Exercise

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

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

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

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

Late effects and survivorship

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

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

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

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

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.

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

TYPE OF STUDY: Systematic review

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

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

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

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

TOTAL REFERENCES RETRIEVED: N = 867

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

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

PHASE OF CARE: Multiple phases of care

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

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

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

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

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

TYPE OF STUDY Combined systematic review and meta analysis

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

KEYWORDS  terms related to cancer, exercise, and depression    

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

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

TOTAL REFERENCES RETRIEVED : N =60

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

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

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

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

PHASE OF CARE Active Treatment

APPLICATIONS Late Effects and Survivorship

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

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

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

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).

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 evaluate the effects of exercises and aerobic on cancer survivors
• TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: Web of Science, Scopus, Cochrane Library, CINAHL, Medline
• YEARS INCLUDED: 1988-2017
• INCLUSION CRITERIA: Adult diagnosed with cancer
• EXCLUSION CRITERIA: Not specified

• TOTAL REFERENCES RETRIEVED: 65 articles for 140 meta-analyses reported
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Umbrella review following PRISMA

• FINAL NUMBER STUDIES INCLUDED: 65 
• TOTAL PATIENTS INCLUDED IN REVIEW: Not specified. Each category (cardiovascular fitness = 8,306 (55-1,310), muscle strength = 10,367 (241-1,244), fatigue = 59,233 (78-5,603), quality of life = 24,893 (78-2,357), depression = 13,538 (78-2,929); some patients are not reported in few articles.
• SAMPLE RANGE ACROSS STUDIES: See above in parenthesis for each category. 
• KEY SAMPLE CHARACTERISTICS: Different type of cancer

PHASE OF CARE: Not specified or not applicable

The effects of exercises on thousands of patients in 140 meta-analyses are reviewed. The beneficial effect is statistically significant in 75% of the meta-analyses. The effect for cardiovascular fitness and muscle strength are classified as moderate, and the effect on fatigue, quality of life, and depression are classified as small. The incidence of exercise-related adverse event is very low (3.5%). The large majority of the studied cancer population are patients with breast cancer.

The study shows how exercises have an important role in the well-being of patients and survivors. It would be interesting to have another meta-analyses on different cancer populations and at different stages of the disease/treatment. It would also be interesting to have the results by gender.

• Low sample sizes
• This study is mostly about patients with breast cancer

Nurses should encourage patients to have a physical activity. Cardiovascular markers and muscular fitness is improved with exercises as well as depression, fatigue, and quality of life to a lesser extent. In addition, it is relatively easy to find information on how to exercise.

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.

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

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

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

• Single site
• Uppsala, Sweden

Randomized controlled trial (RCT)

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

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

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

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 detect the optimal timing for the initiation of an exercise training intervention

This was a 12-week lifestyle intervention consisting of five components: physician referral and clinic support, health education, behavior change support, social support through group-based settings, and an individualized exercise program based on patient need. Patients were asked to attend exercise sessions twice a week with additional at-home implementation of the exercise regimen twice more per week. The individualized exercise programs consisted of progressive resistance-training programs with a short, moderate intensity warm-up followed by two sets of 8 repetitions for 10 exercises. Progression of the regimen occurred at weeks 4, 6, and 9, as appropriate. In addition to attending the exercise sessions, participants were required to attend six education sessions after their exercise sessions.

• N = 60   
• AGE = 56.1 years (SD = 9.2 years)
• MALES: 81.7%, FEMALES: 20.3%
• CURRENT TREATMENT: Chemotherapy, radiation, combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Head and neck cancer

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: University of Calgary

PHASE OF CARE: Multiple phases of care

The study design is a randomized, controlled exercise trial in which patients were randomly assigned to either the immediate lifestyle intervention (ILI) group or the delayed lifestyle intervention (DLI) group.

