functional Assessment of Cancer Therapy–Fatigue
• Community Health Activities Model Program for Seniors (CHAMPS) questionnaire

Fatigue declined in all patients. There was a greater decline among the intervention group, but the difference was not significant. Estimated activity level of walking METs was not significantly different between groups at baseline, but levels post-intervention are not reported. Overall, participants in the intervention group completed 86% (range = 62%–100%) of prescribed walking sessions.

Findings suggest relatively good adherence to home-based walking prescriptions and suggest that this activity may improve fatigue symptoms.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Questionable protocol fidelity
• Other limitations/explanation: No measures were taken to check phone follow-up fidelity. Fifty percent of patients in the control group were African American, compared to only 10% in the intervention group. The intervention group was almost twice as large as the control group.

Findings suggest that a prescription for a home-based walking program can be a practical way to improve or maintain physical activity among women with breast cancer after initial treatment, and that this activity can improve symptoms of fatigue. There were multiple limitations to this study; however, multiple studies have shown that exercise is effective to reduce fatigue. Previous findings regarding self-managed exercise programs have been mixed. This pilot study suggests that a prescription for exercise, patient counseling and follow-up contacts may facilitate performance of home-based exercise.

To demonstrate the effects of an exercise program on endurance, strength, lung function, and quality of life in patients undergoing allogeneic transplantation.

Forty-seven patients undergoing allogeneic transplantation during a three-year period were recruited and randomized into either the exercise group (EG) or the control group (CG). The EG received daily aerobic endurance training with a cycle and ADL training, involving relaxation, stair climbing coordination, and strengthening. Exercise was done 20–30 minutes per day, twice daily. CG patients received standard physiotherapy for 20 minute five days per week, consisting of active and passive mobilization with low intensity. Fatigue measurement was conducted two days after admission and one day before discharge. Exercise began the first day after transplantation.

• N = 33
• MEAN AGE: EG 41.41 years, CG 42.81 years
• MALES: EG 6%, CG 3%; FEMALES: EG 3.5%, CG 7%
• KEY DISEASE CHARACTERISTICS: Patients with malignant hematologic disease undergoing bone marrow transplantation

• SITE: Single site  
• SETTING: Inpatient
• LOCATION: Center of Transplantation in Idar-Oberstein, Germany

• PHASE OF CARE: Active treatment

• RCT

• Modified WHO test on a cycle ergometer (aerobic endurance)
• Digimax2000-load cell (strength) 
• Vital capacity, forced vital capacity (lung function)
• EORTC-QLQ C30 (quality of life)

Increase in the experience of fatigue in the CG. Deterioration of physical function was seen in both study groups. There was improved emotional state for patients in the EG (p = .028). Relative endurance improved in EG both groups. There was no significant group by time effect on fatigue. No effect for strength, lung function, or anthropometric assessments reached significance in either group.

The only significant difference between the two groups was found in relative endurance in favor of EG.

• Small sample (< 30)
• Patients, therapists, and outcome assessors were not blinded to the groups.  
• Some patients in the CG exercised on the cycle ergometers that were used in the EG.
• It was stated that exercise would not be done if patients were unable to participate due to clinical condition, etc., but no information is provided regarding the actual percent who were able to adhere to the exercise schedule.

Physical activity during acute phase of transplantation appears safe and can improve physical endurance and strength.

To investigate the feasibility of an intervention aimed at increasing exercise participation and improving dietary behavior in survivors of colon cancer and obtain preliminary data on the effect of the intervention on fatigue, exercise, and dietary outcomes.

Patients were randomly assigned to intervention or standard care control groups. The 12-week intervention included supervised and home-based exercise and dietary advice. During the first six weeks, the experimental group attended two group supervised exercise sessions of 30 minutes of aerobic exercise. Participants were asked to continue the same time of activities at home once a week during the same period and were asked to keep an exercise log. During the last six weeks, participants attended a supervised session once a week and were to perform two weekly home-based exercise sessions. Participants were given a dietary advice information pack and periodically attended healthy eating seminars encouraging reduction in saturated fat, increased fiber intake, reduction in refined carbohydrates, and limited alcohol intake.

• The sample was comprised of 18 survivors of colon cancer.
• Mean age was 69 years (range 52–80); 66.6% of patients were female and 33.3% were male.
• Of the patients, 83.3% had undergone surgery and one-third had received chemotherapy.
• Average time from the end of treatment was slightly greater than 16 months.

• Single site
• Outpatient
• United Kingdom

Patients were undergoing the transition phase after initial treatment.

This was a randomized, controlled trial that was single-blinded for some outcome measures.

• Godin Leisure Score Index for exercise behavior
• Functional Assessment of Cancer Treatment–Fatigue scale (FACT-F)
• Functional Assessment of Cancer Treatment–Colorectal scale (FACT-C) for quality of life
• Skeletal muscle fatigability assessed via electromyogram (EMG) signal analysis

There was an overall 90% attendance rate at supervised exercise sessions and a 77% attendance rate at dietary seminars. Of those in the intervention group, 66.6% returned exercise logs, and among these, there was a 94% rate of adherence to independent aerobic exercise for 25 to 30 minutes. There was no significant difference between groups in exercise behavior. Fatigue scores improved significantly in the intervention group (p = 0.005) compared to controls. There was a significant increase in dietary fiber intake (p = 0.044), with no other differences in dietary habits. Compared to controls, there were significant improvements in chair sit to stand performance (p = 0.003) and aerobic exercise tolerance (p = 0.01).

Combined supervised group and home-based individual exercise with dietary education was shown to be feasible and demonstrated preliminary positive effects on fatigue and dietary fiber intake.

• The study had a small sample size, with less than 30 participants.
• Standard care was not described.
• There is no information about other interventions or symptoms that might affect outcomes.
• The study design lacked an attentional control.
• There was a 6% dropout rate.
• There was a relatively limited time frame of follow-up.
• Given no difference between groups in exercise behavior overall, findings suggested that the group aspect with seminars and supervised exercise sessions may have been the important difference.

Findings suggested that an intervention combining some group supervised exercise and some home-based exercise is feasible and can be effective in reducing fatigue. Further research in this area is warranted as researchers attempt to determine the most effective ways to provide exercise interventions that patients will adhere to. The combination of some group periodic supervised sessions may improve patient motivations to adhere to a program, given the relatively low dropout rate seen here. This study was performed after completion of cancer treatment.

To evaluate the feasibility and efficacy of an eight-week, supervised exercise program in deconditioned cancer survivors within two to six months of chemotherapy completion

Twice-weekly, aerobically-based group sessions in a hospital setting for a duration of eight weeks plus a home exercise program.

• SITE: Single-site    
• SETTING TYPE: Other    
• LOCATION: Ireland

• PHASE OF CARE: Late effects and survivorship

Prospective, two-arm, randomized controlled trial

• Feasibility: Demand and recruitment rates
• Adherence: Heart rate monitor, diaries, observation, and attendance
• Acceptability: Exit participant interviews
• Fitness: Modified Bruce Protocol (MBP)
• Quality of Life: Functional Assessment of Cancer Therapy–General (FACT-G)
• Fatigue: Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F)
• Physical Health: Physical Function Scale (PFS) of the Short Form (SF) 36
• Physical Activity (PA): RT3 triaxial accelerometer and self-report using the Godin Leisure Time Exercise Questionnaire

Feasibility: 81% eligible patients were recruited to the study. Conflicting data on drop-outs were presented. Exercise intervention was positively received as noted in exit interviews with subjects. Adherence to supervised and home-based exercise intervention was good (76% to 105%, respectively). There were no statistically significant differences between the groups for any health-related fitness outcomes. Total FACIT and fatigue subscale scores were better in the exercise group at three months (mean difference = 6.2, 95%, CI 1.4–11.0).

• Small sample size (< 100)
• Baseline sample/group differences of import: Gender, treatment, and stage of cancer
• Risk of bias (sample characteristics): Gender, treatment, and stage of cancer
• Key sample group differences that could influence results: Majority of sample was female; there was a disproportionate distribution of radiation/chemotherapy-treated patients and patients with late/early-stage in exercise and control groups.
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%: The explanation of withdrawals and reasons do not match the number of subjects that completed assessments at each phase.
• Other limitations/explanation: Variability of activities for home exercise program.

Data support the benefit of exercise to address cancer-related fatigue in the early survivorship period. However, sample was “healthy” with few co-morbidities and, although deconditioned, did not include older adults (> 65 years of age), which raises questions about safety and which type and dose of exercise should be recommended to the large group of cancer survivors who continue to experience cancer-related fatigue.

To evaluate the effect of physical exercise on terminally ill patients with cancer.

Patients in the exercise group exercised three times a week for 20 to 30 minutes for a three- to four-week period. The schedule of exercises was individually planned by a physiotherapist. Study outcome measures were obtained at baseline, weekly, and at the end of the study. No information was provided regarding the control group procedures.

• The sample was comprised of 49 patients. 
• No age, gender, or diagnosis information was provided. 
• All patients were in hospice either at home or in an inpatient hospice setting.

• Multisite
• Inpatient and outpatient
• Poland

Patients were undergoing end of life care/end of life and palliative care phase of care.

This was a two-group comparative trial – no information was provided on whether patients were randomly assigned.

• Fatigue visual analog scale (VAS) (0-10)
• Rotterdam symptom checklist
• Brief Fatigue Inventory (BFI)

There were no apparent effects on outcomes during the first two weeks. By week 3, mean VAS intensity of fatigue declined in the exercise group from 6.5 to 5.5. In the control group, fatigue increased from 6.5 to 7.5 (ANOVA; p < 0.001). Physical symptoms tended to decline slightly in the exercise group and increase slightly in the control group, with changes ranging from 0.1 to .05 (p < 0.05). There were no observable effects on quality of life scores from the symptom checklist data.

Results suggested that individualized exercise can be beneficial for fatigue in terminal patients with cancer.

• The study had a small sample size, with less than 100 participants.
• It was not clear how patients were assigned to study groups.
• No demographic or disease-related information was reported, so any relevant differences between groups that might affect findings cannot be determined.
• BFI results were not reported, and only a VAS fatigue measure analysis was given.
• Use of the symptom checklist for the single quality of life measure is questionable.
• Statistically significant outcome changes seen here were very small.
• The types of exercise provided were not described.

The study did not provide strong evidence for the effectiveness of exercise due to multiple issues in this report and the small measured changes seen. Findings suggested that exercise may be beneficial in terminally ill patients and showed that there were no apparent adverse effects from the activity provided to these patients.

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.

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.

• 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.

• Single site
• Outpatient
• Spain

Patients were undergoing the transition phase after active treatment.

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

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

• 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.

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.

• 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. 

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.

To report the effects of a strength training and walking program in patients with stage IV lung and colorectal cancer.

Patients were given usual care or 1.5 hours of training by a physical therapist on rapid, easy, strength training exercises (REST) and pedometer-based walking using an instruction manual, resistance bands, an exertion rating scale, and a study log. They were then followed bimonthly by telephone for eight weeks.

• The study reported on a final sample of 56 patients.
• Mean patient age was 63.8 years in the intervention group and 65.5 years in the control group.
• The intervention group was 48.5% male and 51.5% female. The control group was 57.6% male and 42.4% female.
• Patients had stage IV lung or colorectal cancer.

• Single site 
• Outpatient setting
• Mayo Clinic

Patients were undergoing the end of life phase of care.

The study was a single-blinded, randomized, controlled trial.

• Activity Measure for Post-Acute Care Computerized Adaptive Testing (AM-PAC CAT)
• AM-PAC Mobility
• Functional Assessment of Cancer Therapy-General (FACT-G)
• FACT-Fatigue (FACT-F) subscale
• Numerical rating scale for pain and sleep quality
• Pedometer step-count logs
• REST logs
• Vital sign collection

Mobility, fatigue, and sleep measures were statistically significant between the intervention and control groups from baseline to week 8 (p = 0.002, p = 0.03, and p = 0.002, respectively), in favor of exercise. Other measures did not show significance. The number of REST sessions and weeks logged with step counts were associated with changes in the mobility score. Survival and withdrawals did not differ significantly between the groups.

A home-based intervention using walking and strength exercises may improve mobility, fatigue, and sleep quality in patients with stage IV colorectal or lung cancer.

• The study had a small sample size, with less than 100 participants.
• The study had risks of bias due to no blinding and no appropriate attentional control condition.

The teaching of walking exercises and strength routines may improve functioning in this patient population in terms of mobility, sleep quality, and fatigue. The one-time education session may be appealing to nurses looking for a timely intervention to help improve these symptoms.

To compare usual care with a home-based individualized exercise program (HBIEP) in patients receiving intensive treatment for multiple myeloma (MM) and epoetin alfa therapy.

This was a randomized trial with repeated measures of two groups (one experimental and one control) and an approximate 15-week experimental period for the HBIEP. The control group received a recommendation to walk 20 minutes three times per week. In the HBIEP, patients were given color-coded stretch bands and materials to illustrate exercises to be used, and they were to perform aerobic walking to reach 65% to 80% of the maximal heart rate. Patients mailed in weekly activity summaries. Assessments were performed at baseline, 10 to 12 weeks later prior to the second chemotherapy cycle, and three to four weeks later when finishing stem cell collection.

• The study was comprised of 187 patients (92 in usual care and 95 in the intervention).
• Age ranged from 35 to 76 years in the usual care group and 25 to 76 years in the intervention group.
• In the usual care group, 60% of patients were male and 40% were female.  In the intervention group, 57% of patients were male and 43% were female.
• Patients were newly diagnosed with MM and were eligible for treatment with an aggressive protocol that included stem cell transplant. 
• The majority of patients were well educated and had great motivation to exercise. The intent of the intervention was to determine whether specific exercises were more effective in improving sleep and decreasing fatigue.

• Single site
• Multiple settings
• Southern United States international referral center

• Patients were undergoing the active antitumor treatment phase of care.
• The study has clinical applicability for elder care. 

This was a randomized, controlled trial with repeated measures of two groups and a 15-week experimental period.

• Profile of Mood States (POMS) Fatigue Scale
• Functional Assessment of Cancer Therapy-Fatigue (FACT-F)
• Actigraph recordings
• Six-minute walk test
• Hemoglobin levels at baseline and before and after stem cell collection
• Descriptive statistics used to compare demographics
• Treatment effects and repeated measures ANOVA used to determine effects of HBIEP

No statistically significant differences existed among the experimental and control groups for fatigue, sleep, or performance (aerobic capacity). Statistically significant differences (p < 0.05) were found in each of the study outcomes for all patients as treatment progressed, and patients experienced more fatigue and poorer nighttime sleep and performance.

