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Rogers, L.Q., Courneya, K.S., Anton, P.M., Verhulst, S., Vicari, S.K., Robbs, R.S., & McAuley, E. (2017). Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: Randomized trial. Psycho-Oncology, 26, 1901-1906.

Study Purpose

To determine the effectiveness of a three-month intervention which includes a multicomponent physical activity change intervention on the symptoms of fatigue, depressive symptoms, and anxiety

Intervention Characteristics/Basic Study Process

Better Exercise Adherence after Treatment for Cancer (BEAT Cancer). Twelve supervised exercise sessions with an exercise specialist that were tapered over the first six weeks to an exclusively unsupervised home-based program. Face-to-face update counseling session with exercise specialist every two weeks during the final six weeks. Exercise and heart rate monitor sheets were provided to those who were randomized to the intervention. Group sessions for the participants. Those randomized to control received care as usual, which included handouts and publicly available printed materials.

Sample Characteristics

  • N = 222   
  • MEAN AGE: 54.4 years
  • FEMALES: 100%
  • CURRENT TREATMENT:  Radiation, Other
  • KEY DISEASE CHARACTERISTICS: Breast cancer, finished with adjuvant therapy except for adjuvant hormonal therapy
  • OTHER KEY SAMPLE CHARACTERISTICS: 98% non-Hispanic, 84% White, 11% DCIS, 42% stage I, 35% stage II, 12% stage III, 54 mean months since cancer diagnosis, 58% had chemotherapy, 68% had radiation therapy, 50% were on adjuvant hormonal therapy.

Setting

  • SITE: Multi-site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Two midwestern and one southeastern academic institutions

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Study Design

Randomized control trial

Measurement Instruments/Methods

Measurements happened at baseline, immediately postintervention, month 3, 3 months after intervention completion, and month 6. Instruments used were the Fatigue Symptom Inventory and the 14-item Hospital Anxiety and Depression Scale

Results

Adjusted linear mixed‐model analyses demonstrated significant effects of BEAT Cancer versus usual care on fatigue intensity (month 3 mean between group difference [M] = −0.6; 95% confidence interval [CI] [−1, −0.2]; effect size [d] = −0.32; p = 0.004), fatigue interference (month 3 M = −0.8; CI [−1.3, −0.4]; d = −0.4; p < 0.001), depressive symptomatology (month 3 M = −1.3; CI [−2, −0.6]; d = −0.38; p < 0.001), and anxiety (month 3 M = −1.3; CI [−2, −0.5]; d = −0.33; p < 0.001). BEAT Cancer effects remained significant at month 6 for all outcomes.

Conclusions

This intervention reduced fatigue, depressive symptomatology, and anxiety up to three months postintervention compared to treatment as usual.

Limitations

Intervention expensive, impractical, or training needs

Nursing Implications

Nurses can safely recommend exercise as tolerated to breast cancer survivors who have completed adjuvant treatment. There are several exercise programs widely available, including Livestrong and STARS Cancer rehabilitation programs.

Print

Packel, L., Fang, C.Y., Handorf, E., & Rodoletz, M. (2017). A 12-week exercise and stress management pilot program from theory through implementation and assessment. Rehabilitation Oncology, 35, 172–180.

Study Purpose

The purpose of the study was to assess the response of an exercise, education, and stress management program (12 weeks) on fatigue levels of community-dwelling cancer survivors.

Intervention Characteristics/Basic Study Process

12-week program that consisted of 10 weeks of supervised moderate-intensity aerobic and strength training combined with 2 unsupervised weeks of home exercise. Supervised weeks included 1 in-person and 2 at-home sessions. Participants also received education on nutrition, stress management (mindfulness), and sleep.

Sample Characteristics

  • N = 16   
  • MEAN AGE: 68.5 years
  • MALES: 38%
  • FEMALES: 62%
  • CURRENT TREATMENT: Not applicable
  • KEY DISEASE CHARACTERISTICS: Some patients were receiving active treatment and some were in survivorship
  • OTHER KEY SAMPLE CHARACTERISTICS: 24% of patients had breast cancer

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Philadelphia area

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Study Design

Single arm, pre-/post-test design

Measurement Instruments/Methods

FACT-Fatigue, HADS, NCCN Distress Thermometer, 6-Minute Walk Test, and Sit-to-Stand Test

Results

Significant improvements were noted in fatigue (p = 0.008), physical well-being (p = 0.004), and in the anxiety subscale scores of the HADS (p = 0.047). Increases in 6MWT distance (p = 0.002) and Sit-to-Stand Test score (p = 0.018) were also observed. Significant reductions in psychological distress were found (p = 0.003); however, no significant changes were observed in emotional well-being (p = 0.855), social well-being (p = 0.327), or depression (p = 0.221).

Conclusions

The program had some barriers to recruitment and retention but was able to identify a statistically significant improvement in fatigue, physical well-being, and anxiety as well as increased in the 6MWT distance and Sit-to-Stand Test score.

Limitations

  • 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)

Nursing Implications

Exercise, stress management, and behavior change are moderately feasible and may have an impact on cancer-related fatigue and anxiety. Larger studies are needed to confirm these results.

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Cobeanu, O., & David, D. (2018). Alleviation of side effects and distress in breast cancer patients by cognitive-behavioral interventions: A systematic review and meta-analysis. Journal of Clinical Psychology in Medical Settings, 25, 335–355.