• Godin Leisure-Time Exercise Questionnaire
• Functional Assessment of Cancer Therapy (FACT)
• FACT-Anemia (FACT-An)
• FACT Head/Neck Symptom Index-22 (FHNSI-22)
• FACT-An Trial Outcome Index
• Center for Epidemiological Study Depression Scale (CESD)
• Patient-Generated Subjective Global Assessment (PG-SGA)
• Intervention survey
• Body composition, fitness, functional, flexibility tools

No significant differences were reported for lean body mass or percentage body fat during the 24 weeks. A main effect of time for lean body mass, body mass index, and percentage body fat was detected (lean body mass: F[2,74.5] = 54.141, p < 0.001; BMI: F[2,74.5] = 67.955, p < 0.001; percent body fat: F[2,74.5] = 29.679, p < 0.001). No between group statistical difference was detected for fitness outcomes, the six-minute walk test (6MWT), or the sit-to-stand test (SST), which may be because of the small sample size. No statistical differences were observed between the two groups’ quality of life during the 24-week period. A significant effect was observed on depression, but no associated difference was observed between study groups.

The intervention did not demonstrate an effect on patient outcomes.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable

This study did not show efficacy of an intervention involving exercise and supportive interventions. The findings are limited by study design aspects and sample size.

To determine the effectiveness of a 12-week, home-based walking exercise program in managing anxiety, depression, and the severity of cancer-related symptoms while investigating the psychological effects of home-based walking exercises on patients with lung cancer

116 patients were randomly assigned to the walking-exercise group (58) or the usual-care group (58). The exercise program consisted of a 12-week, home-based, moderate-intensity walking exercise of 40 minutes per session with three sessions per week and weekly exercise counseling. Patients were given a booklet and instructions on the mode intensity and frequency of exercise, pulse rate measurement, Borg’s rating of perceived exertion scale (RPE), prevention of sports injuries, and the time point of terminating the exercise. The participant was to achieve a target heart rate of 50%–80% based on the Korvonen method and a score of 13–15 on the RPE scale. Measurements were recorded at three time points: baseline, three months, and six months.

• N = 116  
• AGE RANGE = 37–88 years
• MALES: 54, FEMALES: 62
• KEY DISEASE CHARACTERISTICS: Primary lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Excluded if patient participated in regular exercise or received cognitive behavior therapy in the past six months

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

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

Parallel, randomized, controlled, single-center trial

• Hospital Anxiety and Depression Scale (HADS)
• Taiwanese MD Anderson Symptom Inventory (MDASI)
• Statistical analysis: Intention-to-treat (ITT) approach

There were no statistically significant differences in the baseline demographic data, disease characteristics, or baseline physical activity between the two groups. 44.8% of the exercise group completed the intervention. The exercise adherence rate was 59.7%. No exercise-related adverse effects were observed during the study period. The mean anxiety score of the walking exercise group declined by 1.04 points between baseline and the six-month completion. This was not statistically significant. The mean anxiety score of the usual care group at the third month increased significantly (mean difference = 1.72, P = 0.012) and remained stable until the sixth month. The anxiety scores of the walking exercise group declined by 0.63 points at the third month and by 1.03 points at the sixth month. A significant interaction term of the model at the third month and sixth month verified that the walking exercise reduced anxiety over time. The mean depression scores of the walking exercise group gradually declined, but there was no statistical significance. The mean depression scores for the usual care group significantly increased by the sixth month (mean difference = 1.35, P = 0.071). Participants engaging in walking exhibited additional reductions in depression over time. The mean symptom scores of the walking exercise group declined from baseline to the third month and remained stable. The mean symptom scores of the usual care group remained unchanged from baseline. A marginally significant difference between both groups was seen at the third month (1.50 versus 2.08, P = 0.053).

The authors concluded that the walking exercise program effectively reduced anxiety and depression over time. The benefits of exercise demonstrated in other cancer populations applied to patients with lung cancer as well. No substantial reduction was observed regarding the effect of the exercise program on symptom relief. However, the symptom scores of the exercise group were marginally lower over time. Adherence and dropout rates suggested that regular follow-up calls and encouragement to continue exercise would be beneficial.

• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results 
• Selective outcomes reporting 
• Measurement validity/reliability questionable
• Other limitations/explanation: Generalized symptom improvements in a large subset of symptoms (i.e., pain, fatigue, nausea, sleep disturbance, sadness, shortness of breath, difficulty remembering, poor appetite, drowsiness, dry mouth, distress, vomiting, numbness) instead of measuring the outcomes of a targeted symptom

Exercise is a valuable intervention for anxiety and depression in patients with cancer. Nurses should consider education and training for patients to establish regular exercise programs as a supportive care intervention.