The effect of exercise seemed to be minimal on decreasing fatigue, improving sleep, and improving performance. Exercise is safe and has physiologic benefits for patients undergoing MM treatment and, when combined with epoetin alfa, helped to alleviate anemia.

• The study had a risk of bias (sample characteristics) because it consisted of mostly well-educated patients.
• A key sample group difference that could influence the results included the inclusion of mostly well-educated patients.
• Patients self-reported compliance with HBIEP. This was a home-based program, so no observation was performed. 
• Patients in the control group were not discouraged from exercising.
• No patient could perform the strength tests.
• Anemia was present at baseline in the majority of patients, and all participants would become anemic with treatment; therefore, all patients received treatment for anemia, which potentially limited the results.

Although the results might indicate no derived benefit, patients became more fatigued, slept less, and experienced a decline in performance with more treatment. The HBIEP group required fewer red blood cell transfusions to maintain a similar hemoglobin level, less platelet transfusions, and fewer days to collect stem cells. When combined with epoetin alfa therapy, exercise had an effect in decreasing cancer-related anemia and improving cell count recovery after high-dose chemotherapy. These are benefits to patients and the healthcare economy. Cancer rehabilitation exercises may result in improved performance. Having fatigue prior to treatment might predict having fatigue after treatment. Energy conservation measures should be considered with endurance and resistance exercises. Rehabiltation therapy might be needed for deconditioned patients. Exercise should be tailored individually based on the patient's disease stage, presence of bone lesions, and values. The HBIEP may have helped to alleviate anemia, but there is no evidence that HBIEP combining muscle strengthening and aerobic walking exercises decreases fatigue.

To determine if supervised exercise minimizes toxicity in patients receiving androgen deprivation therapy (ADT)

Patients were randomly assigned to usual care or a three-month exercise program. The program included aerobic and resistance exercise sessions two times per week in various exercise clinics. Sessions were conducted in groups and supervised by exercise physiologists. Sessions were 60 minutes in length involving moderate- to high-intensity aerobics. Study measures were obtained at baseline and after three months.

• N = 63
• MEAN AGE = 68.4 years
• MALES: 100%         
• KEY DISEASE CHARACTERISTICS: Prostate cancer receiving ADT

• SITE:  Multi-site
• SETTING TYPE:  Outpatient  
• LOCATION:  Australia

Randomized controlled trial

• Body composition measures
• 400 m walk test
• Static balance test
• Activities Specific Balance Confidence scale for falls self efficacy
• SF-36
• EORTC-QLQ-PR25
• FACIT Fatigue scale
• Brief Symptom Inventory (BSI) for anxiety and depression

Exercise participants attendance at sessions ranged from 14-24 sessions out of a possible 24 sessions. There was a non-significant trend for those in the exercise group to have less loss of lean body mass. Fatigue scores (SF-36) remained stable in the exercise group, whereas fatigue increased in the control group (p = 0.045). Depression remained stable in the exercise group and increased in the control group (p = 0.054). There was no difference between groups in anxiety.

Participation in a group-based, supervised, moderate- to high-intensity exercise program was associated with lower fatigue and improvement in some functional domains after three months when compared to usual care. No significant impact was noted on anxiety or depression.

• Small sample (less than 100)
• Risk of bias (no blinding)
• Measurement validity/reliability questionable
• Subject withdrawals 10% or greater
• Other limitations/explanation:  More patients in usual care withdrew and there is no clear ITT analysis. BSI measures were only for anxiety and depression.

The findings add to the body of evidence that exercise is beneficial for patients with cancer to reduce fatigue associated with cancer and cancer treatment.

To examine effects of a rehabilitation program

Patients were randomly assigned to an early exercise group or a delayed exercise group. Participants attended rehabilitation sessions five times per week for four weeks. Sessions involved the use of upper and lower extremity stretching, aerobic, and strengthening exercises. During weeks 1–4, the early exercise group participated, and during weeks 4–8, the delayed group participated. Patients were evaluated at baseline and at two, four, six, and eight weeks.

• N = 62  
• MEAN AGE = 46.1 years (SD = 8.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer; 53% had a lumpectomy; and all completed initial cancer treatment

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: South Korea

• PHASE OF CARE: Active antitumor treatment

Randomized, parallel group trial with repeated measures

• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30)
• Cycle test for cardiorespiratory function
• Fatigue Severity Scale (FSS)
• Muscle strength measurements

Patients in both groups showed significant improvements in all measures except body image (p < 0.001). The greatest improvements were shown during the period of time that individuals were participating in the exercise sessions in both groups. There was no significant difference between groups.

The exercise combinations used here were effective in reducing fatigue and improving quality of life among participants

• Small sample (< 100)
• Risk of bias (no blinding)
• Other limitations/explanation: Out of the 212 people who initially consented, only 62 actually participated in the study. This suggests that the program may not be acceptable to the majority of patients. There is a possible testing effect with repeated measures over a short period of time. No information is provided regarding adherence to exercise sessions.

The findings of this study add to the already extensive body of evidence that various forms of exercise are beneficial to reduce fatigue in patients with cancer. This study showed effects specifically during the time in which participants were exercising, suggesting the need for ongoing involvement in activity to maintain effectiveness

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

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.

• 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

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

PHASE OF CARE: Transition phase after active treatment

Prospective, randomized controlled study

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

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.

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.

• 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

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.

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.

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.

• 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.

• Single site
• Outpatient
• Turkey

The phase of care was late effects and survivorship.

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

• 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
   

• 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.

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.

• 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.

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

To evaluate the effectiveness of a the telehealth-delivered exercise intervention on symptoms among breast cancer survivors

Patients were randomized to the telehealth intervention or usual care. After baseline assessment, those in the study group received instructions on how to access the private area of the system. The intervention consisted of three sessions per week of exercise following recommendations of the American College of Sports Medicine for cancer survivors. Each session was delivered online. The system allowed participants to send messages and set up video conferencing, participants to write questions or comments, and research staff to comment and monitor performance remotely. Participants received phone calls from research staff if needed. The intervention lasted eight weeks. Usual care patients received basic written recommendations for exercise. After six months, they were offered the opportunity to participate in the telehealth program. Assessments were done at baseline, at completion, and at six months.

• N = 72   
• MEAN AGE = 48.3 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: All had breast cancer and previous surgery. Most also had previous radiotherapy and chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: Most had surgery within the last 12 months.

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

• PHASE OF CARE: Late effects and survivorship

• Randomized, controlled trial

• EORTC Cancer Core Quality of Life (EORTC QLQ-C30) and EORTC Breast Cancer Quality of Life (QLQ-BR23)
• Brief Pain Inventory (BPI)
• Handgrip strength
• Isometric abdominal and back strength 
• Sit-to-stand test for lower body strength
• Piper Fatigue Scale (PFS)

After the intervention, the telehealth group reported lower pain severity (p = 0.001) and interference (p = 0.045). The telehealth group reported improved total fatigue perception compared to controls (p = 0.001). This improvement was maintained at the six month follow-up (ES d = –0.75, p = 0.002). Adherence rate for exercise sessions was 93.9%. Muscle strength and quality of life (QOL) were also improved in the telehealth group compared to controls. There were no technical issues or adverse effects of the intervention observed.

An online exercise and interaction approach was effective in reducing pain and fatigue and improving QOL and muscle strength. The program had good patient adherence.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Intervention was expensive and impractical, or training needs existed.
• Baseline pain and type of pain are not reported.  
• Baseline fatigue was lower among the intervention group.
• Authors noted that a large number of staff were involved in the provision of this program, which may limit the ability to sustain this type of program.

The online delivery of an interactive exercise intervention was shown to be effective. An Internet-based intervention may be a useful alternative to traditional approaches to deliver such interventions, particularly in the setting of barriers such as distance and time. The comparative costs for staff time to deliver and maintain this type of intervention need to be evaluated.

To evaluate the effectiveness of a self-managed, home-based walking program of moderate intensity

Prior to randomization, patients completed baseline questionnaires before beginning chemotherapy and after completing two of six cycles of chemotherapy. Patients were then randomized to usual care control or usual care plus exercise groups. Patients in the exercise group were given an intervention booklet with recommendations to ensure adherence, tips, guidance, and a diary to keep a log of walking duration and intensity. Self-management strategies used for guidance were based on the theory of planned behavior, including setting weekly goals, reflecting by writing achievements and shortfalls, and modifying goals. Pedometers were provided to the walking group. The intervention lasted 12 weeks.

• N = 50   
• MEAN AGE = 53.7 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: All had breast cancer, and most were grade 2 or 3; 72% were postmenopausal.
• OTHER KEY SAMPLE CHARACTERISTICS: Sixty percent were reported to be inactive at baseline.

• SITE: Single site   
• SETTING TYPE: Home    
• LOCATION: United Kingdom

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Hospital Anxiety and Depression Scale (HADS)
• Functional Assessment of Cancer Therapy (FACT)-Fatigue scale
• Self-Esteem Scale
• Profile of Mood States (POMS) short form
• Borg Rating of Perceived Exertion (RPE) scale
• Pedometer measures of steps taken each day
• General Practice Physical Activity Questionnaire

Eighty percent adhered to the intervention based on walking diaries. Group by time analysis showed that the intervention had a positive effect on fatigue (p = 0.02). No effects on anxiety or depression as measured by HADS were reported.

The self-managed, home-based walking program had a positive effect on fatigue.

• Small sample (< 100)
• Risk of bias (no blinding)

This study adds to the body of evidence showing that exercise has a positive effect on fatigue. A self-managed, home-based walking program is a practical approach to incorporating activity during active treatment. 

To evaluate two modes of delivery of an exercise intervention:  provided either face-to-face or via the telephone.

Women were randomized to one of three groups:  face-to-face exercise, telephone exercise intervention, or usual care.  For those in the exercise interventions, the intervention involved 16 sessions, starting weekly and tapering to monthly contact after four months.  The exercise prescription was provided in sessions to progress to exercising 45 minutes at least four days per week, incorporating both aerobic and strength-based exercise.  Assessments were performed at baseline and six weeks, six months, and 12 months postsurgery.

• One hundred ninety-four participants were included.           
• Median age was 52 years (range 29–70).
• One hundred percent of patients were female.
• All patients had breast cancer; 69% were getting chemotherapy during the trial, 71% were receiving radiation therapy, and 64% began hormone therapy.

• Single site       
• Outpatient        
• Australia

Patients were undegoing the active antitumor treatment phase of care. 

This was a single-blind, randomized, controlled, longitudinal study.

• Functional Assessment of Cancer Therapy (FACT) – Breast
• Functional Assessement of Chronic Illness Therapy – Fatigue (FACIT)
• Disabilities of the Arm, Shoulder, and Hand Questionnaire
• Greene Climacteric Scale
• Neuropathic pain scale
• Three-minute step test (fitness measure)

Upper body function and adverse effects, such as menopausal symptoms, pain, anxiety, and depression, improved over time for all patients, with no differences between groups. The adherence rate was 88% in the face-to-face exercise group and 81% in the telephonic intervention group.  Patients in both exercise intervention groups showed greater improvement in fatigue symptoms over time (p = 0.032). At the end of the study, fatigue scores improved by 4.9 points in the face-to-face intervention and by 6.8 points in the telephonic group.  In the usual care group, fatigue initially got worse; however, scores improved by 4.6 points by 12 months. Sixty-six percent of those in the usual care group also participated in at least 180 minutes of physical activity per week and had an increased level of activity from baseline.  Quality of life improved significantly more in the intervention groups over time (p = 0.03)

Findings suggested that delivery of an exercise prescription and instruction via the telephone can be an effective method of delivering an exercise intervention for women with breast cancer.  Results of this study support those of others demonstrating improvement in symptoms in all patients over time, but significantly greater improvement in fatigue with exercise interventions.

• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Unintended interventions or applicable interventions not described would influence the results.
• Findings were not generalizable.
• Patients were not blinded, and it was noted that control group patients also increased their activity, which could have confounded the results.  Although adherence to the exercise intervention was measured, mainly educational and motivational in nature, actual performance of exercise was not clearly measured.

Findings suggested that providing an exercise prescription might be an effective way to engage patients in exercise, which can reduce symptoms of fatigue.  This study demonstrated that providing an exercise program intervention via telephone contact can be as effective as engaging patients in a face-to-face intervention. This suggests that telephonic contact to teach and motivate patients to exercise may be an effective and practical way to deliver an intervention.

To evaluate the feasibility, safety, acceptability, and effects of a home-based exercise intervention.

Patients were screened for inclusion, and baseline measures were obtained prior to surgery. Each patient was assigned a primary nurse for the duration of the study to ensure continuity of care. Prior to surgery, participants were taught approaches to increase self-efficacy in self-management of fatigue and were prepared to participate in the exercise intervention after surgery. Within three days of hospital discharge, patients were contacted by telephone and screened for readiness to start exercise. When ready, a home visit was scheduled to set up the exercise equipment (the Nintendo Wii Fit Plus), the particpant was educated in the exercise intervention, and teaching for self-management was reinforced. The exercise intervention provided a virtual reality scenario for walking. After week 2, another home visit was performed, and telephone contacts were made at three and six weeks. Patients completed study tools at the end of six weeks via mail.

• Seven participants (28.6% male, 71.4% female) were included.
• Mean age was 64.4 years (range 53–73).
• All participants had lung cancer and were postthoracotomy.  
• Most participans were employed and had no children living at home. 
• Comorbid conditions included osteoarthritis, hypertension, and chronic obstructive pulmonary disease.  
• Some patients started chemotherapy and/or radiation therapy within the study period.

• Multisite 
• Home 
• Michigan

Patients were undergoing the active antitumor treatment phase of care.

This was a prospective, single-group, feasibility trial.

• Acceptability questionnaire
• Brief Fatigue Inventory (BFI)
• Fatigue Self-Management Instrument
• Self-efficacy for walking instrument
• Walking duration instruments
• Activities-Specific Balance Confidence (ABC) scale
• Daily diary to record fatigue and exercise use

Mean adherence to the exercise intervention was 96.6% (range 90%–100%). Participants reported a high level of satisfaction with the exercise intervention.  Overall decline in fatigue was seen from postsurgery to the end of the study. All participants stated that the intervention helped them to manage their fatigue. Fifty percent of those approached for participation consented and completed the study.