Purpose

  • STUDY PURPOSE: Ascertain the effect of cognitive-behavioral interventions (CBI) in patients with breast cancer during active treatment for breast cancer; determine effect sizes on side effects of treatment, distress, and quality of life; determine moderators of effect size.
  • TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

  • DATABASES USED: PsycINFO and MEDLINE
  • YEARS INCLUDED: 1996-2012
  • INCLUSION CRITERIA: Randomized control trial to assess the efficacy of CBI in side effect management of breast cancer during treatment. Interventions studied were started upon treatment initiation or before completion of treatment. The study must have included a control group, was in English, and publications were from a peer-reviewed journal. Paper must have sufficient data to compute an effect size
  • EXCLUSION CRITERIA: Studies that focused on alleviation of surgical side effects; studies that investigated CBI use in physical symptoms not associated with treatment side effects.

Literature Evaluated

  • TOTAL REFERENCES RETRIEVED: 786
  • EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Criteria applied for inclusion in meta-analysis were listed in publication. There was no method to assess the risk of bias in individual studies and no report of the quality of studies included.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED: 19 
  • TOTAL PATIENTS INCLUDED IN REVIEW: 2,220
  • SAMPLE RANGE ACROSS STUDIES: 34-303
  • KEY SAMPLE CHARACTERISTICS: Patients with breast cancer receiving neo-adjuvant or adjuvant treatment.

Phase of Care and Clinical Applications

PHASE OF CARE: Active anti-tumor treatment

Results

Overall, results demonstrated a modest but statistically significant effect on side effect improvement (p = 0.005) with CBI. More specifically, CBI was associated with statistically significant improvements in nausea and vomiting (p < 0.001), overall distress (anxiety and depression, mood, stress, hostility) (p < 0.001), anxiety (p = 0.001), and quality of life (p < 0.001). The review results found non-significant effects on fatigue (p = 0.63), sleep disturbance (p = 0.314), pain (p = 0.854), and depression (p = 0.063). The authors hypothesized that this lack of significance could be due to low power of analysis across the studies on fatigue, sleep, and pain, as well as lack of tailored interventions specific to those symptoms. Lack of significance for CBI on depression could be due to failure to pre-screen participants for depression prior to beginning the intervention.

Conclusions

CBI is effective in reduction of many physical and psychological distress symptoms, including nausea and vomiting, anxiety, and quality of life. Additional research are studies with larger sample sizes are needed to further validate findings. In addition, further research is needed to examine which CBI protocols are most effective for specific symptoms, as well as greater uniformity in the reporting of CBI interventions.

Limitations

  • Limited number of studies included
  • No quality evaluation
  • High heterogeneity
  • Inconsistency in reporting of intervention descriptors such as length of treatment and types of professionals administering the intervention

Nursing Implications

CBI has efficacy in improving some physical and psychological symptoms and quality of life in breast cancer patients undergoing active therapy. It is important for nursing to assess and advocate for patients who may benefit from CBI and facilitate access to such interventions as part of the overall treatment plan.

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Computerized Cognitive Rehabilitation

Cognitive rehabilitation involves behaviorally-oriented interventions designed to improve performance in cognitive and functional areas (Bray et al., 2017; Levine et al., 2000). Computerized cognitive rehabilitation is the provision of such practice via a computer program. 

Transversus Abdominis Plane (TAP) Block

Transversus abdominis plane (TAP) block refers to the infiltration of local anesthetics into the fascial plane between the internal oblique and transversus abdominis muscles (Oh et al., 2017).​  

Peripheral Nerve Block

Peripheral nerve block refers to the use of local anesthetics to block peripheral nerves, which blocks the signaling of pain stimuli from the tumor to the central nervous system (Klepstad et al., 2015; Swarm, Karanikolas, & Cousins, 2000). This intervention has been studied for treatment of cancer-related pain. 

Morphine and Magnesium

When opioids bind to their receptors, pain transmission is reduced (Baaklini, Arruda, & Sakata, 2017; Nechifor, 2012), but the sensitivity to pain may increase (Angst & Clark, 2006; Baaklini et al., 2017; DuPen, Shen, & Ersek, 2007). Magnesium plays a role in pain sensitivity (Baaklini et al., 2017; Célèrier et al., 2000) and has been studied in combination with opioids for cancer-related pain. 

mHealth Symptom Management

mHealth symptom management refers to the use of mobile health, or mHealth, devices to help manage symptoms in patients with cancer. mHealth involves the use of devices with mobile computing capabilities to monitor, track, and transmit health data continuously and in real time (Steinhubl, Muse, & Topol, 2015). 

Steinhubl, S.R., Muse, E.D., & Topol, E.J. (2015). The emerging field of mobile health. Science Translational Medicine, 7, 283rv3. https://doi.org/10.1126/scitranslmed.aaa3487

Vitamin D3 for Aromatase Inhibitor-associated Musculoskeletal Symptoms (AIMSS)

Vitamin D is involved in maintaining the collagen-rich osteoid surface of the skeleton. Low levels of vitamin ​D may lead to demineralization of that surface, which may​ contribute to pressure and pain (Felson & Cummings, 2005; Holick, 2006, 2007; Shapiro et al., 2016). The active hormone 1a,25-dihydroxyvitamin D3 promotes muscle cell growth, which may foster better ​muscle function (Boonen  et al., 2006; Ceglia, 2008; Shapiro et al., 2016) and decreased skeletal pain​ (Shapiro et al. 2016).

Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy combines the principles of cognitive therapy with meditation practices to foster mindfulness (MBCT.com, n.d.). Mindfulness focused on mentally attending to an experience in a nonjudgmental way (Johannsen et al., 2016, Piet, Wurtzen, & Zachariae, 2012). Mindfulness-based cognitive therapy has been studied in several symptoms and side effects of cancer treatment, including anxiety, depression, and pain. 

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