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 the effects of exercise dose and type on psychosocial distress in patients with breast cancer receiving chemotherapy

Patients were computer-stratified by center and protocol and randomly assigned in a 1:1:1 ratio to standard (STAN), combination (COMB), or high-volume (HIGH). Participants exercised for the duration of their chemotherapy schedules. STAN treatment followed the Physical Activity Guidelines for Americans. The guidelines recommend a minimum of 75 minutes per week of vigorous aerobic exercise over three days per week. HIGH followed double the minimum guidelines of 150 minutes per week, and COMB followed the STAN guideline with the addition of a standard strength training program for three days per week. Exercise was supervised, and attendance, duration, and the intensity of aerobic exercise, weight, sets, and repetitions of strength training were recorded.

• N = 301  
• AGE RANGE = 45–55 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer stages I–III initiating adjuvant chemotherapy

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

• PHASE OF CARE: Active antitumor treatment

Randomized trial

• Short version of Center for Epidemiological Studies-Depression Scale (CES-D)
• Short form of the Spielberger State-Trait Anxiety Inventory (STAI)
• Perceived Stress Scale (PSS)
• Rosenberg Self-Esteem Scale (RSES)

There were no significant differences in managing depressive symptoms with HIGH and COMB exercises compared to the STAN exercise. COMB and HIGH exercises were effective in managing depressive symptoms in patients with clinical levels of depressive symptoms at baseline. There were no differences between the groups in anxiety scores.

Compared to standard exercise, higher volumes of exercise did not improve depressive symptoms, but it was effective in managing depressive symptoms in patients with clinical levels of depressive symptoms at baseline.

• Risk of bias (no blinding)

Depression is the most common psychological symptom in patients with cancer. Oncology nurses should encourage patients to perform standard aerobic exercise to improve depressive symptoms. Exercise also has been shown to be beneficial for anxiety and fatigue.

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 determine the effectiveness of physical activity following surgery for breast cancer in improving depression and quality of life

Participants were randomized between a CBSM (cognitive behavioral stress management) intervention group (which corresponds to a 2 hours per week meeting for 10 consecutive weeks) and a single-day psychoeducational control group. The CBMS intervention consist in a structured intervention with relaxation and cognitive behavioral therapy, coping effectiveness training, assertiveness, and anger management.

• N = 240   
• AVERAGE AGE: 50.3 years
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer; surgery for primary breast cancer in the 2-10 weeks prior to enrollment.
• OTHER KEY SAMPLE CHARACTERISTICS: More than 50 % have completed a college degree; more than 75% are married or partnered. Exclusion: Diagnosis of stage IV breast cancer or other cancer, except skin cancer

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Miami, Florida

PHASE OF CARE: Active anti-tumor treatment

Randomized control trial

7-item Perceived Interference Subscale of the 12-item Fatigue Symptom Inventory, IBS for depression, 7-Item Functional Well-Being Subscale of the Functional Assessment of Cancer Therapy (FACT-B)

Both the control and the intervention arm saw significant changes in clinician-rated depression and depressed mood (control: standardized B = 0.15; B = 0.29, p = 0.049; p < 0.001) (intervention: standardized B = 0.14; B = 0.29, p < 0.001;p < 0.001) with regard to FRDI; however, there were no significant changes in functional QOL with either arms with regard to FRDI.

The study shows that a moderate physical activity improves fatigue, depression, and quality of life for patients with breast cancer , and nurses should make a point of encouraging this. Future replications are needed, the sample chosen may already have the awareness of the health benefits of physical activity before the study was enacted.

• Key sample group differences that could influence results
• Findings not generalizable
• Other limitations/explanation: The limitation can be seen in the fact that the data have been collected in a group of White, highly motivated, well-educated women. Those results should not be generalized to an entire population.

Nurses should encourage physical activity in patients with breast cancer.