Use of the Nintendo Wii Fit Plus sytem for a home-based exercise intervention was shown to be feasible and effective in helping patients self-manage fatigue in this small study.

• The study had a small sample size, with less than 30 participants.
• The study had risks of bias due to no control group, no blinding, no random assignment, and no appropriate attentional control condition.
• Measurements/methods were not described.
• The intervention was expensive, impractical, and had training needs.
• Tools used in the study were not well described. 
• The Nintendo Wii Fit Plus system has associated costs that would need to be met.

Findings suggested that use of home virtual reality exercise programs, such as the Nintendo Wii Fit Plus system, can be a feasible and effective way to promote exercise for the self-management of cancer-related fatigue.

To explore the efficacy of a virtual reality home-based exercise program for managing fatigue during adjuvant therapy in patients with postthoracotomy lung cancer.

Patients were initially provided self-management education for fatigue and a Nintendo Wii system for walking and balance exercise in the home. Nurses initiated the program in a home visit, performed follow-up at two weeks, and contacted patients via telephone for reinforcement at three and six weeks in the initial study. This report involved extension of the initial study for an additional 10 weeks while patients were receiving adjuvant therapy. Patients wore a pedometer to record the number of steps per day and were to use the program five days per week.

• Seven participants (28.6% male, 71.4% female) were included in the study.
• Mean age was 64.4 years (range 53–73).
• All participants were postthoracotomy for non-small cell lung cancer. 
• Five patients began chemotherapy at five weeks postsurgery.

• Multisite 
• Home 
• Michigan

Patients were undergoing the active antitumor treatment phase of care.

This was a prospective trial.

• Acceptability questionnaire
• Brief Fatigue Inventory (BFI)
• Fatigue Self-Management Instrument
• Self-efficacy for walking instrument
• Walking duration instruments
• Activities-Specific Balance Confidence (ABC) scale
• Daily diary to record fatigue and exercise use

Adherence to the exercise protocol declined slightly from the previous six-week study to an overall adherence of 87.6% (range 59%–100%). All patients reported unmanaged symptoms unrelated to the exercise at some point in the 10 weeks. Fatigue scores increased slightly from weeks 6 to 14 and then declined further. Self-efficacy for walking and self-management were relatively stable. There was high variability in the average walking steps per day from the pedometers.

Results suggested continued feasibility and overall efficacy of the virtual reality home-based exercise and balance program tested. Findings showed that, over longer periods of time, program adherence declined and was more variable. Some of this variability in exercise adherence and fatigue scores may be associated with periods of adjuvant chemotherapy and radiation therapy.

• The study had a small sample size, with less than 30 participants.
• The study had risks of bias due to no control group, no blinding, no random assignment, and no appropriate attentional control condition.
• The intervention was expensive, impractical, or had training needs.
• The Nintendo Wii system had associated costs.

The use of a home virtual reality–based approach to facilitate exercise among patients with cancer is a promising approach for self-management of fatigue.  Larger well-designed research using this approach is warranted.

To design and test the feasibility and acceptability of a postsurgical intervention with exercise for patients with non-small cell lung cancer to promote perceived self-efficacy for fatigue self-management targeting cancer-related fatigue (CRF) severity and its associated fatigability

Participants performed warm-up exercises designed for the patient population. Wii walking was self-paced and comfortable for participants with the Wii exercise equipment, creating a virtual environment in a town of happy people providing encouragement to continue. Patients started walking five minutes each day for five days during week 1 and increased by five-minute intervals per day until a goal of 30 minutes per day of Wii walking was reached by week 6. The nurse assessed each participant’s readiness to advance the walking prescription. Participants also completed balance exercises five days a week from weeks 1 to 6 from a menu of predetermined Wii balance exercises, which used a gaming format. Data were recorded in the participants' daily diaries and confirmed by research staff as recorded in the Wii Fit Plus.

• N = 72   
• AGE RANGE = 37–89 years
• MEAN AGE = 67 years
• MALES: 44%, FEMALES: 56%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Early to late stage suspected non-small cell lung cancer receiving a surgical intervention
• OTHER KEY SAMPLE CHARACTERISTICS: Participants had to be at least 21 years of age; have a Karnofsky Performance Status of 70% or greater; have medically stable comorbid conditions presurgery; get the approval of a surgeon prior to and after surgery; have phone access; be able to speak and write English; own a television; have no severe sensory impairment that would increase the risks of exercise; have no metastatic disease requiring portable oxygen for activities of daily living; weigh equal to or less than 330 pounds; and have no history of photosensitive seizures or dementia, which would limit safety or full participation.

• SITE: Multi-site   
• SETTING TYPE: Home    
• LOCATION: Michigan

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Elder care

Two-arm, randomized, controlled trial to compare the impact of a six-week rehabilitative CRF self-management exercise intervention post-surgical hospital discharge. The control group used a Wii-based walking and balance home program at home.

Feasibility: Rates of recruitment, adherence, retention, and monitoring of adverse events

Acceptability: 15-item acceptability questionnaire developed by the researchers

Efficacy:

• Brief Fatigue Inventory (BFI)
• Perceived Self-Efficacy for Fatigue Self-Management
• Perceived Self-Eefficacy for Walking Duration
• Activities-Specific Balance Confidence Scale
• Cancer-related fatigue self-management behaviors diary

Functional status:

• Capacity-fatigability six-minute walk test (6MWT) (fatigue reported during the 6MWT and distance walked in six minutes)
• Performance: Modified Borg Scale (fatigue severity during the 6MWT) and Medical Outcomes Study Short Form 36, version 2, Acute Recall
• Demographic questionnaire
• Modified version of the Comorbidity Questionnaire
• Smoking-Behavioral Risk Factor Survey
• Karnofsky Performance Status Score

Feasibility and acceptability: Recruitment, vulnerable population, adherence, and acceptability goals were exceeded. No adverse events were reported.

Efficacy: At week 6, interval scores for CRF, CRF self-management, walking, balance, and fatigability were significantly different (p < 0.001) between the intervention group and control group. Participants exceeded minimum walking-balance exercise behaviors during the six-week study period. Functional performance decreased postsurgery in both the control and intervention groups. Improvement occurred in weeks 1–6 for both groups but improved more slowly in the control group versus the intervention group.

A home- and Wii-based exercise and balance program for patients with lung cancer postsurgery is a feasible, acceptable, safe, and effective method to improve fatigue and fatigability in this patient population.

• Small sample (< 100)
• Risk of bias (no blinding)

Early rehabilitation exercise and balance interventions for patients undergoing surgery for non-small cell lung cancer are feasible, acceptable, and safe. Additional research is needed to determine factors to enhance adherence to exercise and balance interventions beyond the immediate postsurgical period (six weeks) and to determine their effects on prognosis and functional (physical and mental) capacity.

To describe the effects of a postsurgical home exercise intervention implemented immediately after hospital discharge on cancer-related fatigue (CRF), other symptoms, functional status, and quality of life (QOL) in individuals with non-small cell lung cancer (NSCLC)

Patient education in a hospital regarding exercise was followed by a home visit from a nurse educated on warm-up exercises, light intensity exercise such as walking, and balance exercises with a Wii. Patients were instructed to increase walking to goal of 30 minutes a day in week 6.

• N = 7  
• MEAN AGE = 64.6 years (range = 53–73 years)
• MALES: 29%, FEMALES: 71%
• KEY DISEASE CHARACTERISTICS: All received lobectomy for NSCLC; average of 5.9 comorbidities
• OTHER KEY SAMPLE CHARACTERISTICS: Five of seven patients started chemotherapy in week 5.

• SITE: Single site    
• SETTING TYPE: Home    
• LOCATION: University teaching hospital in Michigan

• PHASE OF CARE: Active antitumor treatment

Pilot study

• Brief Fatigue Inventory (BFI)
• MD Anderson Symptom Inventory (MDASI) core and lung module (symptom severity)
• Medical Outcomes Short Form-36 (MO SF-36 v.2) acute recall (function)
• Ferrans and Powers Quality of Life Index (FP QLI) (QOL)

• Fatigue: Presurgery = 3.5, postsurgery = 4.8, and week 6 = 2.8
• Overall physical function: Presurgery = 49.8, postsurgery = 31.5, and week 6 = 45.9
• QOL: Presurgery = 23.5, postsurgery = 22.4, and week 6 = 23.8

Cancer-related fatigue decreased below presurgery levels after six weeks of exercise intervention.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition) 

Home-based exercise may reduce cancer-related fatigue in patients with NSCLC postsurgery.

To investigate the effects of supervised exercise training on cardiopulmonary function and fatigue in cancer survivors undergoing various clinical treatments.

Patients were divided into four groups based on specific type of treatment:  surgery alone (n = 22); surgery and chemotherapy (n = 30); surgery and radiation (n = 17); and surgery, chemotherapy, and radiation (n = 27). Following comprehensive screening and medical examination, cardiovascular endurance, pulmonary function, and fatigue were assessed. Individualized exercise prescriptions and six-month exercise interventions were developed. Participants attended supervised exercise sessions two to three days per week for six months.

• Ninety-six patients were included in the study.
• This was a convenience sample of breast cancer survivors undergoing various clinical treatments. 
• Age was 57.9 years (standard deviation = 10.4 years). 
• All patients were females with breast cancer. 
• All patients had undergone surgery.
• No significant differences were observed in age, height, or weight between groups.

• Single site
• Outpatient
• Oncology rehabilitation center

This was a pre-/posttest quasiexperimental study.

• Repeated measures ANOVA and ANCOVA were used to compare the effectiveness of the interventions and difference among treatment groups.
• Main variables were systolic and diastolic blood pressure, resting heart rate, forced vital capacity, forced expiratory volume, predicted oxygen consumption, time on treadmill, and fatigue.
• The revised Piper Fatigue Scale (PFS) was used to assess cancer-related fatigue.
• The behavioral fatigue subscale includes six questions and was used to assess the effect of fatigue on school and work, interacting with friends, and the overall interference with activities that are enjoyable.
• The affective fatigue subscale includes five questions to assess the emotional meaning attributed to fatigue.
• The sensory subscale includes five questions to assess mental, physical, and emotional symptoms of fatigue.
• The cognitive and mood fatigue scale consists of six questions.
• The average score on the 22 total questions from the subscales provided the total fatigue score.

Cardiopulmonary function (predicted maximal oxygen consumption and time on treadmill) significantly increased in all groups after exercise training. In addition, resting heart rate and forced vital capacity significantly improved in those undergoing surgery, chemotherapy, and radiation. Psychologically, the exercise intervention resulted in significant reductions in behavioral, affective, sensory, cognitive, mood, and total fatigue scale scores in all three groups who received treatment with surgery. The breast cancer survivors in the surgery alone group showed significant reductions in behavioral, affective, and total fatigue scale scores but not in sensory, cognitive, and mood fatigue scale scores.

The results suggested that moderate-intensity individualized exercise maintains or improves cardiopulmonary function with concomitant reductions in fatigue, regardless of treatment type. Moreover, cancer survivors receiving combination chemotherapy and radiotherapy following surgery appear to benefit to a greater extent as a result of an individualized exercise intervention.

• This was a convenience sample of women from one geographic location.
• The study lacked a control group.

Symptom management recommendations should be given to cancer survivors concerning the effectiveness of exercise throughout the cancer continuum, and the importance of participating in a cancer rehabilitation exercise program should be emphasized.

To compare the effects of a scheduled, home-based exercise intervention to the effects of advising patients to exercise on fatigue, physical fitness, and physical activity level

Patients who had surgical treatment and were receiving adjuvant chemotherapy for breast cancer were randomly assigned to the scheduled exercise or control comparison groups. The intervention combined resistance and aerobic exercise with resistance bands and strength training three times per week along with 30 minutes of brisk walking daily. Those in the experimental group received motivational phone calls every two weeks. Patients in the control group were advised to continue their regular activity levels and had one follow-up phone call. Study measures were obtained at baseline, prior to chemotherapy, 8–24 weeks at the end of chemotherapy, and about six months after completing chemotherapy.

• N = 54
• MEAN AGE = 52.2 years (SD = 9.3 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: 88.4% of patients had stage I or II disease; 80.6% had college-level education;  81% were living with a partner, and about one half were employed full or part-time.

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Norway

• PHASE OF CARE: Multiple phases of care

Randomized controlled trial (RCT)

• Schwartz Cancer Fatigue Scale (SCFS-6)
• International Physical Activity Questionnaire (IPAQ)
• Six-Minute Walk Test (6MWT)
• Exercise diary

Fatigue scores increased significantly from baseline to the end of chemotherapy for all patients (p = .003) with no difference between groups. Fatigue returned to baseline levels after the end of chemotherapy with no difference between groups. A similar pattern was shown for all patients in physical fitness. There were no differences between groups in mean levels of physical activity per week, though there was a slight trend toward more exercise in the intervention group.

There were no additional effects of a scheduled home exercise program to reduce fatigue compared to individuals who were simply encouraged to maintain appropriate exercise levels.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Subject withdrawals ≥ 10%

Study findings show a pattern of fatigue such that fatigue increases significantly during chemotherapy and then declines after the end of treatment. Both groups of patients in this study performed exercise at general recommended levels, which likely accounts for the lack of differences in fatigue found. These results suggest that patients do not necessarily need to have scheduled approaches to exercise, and that encouraging patients to maintain at least moderate exercise levels can be effective. Nurses can encourage patients to maintain exercise and choose approaches that they prefer in order to maintain motivation for regular activity.

To investigate the feasibility of two different training programs including resistance and aerobic exercise in a small cohort of patients with advanced gastrointestinal cancer undergoing palliative chemotherapy; the study aimed to investigate potential effects of these programs on quality of life according to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) as well as on physical performance, biological parameters, and activities of daily living

• N = 26 randomized (21 completed)  
• AVERAGE AGE = 55 years
• MALES: 10, FEMALES: 11
• KEY DISEASE CHARACTERISTICS: Gastrointestinal (GI) tumors with advanced disease; 48% new diagnosis; varied treatment modalities
• OTHER KEY SAMPLE CHARACTERISTICS: Some patients had a history of operation or radio-chemotherapy at initial diagnosis and were undergoing palliative chemotherapy.

• SITE: Single-site    
• SETTING TYPE: Not specified    
• LOCATION: Supervised exercise (does not specify)

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care 

Two-group randomized trial

• Quality of Life (QOL): European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Physical Performance: Muscular strength and cardiorespiratory fitness
• Daily Physical Activity: Wearing a SenseWear^® wristband; Freiburg Questionnaire of Physical Activity
• Biologic Parameters: Peripheral venous blood parameters
• Exercise preference

The postinterventional fatigue level decreased in both subgroups, suggesting that both programs seem to have positive effects on fatigue in patients undergoing palliative chemotherapy.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)

Further prospective, controlled trials with larger sample sizes are needed to adequately analyze the efficacy of these programs in patients with advanced gastrointestinal cancer currently undergoing palliative chemotherapy.

To evaluate the effectiveness of a high-intensity (HI) and low-to-moderate–intensity (LMI) resistance and endurance exercise program compared with a wait-list control (WLC) group on physical fitness and fatigue in a mixed group of cancer survivors who completed primary cancer treatment, including chemotherapy

• N = 277  
• MEAN AGE = 50s
• MALES: 18%, FEMALES: 82%
• KEY DISEASE CHARACTERISTICS: Patients with lymphoma and breast, ovarian, colon, cervix, and testis cancer from stage I to Stage IV
• OTHER KEY SAMPLE CHARACTERISTICS: Patients who completed primary cancer treatment

• SITE: Single site    
• SETTING TYPE: Not specified    
• LOCATION: Patients recruited from nine Dutch hospitals

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care, palliative care 

• Randomized, controlled trials including three study arms: HI exercise, LMI exercise, and WLC
• Double-blinded study

• Cardiorespiratory fitness was measured during a maximal exercise test on an electronically braked cycle ergometer.
• Upper body muscle strength was assessed using a Jamar hand-grip dynamometer.
• Fatigue was assessed using the Multidimensional Fatigue Inventory (MFI).
• Health-related quality of life (HRQOL) was measured using the European Organization Research and Treatment of Cancer Core Quality of Life (EORTC QLQ-C30)

The HI (β = 2.2, 95% confidence interval [CI] [1.2, 3.1]) and LMI (β = 1.3, 95% CI [0.3, 2.3]) groups showed significantly larger improvements in peak VO₂ compared to the WLC group. Improvement in peak VO₂ was larger for the HI group than the LMI group (β = 0.9, 95% CI [−0.1, 1.9]), but the difference was not statistically significant (p = 0.08). Relative improvements in peak VO₂ were 20% and 15% for the HI and LMI groups, respectively, which is in line with the relative improvements in healthy adults after a 12-week exercise program. No significant intervention effects were found for grip strength and 30-second chair-stand tests. Compared to the WLC group, both the HI and LMI groups showed significant improvements in general fatigue (HI: β = −1.3, 95% CI [−2.2, −0.4] and LMI: β = −1.1, 95% CI [−2, −0.2]), physical fatigue (HI: β = −2, 95% CI [−2.9, −1.1] and LMI: β = −1.4, 95% CI [−2.3, −0.5]), and reduced activity (HI: β = −1.1, 95% CI [−1.9, −0.2] and LMI: β = −1.2, 95% CI [−2.1, −0.3]), with no significant differences between both interventions. The HI group showed a beneficial effect on motivation compared to the LMI group (β = −0.8, 95% CI [−1.5, −0.03]) and WLC group (β = −1.2, 95% CI [−1.9, −0.4]), with no significant differences between the LMI and WLC groups. Furthermore, the HI group showed a significant reduction in mental fatigue compared to the WLC group (β = −0.9, 95% CI [−1.7, −0.2]). The effects on peak VO₂ were modified by age (HI: β_interaction = −0.2, 95% CI [−0.3, −0.1], p = 0 and LMI: β_interaction = −0.1, 95% CI [−0.2, −0.01], p = 0.03), indicating larger effects for younger participants. No significant interaction effects for gender or diagnosis were found for physical fitness or fatigue.

Supervised HI exercise can be safely recommended to cancer survivors shortly after their completion of cancer treatment. HI and LMI exercise were equally beneficial in counteracting general and physical fatigue.

Advising patients to exercise or referring them to exercise specialists to exercise under supervision is beneficial when possible.

• N = 121   
• AGE = 50.5 years (SD = 8.7 years)
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, radiation, combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Breast cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: All participants were diagnosed with breast cancer and were currently undergoing or were within three months of completing chemotherapy.

• SITE: Single site   
• SETTING TYPE: Other    
• LOCATION: Community program operates within the Health and Wellness Lab at the University of Calgary in Alberta, Canada

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

Pre-post design

• Physical health outcomes
• Health-related quality of life, fatigue, cognitive function, and depressive symptoms
• The physical well-being (PWB) subscale score
• Functional Assessment of Cancer Therapy-Breast (FACT-B) total score
• The FACT-B Breast Cancer Subscale (BCS) score
• FACT-General (FACT-G)
• The FACT-G physical well-being (PWB) subscale score
• The FACT-G emotional well-being (EWB) subscale score
• Center for Epidemiological Studies Depression Scale (CESD)
• FACT-Cognitive Function (FACT-Cog)

• Body mass index increased from baseline to 12 weeks by 0.5 kg/m² (p = 0.01). No significant differences were reported in participant-reported quality of life, fatigue, cognitive function, or depressive symptoms from baseline to 12 weeks.
• For the 24-week intervention, many of the physical health outcome measures improved significantly.
• The FACT-B total score at 24 weeks improved by 7.4 points compared to both (p = 0.002).
• The FACT-G score at 24 weeks improved by 5.9 and 5.6, respectively, compared to baseline (p = 0.003) and 12 weeks (p = 0.001). The FACT-B Breast Cancer Subscale (BCS) score at 24 weeks improved by 1.4 (p > 0.05) compared to baseline and by 1.8 compared to 12 weeks (p = 0.038).
• The physical well-being (PWB) subscale score at 24 weeks improved by 1.8 and 2.8 compared to baseline (p = 0.015) and 12 weeks (p = 0.002), respectively. The emotional well-being (EWB) subscale score at 24 weeks improved by 1.6 compared to baseline (p = 0.029) and by 0.7 compared to 12 weeks (p > 0.05). The functional well-being (FWB) subscale score at 24 weeks improved by 2.1 and 1.7 compared to baseline (p = 0.017) and 12 weeks (p = 0.01), respectively. No significant differences in social well-being (SWB) subscale scores existed at 24 weeks. Participant-reported fatigue measured by the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) questionnaire improved 5.1 at 24 weeks compared to 12 weeks (p = 0.002).
• No significant differences in cognitive function measured by the FACT-Cog were reported. 
• Depressive symptoms measured by the CESD improved (decreased) at 24 weeks by 2.8 and 2.9 compared to baseline (p = 0.05) and 12 weeks (p = 0.009), respectively.

• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)
• Risk of bias (sample characteristics)

To determine if there was an improvement in fatigue, strength, and quality of life (QOL) in individuals within one year of treatment for an individualized physical therapist–prescribed exercise intervention.

Cancer survivors participated in an exercise class (one hour two times weekly) that included instruction and supervision in cardiovascular, strength training, and flexibility exercises. Measurement of fatigue, strength, and repetition of prescribed exercises occurred. The individualized exercise program was prescribed by a single therapist and was based on the patient’s medical history, diagnosis, age-related changes, treatment stage, and goals. Flexibility, strength, and balance assessments were conducted, and participants were retested at the conclusion of the program. Patients were encouraged to exercise two times weekly.

• Two hundred patients (91 females and 41 males) were enrolled; 132 (66%) completed the program.
• Mean age was 57.48 years. One patient was younger than 21 years and five patients were between 81 and 90 years; the majority (n = 36) were between 61 and 70 years.
• Stages of cancer were I through IV.
• Diagnoses included breast, colorectal, lung, ovarian, non-Hodgkin lymphoma, prostate, and other cancers.
• Most patients were undergoing active treatment, and most had undergone surgery, chemotherapy/hormonal, and radiation therapy.

• Single site
• Cancer Well-Fit Exercise Program at Synergy Health and Fitness Center on the campus of Exeter Hospital, Exeter, New Hampshire

This study included a pre- and posttest and a two-tailed t test. 

• Visual analog scale (VASF) to measure fatigue (Glaus reported validity and reliability but did not report the actual number)
• Jamar dynamometer to measure upper extremity strength (Bohannan reported as valid and predictive of postoperative complications and related to functional loss but did not report the actual number)
• Cybex VR2 seated leg press machine to measure lower extremity strength
• Segal tested lower-extremity muscular fitness with repetitions to fatigue for prediction, and Sale and MacDougall published data regarding repetitions to fatigue. The amount of weight lifted and the total number of repetitions performed were used to estimate a predicted one repetition maximum according to Brzycki’s regression equation.
• Short Form 36 Health Survey (SF-36) was used to measure QOL. This total score and eight subscales were analyzed pre- and post exercise intervention. They included physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, mental health, and reported health transition.

Overall fatigue improved significantly (p = 0.004). Overall lower-extremity anaerobic endurance increased significantly (p = 0.000). Overall nondominant grip strength increased significantly (p = 0.000). Overall QOL improved significantly (p < 0.01). The intervention was well tolerated in all of the diagnostic, stage, and age groups with no adverse events. The 81- to 90-year-old group had the highest completion rate, followed by the 71- to 80-year-old group. Survivors with stage IV disease had statistically significant improvement in lower extremity anaerobic endurance and QOL, whereas survivors of lung cancer had statistically significant reductions in their fatigue.

Virtually all patients with various cancer diagnoses and stages of disease, as well as a wide age range and both genders, can safely participate in and will benefit from a strength training program in terms of less fatigue, improved QOL, and increased strength. Oncology rehabilitation is necessary for survivors of cancer.

• The study lacked an appropriate control group.
• The population was primarily Caucasian, and there was limited cultural diversity.
• The study lacked randomization and control group.
• Combination exercise was used; the authors were unable to determine the most effective type of exercise for this population.

Exercise can be performed safely with careful planning. Exercise programs do not need to be restricted to those who are relatively well. Oncology rehabilitation is as necessary for survivors as cardiac rehabilitation. This study is supportive of a comprehensive exercise program.

To compare effects of cardiovascular and resistance exercise on functional mobility in people with advanced cancer

Individuals were randomly assigned to either resistance or cardiovascular exercise groups. Exercise sessions were held in a hospital-based fitness facility twice weekly for 10 weeks. Both groups  participated in flexibility exercises. Sessions lasted 30–60 minutes and were supervised by oncology-trained exercise specialists. Participants completed the study assessments at baseline and one week after study completion.

• N = 52    
• MEAN AGE = 62.35 years (SD = 13.49)
• MALES: 45%, FEMALES: 55%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types. All had advanced cancer determined by an oncologist to be in a terminal stage.
• OTHER KEY SAMPLE CHARACTERISTICS: More than 90% of the patients were currently receiving chemotherapy, radiation therapy, or a combination of these. Baseline mean fatigue was 37.02 on a 0–100 scale.

• SITE: Single site
• SETTING TYPE: Outpatient
• LOCATION: New England

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

• Randomized, parallel group trial

• Short Physical Performance Battery (SPPB)
• 100 mm visual analog scale for fatigue and pain

On average, participants attended 70% of exercise sessions. SPPB scores improved in all over time (p < .001), but improved slightly more in the cardiovascular group (p = .045). Intent-to-treat analysis did not confirm this difference between groups. Fatigue declined over time in all (p = .05), with no difference between groups. There were no significant changes in pain by group or by time.

Findings show improved functional mobility and reduced fatigue over time. This study did not show a difference associated with the type of exercise provided.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Measurement validity/reliability questionable
• Other limitations/explanation: VAS score was only for fatigue. There was a 21% dropout rate and reasons for this are not described. Relatively low levels of fatigue at baseline, suggesting possible measurement floor effect.

This study suggests that both cardiovascular and resistance exercise can be used in appropriate patients with advanced disease, and findings showed that there were no significant changes in pain or fatigue with these interventions.

To contribute preliminary evidence for the feasibility and potential effectiveness of a structured walking intervention on reducing cancer-related fatigue in order to plan for a full-scale study of effectiveness

The study consisted of an eight-week program with three intervention groups: one with the STEPS (a walking program using a pedometer) during rehabilitation, one with STEPS after rehabilitation, and one group with only the rehabilitation program for people with advanced cancer and a > 4 fatigue level on a Visual Analog Scale (VAS).

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: McGill University Health Centre, Montreal, Canada

• PHASE OF CARE: Late effects and survivorship

A pilot randomized trial. The STEPS program was based on the participants’ current walking status and progressed according to fatigue level.

Instruments chosen to measure fatigue and symptoms of anxiety and depression included the following.

• Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System
• Fatigue Symptom Inventory (FSI)/Two-Minute Walk Test (2MWT)
• RAND-36 Survey
• Community Healthy Activities Model Program for Seniors (CHAMPS)
• EuroQol System
• Functional Assessment of Cancer Therapy (FACT-G)
• Hospital Anxiety and Depression Scale (HADS)
• Pittsburgh Sleep Quality Index (PSQI)
• Fatigue Visual Analogue Scale (VAS)

Results demonstrated that the pedometer-facilitated walking intervention adapted to fatigue levels (STEPS program) showed promise as an intervention to decrease cancer-related fatigue.

Compared to rehabilitation alone, the eight-week adaptive walking intervention reduced fatigue and improved physical function and well-being over a 16-week period and was sustained to six months.

• Small sample (< 30)
• Subject withdrawals ≥ 10%

Walking intervention is associated with a trend toward less fatigue; however, this study needs replication in the advanced cancer population. Effectiveness not established.

To test the feasibility and provide a preliminary evaluation of the effects of an exercise program for fatigue, sleep disturbance, mood, and symptoms in patients with cancer

Participants randomly were assigned to the treatment or control group. Patients in the control group received usual care, an educational booklet and DVD, and weekly telephone calls. Patients in the experimental group received initial one-on-one training sessions and were given exercise program kits containing written instructions, a pedometer, and an exercise log. Patients were to choose activities that provided low to moderate intensity exercise and perform these daily for at least 20 minutes. Participants also were asked to walk three to five days per week. Weekly phone calls to the experimental group were made to monitor participation and make adjustments to the walking prescription as needed. The program was planned for 12 weeks.

• N = 23
• MEAN AGE = 46.78 years (range = 31–59 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All patients had breast cancer (mostly stage II). Patients were recruited during chemotherapy given postoperatively.

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Thailand

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Piper Fatigue Scale (PFS)
• General Sleep Disturbance Scale (GSDS)
• Profile of Mood States–Short Form (POMS-SF)
• Memorial Symptom Assessment Scale (MSAS)

Patients in the experimental group demonstrated a nonsignificant improvement in fatigue (d = -0.48). There were no significant group by time effects for other measures. Data were not collected after week 10 because of loss of subject follow-up.

The findings of this study support the known effect of exercise on cancer-related fatigue; however, the small sample in this study limits the strength of these findings.

• Small sample (< 30)
• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Patients in the control group reported higher fatigue levels at baseline.

This study provides minimal additional support for the benefits of exercise among women with breast cancer during active treatment. Exercise has been shown to be effective in reducing multiple symptoms, and nurses should encourage patients to be active.

To evaluate the effects of combined aerobic and strength exercise on physical performance and symptoms in patients who are hospitalized while receiving myeloablative therapy

Patients were randomly assigned to the exercise intervention or usual care. Usual care patients were allowed to undergo physical therapy as medically indicated according to standard practice. The intervention group included ergometer endurance training for 10–20 minutes and resistance exercises for main muscle groups for 20 minutes. Exercises were done five days per week during the entire hospital stay, and training intensity was individually adjusted based on spiroergometry at study entry. Training was suspended if patients experienced fever, infection, thrombocytopenia (platelet < 20,000) cardiac arrhythmia, or life-threatening clinical complications. Neutropenic patients wore masks when they left their rooms. Follow-up assessment was done at 12 months.

• N = 48
• MEAN AGE = 52 years
• MALES: 70.8%, FEMALES: 29.2%
• KEY DISEASE CHARACTERISTICS: Most frequent diagnoses were acute myeloid leukemia (AML) and non-Hodgkin's lymphoma (NHL)

• SITE: Single-site  
• SETTING TYPE: Inpatient  
• LOCATION: Germany

• PHASE OF CARE: Active antitumor treatment

Randomized controlled trial

• Spiroergometry oxygen consumption measurement
• European Organization for Research and Treatment of Cancer Quality of Life (EORTC-QLQ-C30) scale
• Modified Fatigue Impact Scale (MFIS)

The median duration of exercise training was 15 days with the median hospital stay being 21 days. The control group’s lung function as measured by oxygen consumption increased. Treatment group oxygen consumption and expiratory minute ventilation volume was significantly higher at the end of the study compared to controls (p < .05). EORTC physical functioning was significantly higher in the treatment group compared to controls (p = .04). There were no other differences in symptoms between groups. The treatment group complained of fatigue for fewer days than those in the control group (p = .04). Self-report of overall condition at 12 months indicated no significant difference between groups. There were no exercise-related adverse events.

This study demonstrated that exercise training during myeloablative chemotherapy is feasible, well-tolerated, and may improve physical performance during treatment.

• Small sample (< 100)
• Risk of bias (no blinding)
• Subject withdrawals ≥ 10% 
• Other limitations/explanation: High drop-out rate

Findings suggest that exercise training during hospitalization for myeloablative chemotherapy is generally well-tolerated. The study was underpowered to show any effect on symptoms of fatigue; however, exercise training was associated with improved physical performance measures. Nurses can advocate for exercise programs for this group of patients.

To test the hypothesis that physical exercise reduces fatigue and improves physical performance in patients with advanced cancer.

Patients were randomly assigned to physical exercise (PE) or usual care (UC) groups. The PE group had two exercise sessions per week that lasted 50 to 60 minutes after a 10-minute warm-up. Exercise was performed in groups of two to eight and was supervised by a physiotherapist. Sessions included circuit training and stretching/relaxation. Focus was on muscle strength, balance, and aerobic endurance. Pre- and postintervention were performed at baseline at immediately after the intervention period.

• In total, 231 patients (62.3% female, 37.7% male) were included. 
• Mean age was 62.4 years (range 24–86). 
• Multiple types of cancer in advanced stage were included.
• Of the patients, 55% were receiving chemotherapy and 75% had a Karnofsky Performance Status score of 80 or greater.
• Of the patients, 65% had a baseline low level of activity of less than one hour per week.

• Multi-site
• Norway

• Patients were undergoing the end of life phase of care.
• The study has clinical applicability for palliative care.

This was a randomized, controlled trial.

• Fatigue questionnaire
• Physical activity prior to the study (none, <1 hour/week, 1-2 or 3 hours/week)
• Motivation (0-10 numerical scale)
• Physical performance tests: sit-to-stand, grip strength, maximal step length (balance), and shuttle walk (how far and fast one can walk) tests

Median survival times for all included patients were 11.1 months in the PE group and 12.3 months in the UC group. In the PE group, exercise adherence was 69% on average (11 of 16 sessions).  Regression analysis showed no significant between-group effect in physical fatigue (estimated mean difference = -0.3; confidence interval [-1, 1.0]; p = 0.62).  There were significant differences between groups in shuttle walk test (p = 0.008) and grip strength (p = 0.01) results. There were no apparent effects of the exercise intervention on mental or total fatigue, including mental and physical fatigue.

Findings showed that such an exercise program is feasible in patients with advanced disease and limited life expectancy. Findings did not provide support for the hypothesis that exercise reduces fatigue in this group of patients.

• The study lacked an appropriate control group.
• In the PE group, 35.5% of patients were lost to follow-up predominantly due to disease progression.

Exercise programs are feasible for patients with advanced disease. Study findings did not show that the intervention improved the symptom of fatigue, but it did improve some physical performance.

To evaluate the feasibility of a structured aerobic exercise intervention during treatment in a predominately Hispanic population of women.

A convenience sample of women who met the criteria at the time of their outpatient appointments were included. Patients were weighed and measured and completed tests regarding side effect burden and fatigue. Patients were given a sports outlet gift card for walking shoes and a six-month membership to the community health club. They were instructed to make an appointment with a physical therapist and a community health club for exercise. The research intervention was exercise three times a week for one hour with a goal to continue for six months. Exercises involved 10 minutes of warm-ups, 30 minutes of resistance training to improve muscle tone, 20 minutes of brisk walking to improve heart strength, and 10 minutes of cool-down. Assessments occurred at three and six months.

• Thirteen participants (all female) were included, although five did not go to a health club; only eight were available for a one-on-one interview.
• Age ranged from 40 to 63 years.
• Patients had first-time diagnoses of stage II breast cancer.
• Patients had undergone surgery and were either receiving chemotherapy or had completed chemotherapy in the past six months.
• Eight participants were on leave from work following surgery and during chemotherapy/radiation treatment.
• Of the participants, 73% experienced chemotherapy-induced menopause.
• All patients were Hispanic.

• Single site
• Cancer Center Therapy & Research Center, San Antonio, Texas

The study used a mixed qualitative and quantitative, repeated measure, quasiexperimental design.

• Side Effect Burden Scale
• Revised Piper Fatigue Scale (PFS)
• Five-minute walk test
• Strength and range of motion testing
• Penn Shoulder Score
• Hip and waist measurements
• Percent body fat and body mass index
• Pearson correlation coefficients (used in analysis)

Fatigue was significantly correlated with age (p = 0.05), fasting blood glucose (p = 0.05), and weight gain (p = 0.01). Mean weight gain was 15 lb. No changes were seen in fatigue. Qualitative analysis identified physical limitations, family responsibilities, lack of transportation, return to work, and lack of habit development as factors that influenced adherence to the exercise program. Sources of support for adherence included family, peers, employer, and health care providers. Several patients indicated that they preferred to exercise in an area that had only women. Self-report of exercise adherence was 66% at the first follow-up and 7% at the study conclusion.

Social, physical, and psychosocial factors influenced the women’s exercise adoptions. The provision of a gift card and recommendations did not have an effect on fatigue in these individuals.

• The study had a small sample size, with less than 30 participants.
• Observational data relied on recall.
• This was a Hispanic population, so specific qualitative findings may not be applicable to other cultural groups.

A structured exercise program appears to facilitate recovery from cancer. These Hispanic women had difficulty setting aside time to exercise. Support from health care providers was identified as a facilitator of adherence to exercise, suggesting that encouragement to exercise may be helpful. Concrete barriers, such as lack of transportation and dealing with family responsibilities, need to be addressed if patients are to be able to participate in exercise programs. Interventions need to fit lifestyle needs and preferences of the individual.

The primary aim was to determine if a home-based walking exercise program is more effective than usual care in reducing fatigue, sleep disturbances, and depressive symptoms in older women receiving hormonal treatment for breast cancer as a feasibility study.  The secondary aim was to examine the extent to which symptoms and biomarkers of cortisol, serotonin, interleukin-6 (IL-6), and bilirubin are related and change over time.

Participants were recruited from breast cancer clinics and randomized to usual care or a prescribed walking exercise program. Participants were followed over a 14-week period. At an initial clinic visit, demographic data were collected and participants completed study instruments. Study instruments were again completed two weeks later via mail, 12 weeks after baseline at a clinic visit, and at 14 weeks via mail. Cortisol, serotonin, IL-6, and bilirubin were collected at the initial clinic visit and at 3 months. Blood samples were carefully handled to ensure appropriate handling for radioimmunoassay and other laboratory testing. At visit 1 and at 12 weeks, patients were asked to wear a sleep watch actigraph for 72 continuous hours. A study coordinator or investigator explained the walking exercise intervention, which was a moderate walking activity for 20 minutes, four times a week. Participants in the exercise group were shown how to use a pedometer that was provided to them but were not required to use it. Participants were given a log to record the duration and frequency of walking activity.

• Twenty participants (100% female) were included; data analysis was completed on 18 participants.
• Mean age was 65 years (range 56–78). 
• All participants had breast cancer and were being treated with hormonal therapy with tamoxifen, anastrozole, or letrozole.
• Of the participants, 65% were married, 55% were retired, 90% were Caucasian, and 40% had education at the college level or higher.

Participants were included if they

• Were postmenopausal status
• Reported fatigue
• Had a Karnofsky score of 80 or greater.

Individuals were excluded if they had a history of neurologic deficits or mental illness in the past year or had neuromuscular deficits that would contraindicate use of a walking program.

• Setting Type1:  Single site
• Setting Type 2:  Home
• Comprehensive cancer center in southeastern United States

This was a longitudinal, repeated measures, randomized, clinical trial.

• Revised Piper Fatigue Scale (PFS)
• Pittsburgh Sleep Quality Index (PSQI)
• Center for Epidemiological Studies – Depression Scale (CES-D)
• Sleep actigraphy measurements

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 controls. 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 sleep efficiency, the ratio of total sleep time while 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). Serotonin levels were correlated with actual wake time, but correlations were not statistically significant. There were no significant differences in IL-6 or bilirubin between groups or over time. Bilirubin levels in both groups were at or above the upper limit of normal range. Correlation analysis for cortisol, IL-6, and bilirubin were not reported. There were no differences between groups or over time in depressive symptoms. Actual patient adherence to prescribed exercise was not reported. Authors reported that the walking exercise intervention was accepted in this population.

Home-based walking intervention appears to be feasible and acceptable to older women receiving hormonal therapy for breast cancer. The decline in PSQI scores in the exercise group suggests that this type of intervention may be helpful in improving sleep quality in this population. Effects of the exercise intervention on biomarkers are unclear. There was no observed effect of the exercise intervention on fatigue.

• The study had a small sample size, with less than 30 participants.
• There was no intention-to-treat analysis.
• Although significance values were reported, there were no other statistical results provided for significant findings that enabled evaluation of the strength of relationships.
• Actual adherence to the exercise program was not reported, so the actual use of exercise as prescribed cannot be determined.
• It is also unknown whether the control group performed any exercise on their own.
• Although patient self-report of exercise is a limitation itself, results of patient self-reports were not provided or discussed.
• The study design lacked an appropriate attentional control group.

A walking exercise program may be helpful to patients receiving hormonal treatment for breast cancer, but actual effects on fatigue, sleep, and depressive symptoms are unclear.

To determine the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who completed cancer treatment.

Twice weekly over a period of 12 weeks, YMCA personal trainers supervised groups of seven to 14 study participants during 90-minute exercise sessions at 13 YMCA sites. Study measures were administered at baseline and after the 12-week exercise program. The standardized protocol included aerobic warm-up (10 minutes), resistance training (50 minutes), and community building time (e.g., sharing personal experiences, didactic and experiential training in breathing, relaxation, stress management, and nutrition). Precautions or contraindicated movements were noted for each participant, and resistance training was individualized. YMCA personal trainers had at least one year of personal training experience and received a specialized 16-hour group training by a cancer rehabilitation physical therapist. Additional training to address emotional issues for participants and trainers was provided by a licensed clinical psychologist with expertise in cancer survivorship. Participants and immediate family received access to YMCA facility branches and were encouraged to exercise outside of the sessions.

• In total, 187 patients (17.6% male, 82.4% female) with both pre- and postintervention data were included. 
• Mean age was 57.7 years (standard deviation [SD] = 10.3)
• Patients had mixed cancers (55.5% breast cancer, 7.5% lymphoma, and 5% leukemia and prostate cancers).
• Mean time since diagnosis was 5.6 months (SD = 6.9 months).
• Eligibility included being off cancer treatment for longer than 90 days, with no evidence of active disease. Medical clearance was required to participate in the exercise program.  
• Of the patients, 97.3% were Caucasian and non-Hispanic/non-Latino, 63.6% had completed four-year college or graduate school education, and 49.7% reported working full- or part-time for pay.

• Multisite (13 YMCA sites as part of LIVESTRONG Exercise and Thrive [E & T] Program)
• Community
• Western Washington State

Patients were undergoing long-term follow-up postcancer treatment.

This was a prospective pre/post (nonrandomized) study design.

Validated patient-reported outcomes measures included

• Health-related quality of life: Short Form 36 Health Survey (SF-36), version 2
• Fatigue: Fatigue Symptom Inventory (FSI)
• Insomnia: Three items were developed for this study, rated from rarely or never (0) to nearly every day (4) for: “Does it take you more than half an hour to fall asleep at night?” “Do you wake during sleep and have difficulty falling back to sleep?” and “Do you wake earlier than you want in the morning and are you unable to get back to sleep?”
• Physical activity level: SF-36, version 2, physical component summary
• Physiologic measures:  six-minute walk test, resting heart rate, blood pressure, one repetition maximum test (upper and lower body strength), and sit and reach test (flexibility)
• Muscle and joint problems: Muscle and Joint Measure with subscales assessed (1) muscle aches or stiffness (myalgias); (2) joint pain; (3) stiffness or swelling (arthralgias) and muscle cramps; and (4) muscle weakness
• Social support:  brief seven-item measure used in the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study (study testing a psychosocial intervention on patients with postacute myocardial infarction)
• Injuries and/or lymphedema during classes:  Assessment was developed for the study using yes/no response items, including: “During your participation in E & T did you have any injuries?” and “As far as you know did you have any swelling or lymphedema that developed during E & T?” For those participants responding positive to the lymphedema question, subsequent questions were asked to determine if the lymphedema symptoms developed before or during the E & T program and (if lymphedema developed during the program) if the symptoms were a flare-up of existing lymphedema or a new site of lymphedema.
• Program evaluation: Five items were developed for the study, including: “How satisfied are you with your participation in the program overall?,” “Were the staff leading the program competent and knowledgeable?,” and “How easy or difficult was it for you to participate in the program?.”

The study indicated that the community-based exercise program has important beneficial effects on physiologic, symptom, and quality of life health outcomes for cancer survivors and is safe to implement. Findings suggested that the program is helpful for improving fatigue, insomnia, physical function, overall musculoskeletal symptoms, mental health, social support, and physical activity in cancer survivors. Average baseline insomnia ratings of 1.63 (SD = 0.93) differed significantly from postintervention ratings of 1.43 (SD = 0.85) (p < 0.001).  Additionally, the exercise program indicated notable improvements in physiologic measures (blood pressure, upper and lower body strength, walking endurance, and flexibility).

Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed active treatment, have physiologic and psychosocial benefits and appear to be safe. Because the participants self-selected to be part of the study and were screened for their ability to participate, findings cannot be generalized to the larger cancer survivor population.

• The study had a risk of bias due to no control group, no blinding, no random assignment, no appropriate attentional control condition, and the sample characteristics*.
• Participant withdrawals were 10% or greater.
• * Measurement validity/reliability was questionable. Findings were not generalizable. The intervention was expensive, impractical, and/or training needs. Participants were 82.4% female and non-Hispanic (Caucasian); the ethnic and racial homogeneity of the sample limited the generalizability of the findings. More than half of the participants had a breast cancer diagnosis. Self-referral and convenience sampling provided a population of participants who were motivated to self-initiate participation in an exercise program. Several measures were developed for the study, including the measure of insomnia; thus, there was a lack of previous established reliability and validity. Although access to the YMCA was provided to participants, the intervention was expensive in terms of participant time and effort, and personal trainers required special cancer-related training and one year of personal training experience. Having the intervention delivered to groups offsets the cost to a certain degree. Thirty-four of of 221 participants were excluded from the analysis because data were only available at one time point; there was a 15% withdrawal rate.

Survivors may benefit from participating in a community-based exercise program tailored to meet their individual needs as a survivor; however, exercise programs should be preceded by consultation with health care providers. Additional nursing research is needed to determine the effect of resistance training and other exercise protocols in more diverse cancer survivor populations.

To compare a 12-week Nia-based exercise program to usual care on cancer-related fatigue, quality of life, aerobic capacity, and shoulder flexibility in women receiving radiation therapy for breast cancer

Participants randomized to the intervention were instructed in Nia techniques as well as given a DVD for home use. They were instructed to perform the exercises for 20–60 minutes at least three times a week and maintain a log. The control group were instructed to maintain their usual exercise regime and maintain a log. The principle investigator met individually with both groups at the beginning and at 6 and 12 weeks. At the end of the 12 weeks, control group participants were given the opportunity to take part in a Nia group.

• N = 41  
• MEAN AGE = 56 (range = 34–85)
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer receiving radiation therapy

• SITE: Single site  
• SETTING TYPE: Outpatient    
• LOCATION: Northern Ohio

• PHASE OF CARE: Active anti-tumor treatment

• Randomized, controlled study stratified by stage or disease and age

• Fatigue and quality of fife were measured by the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F).
• Aerobic capacity measured by a six-minute walk test
• Shoulder flexibility assessed using a goniometer

Both groups reported increased fatigue at week 6 (completing therapy) with improvement at week 12. Repeated measures of covariance noted statistically significant differences in the Nia and control groups between weeks 6 and 12; the Nia group had a greater increase in FACIT-F scores (p = 0.05).

Sample size and study limitations make it difficult to draw conclusions; however, Nia exercise can be beneficial to women with breast cancer receiving radiation therapy to reduce cancer-related fatigue.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias(sample characteristics)
• Selective outcomes reporting
• Findings were not generalizable
• Intervention expensive, impractical, or training needs
• Questionable protocol fidelity
• Subject withdrawals ≥ 10% 
• Other limitations/explanation: Control group had less fatigue at baseline; both groups reported that keeping a diary reminded them to exercise

Nia exercise can be beneficial to women with breast cancer receiving radiation therapy, particularly those who favor a holistic or complementary approach.

To determine the feasibility of conducting a randomized, controlled trial of exercise in patients with head and neck cancer receiving radiation therapy

Patients were randomly assigned to the intervention group or a control group. Control patients received only nutritional counseling from a registered dietician. Patients in the intervention group received nutritional counseling plus the exercise intervention. Exercise included twice-weekly, supervised exercise sessions for six weeks followed by six weeks of twice-weekly home-based sessions supported by weekly telephone counseling, written materials, and a DVD.

• N = 13 (completed 12 weeks); 15 (completed six weeks)  
• MEAN AGE = 60.5 years (SD = 43–88 years)
• MALES: 80%, FEMALES: 20%
• KEY DISEASE CHARACTERISTICS: All patients had head and neck cancer. About one half had had neck dissection, and one half also received concurrent chemotherapy.

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Illinois

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care

Pilot randomized, controlled trial

• Lean body mass measured by biometric impedance
• Functional Assessment of Cancer Therapy–Fatigue (FACT-F)
• Functional Assessment of Cancer Therapy–Head and Neck (FACT-H&N)
• Physical performance tests

Over the first six weeks, fatigue increased in both groups with no significant difference between groups. Between weeks 6 and 12, fatigue declined in both groups but showed a greater decline in the intervention group. Exercise adherence was 87% in the first six weeks and 57% weeks 7–12.

Less than one half of patients offered the study consented to participate, suggesting low interest and limited feasibility. The final sample size was very small, so no firm conclusions about effects can be drawn.

• Small sample (< 30)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)

This study provides minimal support for the feasibility and efficacy of implementing an exercise intervention among patients with head and neck cancer undergoing radiation therapy. These findings are not in concert with findings from other similar studies.

To examine mediators of fatigue effects of an exercise intervention

Patients were randomized to an exercise intervention or control group. The intervention combined walking and strength training with resistance bands. Walking was gradually increased by week 9 to 40 minute sessions of moderate intensity, four times per week, and participants attended 26 individual exercise sessions supervised by an exercise specialist. Resistance training was two times per week in the last 10 weeks of the study with the supervised aerobic walking sessions. Resistance was advanced as tolerated. Six group meetings with a psychologist also were provided every other week to provide support and improve exercise adherence. The control group was instructed to maintain usual exercise behavior.

• N = 42  
• MEAN AGE = 56.2 years (SD = 7.7)
• KEY DISEASE CHARACTERISTICS: All patients had breast cancer, were at least four weeks post-completion of primary treatment, had an average fatigue score of at least 3 in the past week, or had sleep dysfunction
• OTHER KEY SAMPLE CHARACTERISTICS: Multiple chronic concurrent conditions were excluded

• RCT

• MTI actigraph
• Fatigue Symptom Inventory
• PROMIS general fatigue scale
• PROMIS scales for depression, anxiety, and sleep/wake disturbance
• Serum samples for interleukins (IL-6, -8, -10) and tumor necrosis factor alpha

Adherence to supervised exercise sessions was 91%–93%. Exercise goals for at home were met in 65% of the weeks during the study. General fatigue declined significantly in the intervention group compared to controls (d = –0.49, p < .01). Fatigue interference (d = –0.38, NS) declined in the intervention group. Fatigue intensity increased in the intervention group and declined in controls (d = 0.3, NS). There were no significant differences in depression. Anxiety declined in the intervention group (d = –0.54, p < .05). Sleep/wake dysfunction declined in both groups over time, but more in the intervention group (d = –0.054, p < .01). Positive effects in fatigue intensity were significantly mediated by IL-6, IL-10, IL-6:IL-10, and TNF alpha:IL-10.

The exercise program used here showed a small to medium non-significant effect on fatigue intensity and interference, as measured in this study. Effects of exercise on fatigue were mediated by some cytokine system responses.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Fatigue and sleep disruption measures at baseline were lower in the intervention group, although the difference was not statistically significant, these could have influenced the general trends shown in the study.

Although this study has limitations, findings do provide additional support for positive effects of exercise on cancer-related fatigue among cancer survivors. Findings here show evidence of potential effects through the cytokine system. Adherence to the exercise program in this study was very good, using a support group interaction and the combination of supervised exercise sessions and home-based exercise recommendations. This type of additional support may help many patients adhere to an exercise program.

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

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.

• 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.

• Multisite
• Outpatient
• Multiple locations in Finland

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

This was a randomized, controlled trial.

• 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

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.

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.

• 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.   

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.

To evaluate the effects of a 12-week resistance training intervention in patients with breast cancer during adjuvant chemotherapy

Patients were randomly assigned to the intervention or attention control group. The control group received a supervised group muscle relaxation program with the same session schedule as the intervention group. The exercise intervention involved the use of eight different machine-based progressive resistance exercises without an aerobic component. Both interventions were provided in group settings for 60 minutes twice weekly. Study measures were obtained at baseline and at the end of the intervention period.

• N = 95
• MEAN AGE = 52.7 years (range = 30–71 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All participants had breast cancer. The majority of participants had stage 1 or 2 disease. The mean number of days since surgery was 56. All participants were receiving adjuvant chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: 18% had baseline depression 

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Germany

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Fatigue Assessment Questionnaire (FAQ)
• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Center for Epidemiologic Studies (CES-D) for depression
• Trail Making Test (TMT)

The overall between-group difference in fatigue was –5.8. This difference was not statistically significant. There was no overall effect of the intervention on the affective or cognitive dimensions in the fatigue measure. In a subgroup analysis of women who were not depressed at baseline, the between-group difference was –8.1 (p = –0.039). Fatigue increased in the relaxation group. Cognitive performance on the TMT improved in the exercise group compared to the control group, but the difference was not significant. Depression remained unchanged in both groups.

The findings of this study show that resistance exercise can be helpful in reducing fatigue during adjuvant chemotherapy, particularly in patients who have depressive symptoms. There were no apparent effects of the resistance exercise program on fatigue or cognitive function.

• Small sample (< 100)
• Risk of bias (no blinding)
• Key sample group differences that could influence results
• Other limitations/explanation: A significantly larger proportion of patients in the exercise group had higher depression scores at baseline (p = 0.0098). This difference may have affected overall findings.

Findings showed that resistance exercise reduced fatigue during adjuvant chemotherapy. These effects were more pronounced in women who did not have depressive symptoms at baseline. This points to the potential influence of depression on fatigue and the efficacy of interventions for fatigue. These results suggest the need to ensure the effective management of depressive symptoms to manage fatigue during treatment. The interventions studied here did not show an effect on depression or cognitive function.

To evaluate the effect of gentle strength training on endurance and psychological outcomes in patients with breast cancer.

Patients were randomized to the intervention or control study groups. Patients in the control group participated weekly in gymnastic exercises, such as chair or floor exercises with various sports equipment. Those in the intervention group were trained with strength endurance training, according to individualized training plans based on a training load of 50% of one repetition maximum on a weekly basis. Both groups continued the weekly training program for six months. Data were collected at baseline, after three months, and after six months.

• Thirty-three participants (100% female) were included. 
• Mean age was 56 years.
• All participants had breast cancer and had completed initial antitumor treatments. 
• Participants were an average of approximately nine months since diagnosis.

• Single site 
• Other setting
• Germany

Patients were undergoing the transition phase after active treatment.

This was a randomized, two-group prospective study.

• Endurance test using a bicycle ergometer
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-BR-23) module for quality of life (QOL) and fatigue
• Body mass index (BMI)

There was a significant reduction in BMI in both groups. QOL and fatigue scores showed a significant improvement in both groups at three and six months (p < 0.01). There were no significant differences between groups. The pattern of fatigue change showed decline in both groups by three months. At the six-month time point, the intervention group continued to experience a decline, whereas those in the control group showed increased fatigue, although this level was still below that at baseline.

Both conventional gymnastic exercise and gentle strength training were associated with weight reduction and improvement in fatigue and QOL in women with breast cancer.

• 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 and no blinding.
• Measurement validity/reliability was questionable.*
• * Baseline QOL measures were higher in the intervention group.  There was no information provided regarding patient adherence to weekly sessions.  Fatigue was only measured with a single item from the instrument used.  It was not clear whether patients had relevant levels of fatigue at baseline or if all exercise was supervised or if individuals performed the sessions on their own.

Findings suggested that both types of exercise were beneficial to patients with breast cancer.  Further research in this area would be beneficial to determine those types of exercise and the timing of exercise related to cancer treatment that are most effective for the prevention and management of fatigue.

To compare partially supervised, structured exercise to standard of care for patients with advanced cancer. The primary outcome was general fatigue.

Patients were randomized into three groups. Group A received treatment as usual; participants in group B were taught a structured, individual sports program; and group C received additional ambulatory physiotherapeutical supervision. Exercises were defined based on expert consensus with physical therapists and physicians. Included as “possible exercises” into a catalog and a patient information sheet. For groups B and C, a physical therapist selected applicable exercises from this catalog. Patients were instructed to complete three sessions of endurance and two sessions of strength each week for 20-30 minutes per session. Patients were contacted at weeks 4 and 8, during which groups B and C could ask specific questions and adherence was encouraged. Patients were then followed up with in person at 12 and 24 weeks.

• N = 43   
• AGE = 52.38 years (consented group) 
• MALES: 58%, FEMALES: 42%
• CURRENT TREATMENT: Chemotherapy, radiation 
• KEY DISEASE CHARACTERISTICS: Curative and palliative treatment
• OTHER KEY SAMPLE CHARACTERISTICS: Hematologic, brain, gastrointestinal, lung, head and neck, testicle, and breast cancer, as well as sarcoma

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: University Hospital Carl Gustav Carus, Dresden

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial into three groups

• Multidimensional Fatigue Inventory-14 
• 6-minute walk test (6MWT)
• International Physical Activity Questionnaire Short-Form

No difference in general fatigue was observed. Significant difference was found with mental fatigue (p = 0.03). Over time, all groups experienced an increase in fitness, with group C experiencing the most improvement.

No effects on fatigue were seen.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (sample characteristics)

This study did not find any effect of interventions. The study was underpowered to identify significant differences between groups.

To evaluate the efficacy of resistance training to treat fatigue

• N = 155  
• MEAN AGE = 56 years (range = 29–75 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer stages I–III; received lumpectomy or mastectomy and scheduled for radiotherapy; majority did not receive chemotherapy; study occurred an average of 67 days after surgery
• OTHER KEY SAMPLE CHARACTERISTICS: Age ≥ 18 years; body mass index ≥ 18 kg/m²

• SITE: Single site    
• SETTING TYPE: Outpatient    
• LOCATION: Germany

• PHASE OF CARE: Active antitumor treatment

Single, blinded, randomized, controlled trial

• Fatigue was assessed with the Fatigue Assessment Questionnaire (FAQ), a 20-item self-assessment questionnaire validated for a German-speaking population. 
• Center for Epidemiologic Studies Depression Scale (CES-D)
• Quality of life was assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30 BR23) for breast cancer.
• Trail Making Test (TMT)

• Other limitations/explanation: Patients were blinded, but investigators were not.

This study adds to the already extensive evidence supporting that exercise improves fatigue. This study showed this to be the case for patients receiving radiation therapy treatment and demonstrated that group interaction and attention alone were not responsible for the changes seen by including an attention control group in the study design. Nurses should recommend that patients participate in exercise to combat fatigue during cancer treatment.

To examine the effects of an 18-week exercise program on preventing an increase in fatigue. The intervention is offered early after diagnosis and incorporated into the daily clinical practice setting.

An 18-week exercise program (two 60 minute aerobic and strength exercise session per week and including cognitive behavioral principles) supervised by a physical therapist. The control arm of usual care maintained their usual physical activity pattern for 18 weeks and then could participate in an exercise program.

• N = 164  
• MEAN AGE: 49.7 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer diagnosis less than six weeks before recruitment; scheduled for chemotherapy; stage M0; performance status > 60
• OTHER KEY SAMPLE CHARACTERISTICS: No contraindications for physical activity

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: Netherlands

• PHASE OF CARE: Active antitumor treatment

• Two-arm, randomized controlled trial using computer generated 1:1 randomization

• Quantitative data of outcome assessments at baseline, 18, and 36 weeks postintervention.
• Fatigue: Multidisciplinary Fatigue Inventory (MFI) and Fatigue Quality List (FQL
• Quality of Life: EORTC QOL Core-30 and SF-36®
• Anxiety/Depression: Validated Dutch language version of the 20-item Hospital Anxiety and Depression Scale
• Aerobic capacity by cardiopulmonary exercise test with continuous breathing gas analysis; thigh muscle strength by Cybex dynameter; handgrip strength by mechanical handgrip dynameter; body weight/height and physical activity level by Short Questionnaire to Assess Health Enhancing Physical Activity (SQUASH)

Effects were based on an intention-to-treat analysis using within-group and between-group differences. On the MFI, the only between-group difference seen was a lower increase in physical fatigue at 18 weeks in the intervention group. Although there were decreases in general and mental fatigue in the intervention group at 18 weeks, there was no significant between-group differences. There was no between-group difference on the FQL. The EORTC and Hospital Anxiety/Depression Scale showed decreased QOL, decreased anxiety, and increased depression in both groups at 18 weeks with no between-group difference and improvement in both groups at 36 weeks with decreased improvement in the intervention group. Aerobic capacity and muscle strength were improved in the intervention group at 18 weeks but not at 36 weeks.

An exercise program offered early in the treatment phase of breast cancer appears to positively impact physical fatigue, aerobic capacity, and muscle strength.

• Key sample group differences that could influence results
• Intervention expensive, impractical, or training needs
• Subject withdrawals of 10% or greater 
• Other limitations/explanation:  The control group may have had a high baseline activity level that continued throughout the study. Multiple measurements make interpretation difficult. Requires resources to implement exercise program.

There is an opportunity to continue to study the effect of exercise on fatigue in all patients with cancer. It may be challenging to implement a structured exercise program in clinical practice.

To evaluate the effects of low and moderate to high intensity exercise on fatigue, fitness, and treatment completion rates

Patients were randomized to usual care control, low-intensity, or moderate- to high-intensity exercise groups. Those in the low-intensity group did home-based self-managed activity for at least 30 minutes for five days a week. Those in the moderate- to high-intensity group participated in 50 minute sessions two times per week and were encouraged to also be physically active for 30 minutes per day for five days per week. Study measures were obtained at baseline, at completion of chemotherapy, and six months later. Exercise programs began with initiation of chemotherapy and continued until three weeks after completion of chemotherapy.

• N = 197
• MEAN AGE = 50.7 (SD = 9.1)
• FEMALES:  100%
• KEY DISEASE CHARACTERISTICS:  Breast cancer;  the majority were stage II or III; 78% had radiation therapy as well as chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: 70% were working full or part time

• SITE: Multi-site  
• SETTING TYPE: Outpatient  
• LOCATION: Netherlands

Randomized, controlled trial

• Fatigue Quality List
• Multidimensional Fatigue Inventory
• EORTC-QLQ –C30
• Hospital Anxiety and Depression Scale
• Sleep Quality Inventory
• Physical Activity Scale for the Elderly
• Grip strength with dynamometer
• Exercise diary
• Steep ramp test fitness and endurance testing

Participants attended 71% of exercise sessions, and 55% of those on the low-intensity program followed recommendations at least 75% of the time. Those in the moderate- to high-intensity group had the best endurance and muscle strength results at the end of chemotherapy. Those in the higher-intensity exercise group also had the lowest physical fatigue levels at the end of chemotherapy (p < 0.001).  Those in the low-intensity group had slightly lower fatigue levels than controls. There were no significant differences between groups at three months. There were no significant differences between groups in anxiety or depression scores.

Results of this study showed the lowest physical fatigue scores during chemotherapy among those participating in moderate- to high-intensity sessions. It is unclear if this difference between exercise groups was related to exercise intensity or the overall difference in the amount of exercise done. Effects on fatigue were not maintained at three months postchemotherapy and there were no effects on measures of anxiety or depression

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)

This study adds to the already extensive body of evidence showing the benefits of exercise in managing fatigue during cancer treatment. It is unclear if the amount, duration, or intensity of exercise are most important for deriving benefit from exercise. Group differences seen at the end of chemotherapy were not maintained three months later, and it is unclear what amount of physical activity was done between the end of treatment and final study measurements.

To evaluate the impact of a home-based walking program on patient symptoms of fatigue, sleep disturbances, and mood.

Patients were randomly assigned to the walking program or a usual care control group. The exercise intervention included a walking prescription based on the American College of Sports Medicine guidelines. The targeted exercise prescription included a brisk 20- to 30-minute walk with five-minute warm-ups and cool-downs five days per week. Exercise participants wore pedometers. Usual care patients wore pedometers during the first two weeks only. Throughout the study, patients in both groups received telephone contact on a biweekly basis to discuss physical activity and any concerns. For those in the exercise program, adjustments to the program were made, barriers to walking were discussed, and strategies for resolution were planned.

• One hundred twenty-six patients (61.1% male, 38.9% female) were included.  
• Mean age was 60.2 years (range 28–80).
• Patients had multiple solid tumor types; the most common were prostate, breast, and colorectal tumors.
• All patients were scheduled to receive chemotherapy or radiation therapy.
• Of the patients, 78.6% were Caucasian and 84.9% were married or partnered.

• Single site 
• Home 
• New Jersey

Patients were undergoing the active antitumor treatment phase of care.

This was a randomized, controlled trial.

• Piper Fatigue Scale (PFS)
• Profile of Mood States (POMS)
• Cooper Aerobics Center Longitudinal Study
• Physical Activity Questionnaire (PAQ) for exercise dose
• Pedometer
• Pittsburgh Sleep Quality Index (PSQI)
• Daily exercise and symptom log

Analysis of dropouts showed that significantly more ethnic minorities and those with lower educational levels withdrew (p < 0.03). There were no differences at the end of the study in sleep quality. There were no differences between groups in overall mean emotional distress scores; however, dose-response analysis showed that those who exercised more had less emotional distress (p = 0.03). There were no between-group differences in fatigue; however, analysis showed that those who exercised more had lower fatigue scores (p = 0.03). Subgroup analysis among patients with prostate cancer showed that exercise group members had better sleep quality (p < 0.001), less emotional distress (p = 0.048), and less fatigue (p = 0.009). PAQ findings were moderately correlated with pedometer results, suggesting that the PAQ may be a reasonable measure of exercise dose (Spearman = 0.37; p = 0.002).
 

Findings suggested that a home-based exercise program can be beneficial in patients receiving cancer treatment to reduce fatigue. Among patients with prostate cancer, the program resulted in improved sleep quality and less emotional distress and fatigue.

• The study had a risk of bias due to no blinding.
• Patient withdrawals were 10% or greater.

A home-based walking program is a simple intervention that can be beneficial to patients, and study findings showed that patients who exercised more had less fatigue and improved mood. In patients other than patients with prostate cancer, it did not appear that exercise improved sleep quality. This study included biweekly telephone follow-ups. Other studies have not shown the same level of results with home-based walking, suggesting that the follow-up component is probably important to maintain patient exercise program use. Of interest, patients who were less educated and of ethnic minorities were more likely to drop out of the study. This suggests that these groups of patients need to be examined more in order to see what interventions will be most likely to appeal to them.

The primary aim was to identify the benefits of exercise performed during the entire hematopoietic stem cell transplantation (HSCT) time period. The secondary aim was to explore endurance performance via six-minute walk test (6MWT), isometric muscle strength, functional performance status, physical activity levels via pedometer step count, health-related quality of life, and psychological well-being and distress.

A self-administered exercise intervention was compared to a social contact pedometer-wearing control group. Exercise began one to four weeks prior to hospital admission. Exercise included three endurance (outpatient:  walking; inpatient:  bicycling and treadmill) and two resistance (color-coded bands with different levels of resistance focused on extremities, entire body, and bed exercises) training sessions per week (up to five sessions during hospitalization). Exercise continued six to eight weeks after discharge. The control group reported that moderate physical activity was helpful without instruction, wore step counters, and received thirty minutes of physiotherapy and access to bicycles and treadmills during hospitalization. Both groups received the same number of visits by study personnel.

• One hundred five patients were enrolled, and 80 (40 in each group) were included in the final analysis.
• Mean age was 48.8 years. 
• Thirty-four females and 71 males were included. 
• Patients had acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), myelodysplastic syndrome (MDS), chronic lymphocytic leukemia (CLL), multiple myeloma (MM), lymphoma, and aplastic anemia.

• Multisite
• University Clinic, Heidelberg, Germany and the German Diagnostic Clinic, Wiesbaden, Germany

This was a prospective, multicenter, randomized, controlled trial.

• Borg Scale – perceived exertion scale
• Multidimensional Fatigue Inventory (MFI)
• Profile of Mood States (POMS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Daily log
• 6MWT protocol by the American Thoracic Society estimated aerobic capacity
• Hand-held dynamometer measured maximal isometric voluntary strength
• National Comprehensive Cancer Network (NCCN) Distress Thermometer
• Hospital Anxiety and Depression Scale (HADS)

All assessments were measured at four time points:  baseline, admission, discharge, and six to eight weeks after discharge.

Significant group differences at the end of the intervention were:  general fatigue (p = 0.009); physical fatigue (p = 0.01); and POMS fatigue scale (p = 0.004). The exercise group was superior to the control group in all subscales. Physical capacity increased in the exercise group (p = 0.02) and was inversely correlated with general fatigue (p ≤ 0.01). The Intervention significantly improved the strength of the lower extremities (p = 0.03) (maybe due to walking and biking). The exercise group was significantly more anxious than the control group (p = 0.007). All benefits were observed most predominantly during hospitalization.

This partly supervised exercise intervention was beneficial for patients undergoing allogeneic (allo)-HSCT.

• The study had a small sample size, with less than 100 patients. 
• The 6MWT was not a standard procedure for assessing endurance capacity.
• Interrater reliability was unknown for the hand-held dynamometer.
• Exercise logs were missing (most before and during hospitalization).
• There was no documentation about social support for the control group.

The allo-HSCT patient population should be encouraged to exercise. An exercise intervention is feasible and can alter cancer-related fatigue in the allo-HSCT patient population. Use of preadmission exercise in concert with findings of differences in fatigue between individuals who have higher baseline activity levels suggests that further research in improving capacity and activity levels prior to treatment in various patients is worth investigating.

To examine daily fatigue patterns during the third cycle of chemotherapy in women with breast cancer and predict whether fatigue trajectories differ by exercise or chemotherapy regimens.

Patients completed a daily fatigue diary that included a fatigue rating and items to determine whether they were exercisers or nonexercisers. Patients were asked to complete the diary daily. Weekly telephone calls from an exercise physiologist were used to determine exercise adherence.  Adherence was determined as either a yes or no based on whether the patient exercised at least three days per week for 20 minutes per session and at a “somewhat hard” intensity. Measures obtained during the third course of chemotherapy were used in this analysis.

• Ninety-eight patients (all female) were included.
• Mean age was 49.5 years (standard deviation = 9.3; range 28–72).
• Patients had breast cancer stage III and less.
• Of the patients, 72% were married/partnered, 28% were single, 74% were Caucasian, and 89% were educated more than 12 years.
• Patients were undergoing chemotherapy, with the majority (79%) receiving chemotherapy.

• Multisite  
• Outpatient
• Five cancer centers in the San Fransisco Bay area

Patients were undergoing the active treatment phase of care.

This was a prospective, longitudinal, repeated-measure design primary study; a secondary analysis of these data was performed.

• The fatigue diary had two standard questions, each measured on an 11-point rating scale ranging from 0 (no fatigue/tiredness) to 10 (overwhelming fatigue/tiredness). 
• Determination of exerciser versus nonexerciser status, the Surgeon General’s Guideline for Physical Activity, was used (described as at least three days a week for 20 minutes per session at an intensity of “somewhat hard”).

Average levels of fatigue reported were moderate for the first eight days and mild for the rest of the cycle. Highest levels of fatigue were observed on days 1 to 3 for average and worst fatigue. Five distinct trajectory patterns of cancer-related fatigue (CRF) were identified:  immediate and sharp increase followed by a gradual decline; early peak, a decline, and a sharp increase toward the end of the cycle; small variations among daily scores; chaotic pattern; and step-up evaluation followed by a gradual decline. Nonexercisers had higher average and worst fatigue (p < 0.01). In exercisers and nonexercisers, fatigue declined in severity over time, and the rate of decline was not significantly different between the two groups; however, fatigue levels were consistently higher among nonexercisers.

CRF peaked in the days immediately after intravenous chemotherapy and declined gradually over time. Fatigue tended to be lower in those who exercised as described.

• The study had a small sample size, with less than 100 patients.
• The sample consisted of female outpatients with breast cancer.
• Fatigue was not measured at different times during the day.
• No baseline of fatigue was established prior to chemotherapy.
• The length of the chemotherapy cycle varied depending on the regime.

Nurses should provide anticipatory guidance to patients so that they can plan for the days when they are at most risk for fatigue. Continued exercise during the course of chemotherapy may be helpful in mitigating the severity of fatigue.

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

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.

• 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.

• Single site
• Outpatient
• Taiwan

Patients were undergoing the active treatment phase of care.

This was a randomized, controlled trial.

• 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

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.

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.

• 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.

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.

To evaluate the efficacy of an aerobic exercise program for fatigue in women receiving radiotherapy for breast cancer

Patients were recruited to an intervention group and to a comparison group. The intervention consisted of aerobic exercise using a treadmill with mild to moderate intensity defined as 40%–65% of maximum heart rate. Exercise was done for 20–30 minutes three days per week during six weeks of radiation therapy. Fatigue was assessed prior to radiation therapy and then weekly for six weeks.

• N = 47
• MEAN AGE = 50.3 years (SD = 9.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All patients had breast cancer. Women receiving chemotherapy and radiation therapy were not included.
• OTHER KEY SAMPLE CHARACTERISTICS: The majority were married and not working outside the home.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Taiwan

• PHASE OF CARE: Active antitumor treatment

Two-group, nonrandomized, quasi-experimental study

• Taiwanese Brief Fatigue Inventory (BFI)
• Rate of perceived exertion (Borg scale)

Fatigue trends over time showed a consistent decline in the intervention group and an increase over time in the comparison group. With the intervention, the change in fatigue was -1.09 (p < 0.0001), and in the control group, fatigue increased by 1.45 points by week 6 (p = 0.002). The same pattern was shown for fatigue interference with daily life measures.

The findings of this study suggest that aerobic exercise can reduce and prevent fatigue during radiation therapy. The study's design limits its generalizability and the strength of these findings.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)  
• Subject withdrawals ≥ 10%

This study adds to the body of evidence regarding the efficacy of exercise to combat fatigue during active cancer treatment. This study was conducted during radiation therapy, showing that aerobic exercise can be helpful during this treatment.

To examine the feasibility of a home-based aerobic exercise intervention on reducing fatigue in children with acute lymphoblastic leukemia (ALL).

Institutional review board approval, parental consent and child assent, verbal and written explanations, and baseline assessments were completed. Maximal exercise tests were completed for all, and those in the intervention group were provided with a video and instructions on achieving target heart rate. Parents and patients were instructed on exercise guidelines, safety and health condition assessment, and monitoring. Heart rate monitors were worn and documented.  

The home-based aerobic exercise intervention consisted of following the steps in an exercise video three days a week, for 30 minutes each session, for six weeks. The content of the intervention included three sections:  a warm-up for five minutes, aerobic exercise for 25 minutes, and a cool-down for five minutes. The warm-up and cool-down were aimed to increase 10% to 30% of the heart rate reserve. This was recommended by the American College of Sports Physicians. The aerobic section was designed to increase the heart rate reserve to 40% to 60%. The exercise prescription was individualized after baseline assessment, and the duration ranged from 10 to 30 minutes, gradually increasing to 30 minutes by the third week and after. Patients were instructed to complete the exercise three times per week for six weeks.

• Twenty-two children were included in the study (12 in the intervention group [six boys and six girls; average age = 11.01 years] and 10 in the control group [six boys and four girls; average age = 12.48 years]).  
• They were matched by age and sex.  
• All patients received maintenance chemotherapy for 20 weeks, and they were recruited after completing the dexamethasone.  
• Ten patients (five boys and five girls) in the intervention group adhered to the exercise prescription.
• In the control group, five children (three boys and two girls) reported any exercise with their logs, and they were used for per-protocol (PP) analysis.  
• Of the patients, 54.% were female and 45.5% were male.
• Patients had ALL.
• All patients were receiving maintenance chemotherapy regimens of standard or high-dose chemotherapy.

• Single site
• Home
• Taiwan

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

This was a quasiexperimental control study with multivariate analysis on self-reported levels of fatigue at posttest and one-month follow-up.

• Pediatric Quality of Life Inventory (PedsQL) Multidimensional Fatigue Scale 
• Physical activity log
• Children’s OMNI-Walk/Run Scale
• Stage of change-exercise behavior
• Maximal exercise test for assessing cardiorespiratory fitness
• Only subjective data were reported.
• Hemoglobin was measured to assess for confounding variables, but it was not related to fatigue change patterns.

For the PP analysis, children who received the exercise intervention reported lower general fatigue subscale scores than those in the control group at one-month follow-up (p = 0.03). There were no significant differences between groups at any other study timepoint. For intent-to-treat (ITT) analysis, there was no intervention and time effect for any of the three fatigue subscales at posttest or one-month follow-up. Descriptive statistics were collected, and the intervention effects of the home exercise and data were measured using the mixed-effects model (mixed procedure in SAS). This included fixed-effects for time and group. ITT (for all patients) and PP (for those who adhered to exercise) analyses were used. The mean adherence rate for the six-week intervention was 76% in the ITT analysis and 90% in the PP analysis.

This exercise program was feasible. Children who received the home-based aerobic exercise intervention reported lower “general fatigue” than those in control group at one-month follow-up. There was structured parental involvement, which might have played a role in adherence. Motivating children with cancer to exercise will require additional study.

• The study had a small sample size, with less than 30 participants. 
• The study had potential risks of bias due to no random group assignment and no blinding.

A home-based aerobic intervention program might reduce fatigue in children with ALL who are undergoing maintenance chemotherapy. This study demonstrated a high level of adherence, which the authors attributed to parental involvement. Larger, well-designed clinical trials should be performed to further examine the role of exercise in managing fatigue in these patients, as well as the importance and degree of parental involvement needed for success.

To evaluate the effects of a home-based walking program in postresection patients on cancer-related fatigue, physical function, and quality of life.

Consenting patients were randomly assigned to the walking group or usual care group while in the hospital after surgery. Baseline measures were obtained either in the physician's office prior to surgery or in the hospital. Patients in the intervention group were given a prescription for a graduated walking program and were asked to record the number of minutes or approximate distance walked and any adverse symptoms in a weekly diary. They also received monthly telephone calls to assess their current status and adherence to walking and remind them to mail in their diary information. The intervention group was given a modified “Every Step Counts” booklet, modified to cover a six-month period recommending increasing brisk walking time to 20 minutes in the second month and to 25 to 30 minutes in the third month. Patients in the usual care control group did not receive monthly calls but received one follow-up call at three months. Outcome measures were assessed via the follow-up telephone calls in all groups.

• One hundred two patients (50% male, 50% female) were included.
• Seventy-nine patients completed the final six-month postoperative follow-up.
• Mean age was 66.5 years (range 38–91). 
• All patients had pancreatic, bile duct, or duodenal cancer, and 93% had undergone pancreaticoduodenectomy with pyloru preservation.
• Of the patients, 73% underwent adjuvant therapy with chemotherapy, radiation, or both.
• Patients with stage IV disease were excluded.

• Single site
• Home
• Philadelphia, PA

Patients were undergoing the active treatment phase of care.

This was a randomized, controlled trial.

• Fatigue visual analog scale (VAS)
• Pain VAS
• Medical Outcomes Study (MOS)
• Short Form 36 Health Survey (SF-36), version 2
• Eastern Cooperative Oncology Group (ECOG) Performance Status
• Functional Assessment of Chronic Illness (FACIT) Fatigue subscale

Patients in the exercise group had improved fatigue scores by both VAS and FACIT measures (p < 0.05). Mean change in VAS fatigue score was 1.2, and mean change in the FACIT subscale was 9 points. FACIT scores tended to correlate with disease stage. All patients had a significant reduction in pain. Physical function score changes on the SF-36 were mixed, with the individual subscale score improving more in the exercise group but the composite score improving more in the usual care group. There were no differences between groups in other symptoms observed. Analysis demonstrated a fatigue-related symptom cluster of fatigue, bodily pain, depression, weakness, and anxiety at an average of three months.

Findings supported the benefits of a home-based progressive walking program for patients postsurgical resection.

• The study had risks of bias due to no appropriate control group and no attentional control. 
• It is unclear if some patients had baseline measures performed pre- or postoperatively; the timeframe of these measures related to the surgical procedure is also unclear.
• The study report appeared to provide some conflicting information in this area. There was no subgroup analysis between those who received various adjuvant therapies, although the study groups were similar in terms of percentages that had any adjuvant treatment. There was no stratification based on baseline activity levels and physical functioning. There was no information regarding walking adherence or the activity levels of the control group, so it is not really known if there was a difference in actual exercise between groups.

Findings suggested that a self-managed home-based walking prescription can be helpful to patients with cancer postoperatively. This study adds to the body of evidence related to exercise and fatigue by using a sample of patients who had diagnoses and treatments not previously studied in this area.

PHASE OF CARE: Late effects and survivorship

Adapted from three guidelines by multidisciplinary experts using supplementary evidence and clinical experience. Most recommendations listed verbatim but some modified to include updated evidence or current practice beliefs.

Recommendations focused on patients who have completed active treatment or are considered in clinical remission. Treat underlying causes, moderate physical activity after cancer treatment with PT and lymphedema referrals as needed (meta-analysis, systematic review, [randomized controlled trial [RCT]; 10 cited), cognitive behavioral therapy (meta-analysis, RCT, systematic reviews; 6 cited), psychoeducational therapies (systematic, RCT; 3 cited), psychosocial services, mindfulness-based interventions (RCT; 3 cited), yoga (RCT; 2 cited), acupuncture (RCT; 2 cited), psychostimulants/wakefulness agents (limited evidence in patients who are post-treatment disease-free). Additional areas in which research needed include biofield therapies, massage, music therapy, relaxation, Reiki, Qigong, ginseng, and vitamin D.

Guidelines were tailored to survivors with current evidence as not all evidence done is survivors.

Screening, assessment, and treatment guidelines summarized for use in cancer survivors.

PHASE OF CARE: Multiple phases of care

Two hundred two references were retrieved. The total number of references included and reviewed for updating was not provided. No quality rating is identified.

• Energy conservation
• Physical activity
• Cognitive behavioral therapy (CBT) for sleep shown to be effective
• Counseling

• Limited evidence search
• No quality rating of studies considered
• Studies included for evidence level determination not specified

The guidelines provide suggestions for screening and identify some tools for fatigue assessment and some key interventions for the management of fatigue. They provide an overview of relevant evidence for multiple types of interventions. Major suggestions are identified in the recommendations section of this summary.

To synthesize the literature on the safety and efficacy of exercise training during and after cancer treatment and provide guidelines for exercise for patients with and survivors of cancer. Adults with cancer during and after adjuvant cancer treatment were addressed. The guidelines state that the focus is on sites where the most evidence exists:  breast, prostate, colon, hematologic, and gynecologic cancers.

Evaluation of evidence was based on categories from the National Heart, Lung and Blood Institute (A–D levels). Panel member reviews were presented and discussed at the roundtable, and guidelines were developed by consensus. Specific strategy and terms were not described. Guidelines were developed by an expert roundtable in which members were asked to review relevant literature. The guidelines were limited to an adult population and provided an overview of a volume of evidence in multiple outcome areas related to exercise.

A comprehensive and detailed set of guidelines for exercise approaches applicable for survivors of  breast, prostate, colon, hematologic, and gynecologic cancers was provided in the guidelines, as well as some of the issues of exercise training timing related to phases of care. The guidelines also provided a summary of evidence used per cancer site and identified gaps in research because of the small number of studies in some cases and small sample sizes in many of the studies.

Recommendations for exercise testing were as follows:

• Evaluate for peripheral neuropathies, musculoskeletal morbidities, and fracture risk in those who have received hormonal therapies.
• Assess for risks associated with bone metastases and cardiac risks.
• In patients with breast cancer, evaluate arm and shoulder morbidity prior to upper-body exercise.
• In patients with prostate cancer, evaluate muscle strength and wasting.
• In patients with colon cancer, check for infection prevention behaviors for existing ostomy.
• In patients with gynecologic cancers, evaluate for lower-extremity lymphedema prior to vigorous aerobics or resistance; in patients with morbid obesity assess for safety.
• Exercise testing before walking, flexibility, or resistance training is not required.
• In survivors with or at risk for lymphedema, one repetition maximum testing is safe.

Recommendations for exercise prescription were as follows:

• Allow adequate healing time after surgery (may be as much as eight weeks).
• Resolve arm or shoulder problems with patients with breast cancer before upper-body training.
• Swelling or inflammation in gynecology cases should be resolved before exercise training. 
• Patients with ostomies should have doctor permission before contact sports and weight training.
• Changes in symptoms are reasons to stop an exercise program.
• Patients with bone metastases may need to alter exercise intensity, duration, and mode because of fracture risk.
• Specific cancer site–related recommendations are provided for injury prevention and emergencies.

General activity guidelines were as follows:

• Avoid inactivity.
• Aerobic exercise recommendations are the same as general age-appropriate national guidelines.
• Resistance training should be supervised for at least 16 sessions for patients with breast cancer.
• Patients with radical prostatectomy should also perform a pelvic floor exercise with resistance training.
• Resistance training is more important than aerobics for patients who have received transplants.
• Resistance training should be used with caution in patients with lower-limb lymphedema.
• Age-appropriate flexibility training should be followed.
• Ostomies require avoidance of excessive intra-abdominal pressure.
• Research gaps and recommendations were outlined for yoga, sports, Pilates, and other exercises.
   

No participant associations were described.

The guidelines concluded that there was consistent evidence that exercise is safe during and after cancer treatment, with consideration of specific risks that are associated with various types. Exercise training can be expected to improve aerobic fitness, muscular strength, quality of life, and fatigue. Resistance training can be performed safely in patients with and at risk for lymphedema with breast cancer. Some exercise is recommended for all types of patients. Further study is needed in the areas of dose-response effects of exercise training. The guidelines provided additional evidence-based and expert support for the incorporation of various types of exercise in the care of patients with cancer during and after adjuvant treatment. Continued research is needed in this area in terms of research in other cancer types and determination of dose-response relationships for various outcomes.