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 examine the effects of exercise with proprioceptive neuromuscular facilitation (PNF) on depression and anxiety in women with postmastectomy lymphedema

Subjects performed the exercises for 30 minutes, three times weekly, for 16 weeks. Subjects were divided into three groups, a PNF plus super lizer group (which received light radiation as well), a PNF plus manual lymphatic drainage (MLD) group, and a PNF alone group. All groups received the same exercises. Study measures were obtained every four weeks.

• N = 52  
• MEAN AGE 52.5 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Patients were selected from those who showed lymphedema following mastectomy.

• SITE: Single-site    
• LOCATION: Republic of Korea

Three-group trial with a repeated-measures design

• Beck Depression Inventory (BDI)
• Beck Anxiety Inventory (BAI)

Although there was a group-by-time interaction effect on the results, depression scores declined significantly in all groups with no significant difference between the groups after 16 weeks. Anxiety scores also declined in all groups with no differences between them. At the end of the study, scores were lowest in the PNF plus MLD group. Scores declined more in this group over time.

The findings of this study are inconclusive regarding the impact of PNF exercise on depression and anxiety in women with lymphedema following a mastectomy.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Measurement validity/reliability questionable
• Other limitations/explanation: Repeated-measures design has inherent testing potential as a threat to validity

Exercise and MLD have previously been shown to be of benefit for women with lymphedema, and exercise has been shown to be beneficial in terms of reducing anxiety and depression in patients with cancer. It is not clear whether the specific PNF technique in exercise has any greater benefit. This study had several design limitations.

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

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

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

Nonrandomized retrospective analysis of archived data

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

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

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

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

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

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

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

PHASE OF CARE: Active anti-tumor treatment

• Randomized, controlled trial
• Four groups

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

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

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

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

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

To evaluate the effect of a structured supervised outpatient exercise program on insomnia and depression in patients with cancer.

Patients were referred by their oncologist office to the program. Participants were consented, administered two instruments before and after, and then participated in a 90-minute structured, supervised exercise program two days per week. The exercise consisted of a warm-up, cardiovascular circuit training, strength training, and cool down. The program was for 10 weeks.

• N = 75 
• MEAN AGE: 59 years (SD = 10)
• MALES: 23.1%  
• FEMALES: 59.7%
• CURRENT TREATMENT: Combination of radiation therapy and chemotherapy 
• KEY DISEASE CHARACTERISTICS: Currently on treatment for any type of cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Older than age 18, excluded if within 8 weeks of surgery, within 6 months of treatment, cognitive issues excluded

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: 40-facility Catholic healthcare system in Stockton, California

PHASE OF CARE: Active anti-tumor treatment

• Descriptive observational study
• Patients consented and enrolled

• Insomnia measured with Athens Insomnia scale (AIS)
• Depression measured with Zung Self-Rating Depression Scale (ZSDS)
• Both tests administered on the first and last day of the 10-week program

75 patients were enrolled and 40 completed the 10-week program. The study demonstrated a significant improvement in insomnia. Baseline scores (mean = 9.5; SD = 3.7) compared to final scores (mean = 6.3; SD = 3.5) showed (t = 4.468; p = 0.01). The significance level of 0.05 is over the 90%. The depression scores were also seen as significantly different from baseline (mean = 37.4; SD = 9.7) and final scores (mean = 33; SD = 9.7) (t = 2.427; p = 0.01). The significance of 0.05 is about 80%. The study team also evaluated those who did not complete the program and there was no difference. Depression scores at baseline were higher for those who did not complete the program.

This study showed improvement in depression and insomnia in patients with cancer who participated in a structured, supervised exercise program.

• Small sample (< 100)
• Baseline sample/group differences of import        
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable
• Subject withdrawals ≥ 10%

Nurses should assess patients for insomnia and depression and provide appropriate referrals to structured exercise programs. The cost is low and many cancer centers have existing exercise programs for fatigue which could be combined with the mental health benefits. Nurses could encourage and participate in development of these programs with their healthcare and community fitness centers where none currently exist.

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

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

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

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

PHASE OF CARE: Transition phase after active treatment

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

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

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

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

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

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

• 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 the effectiveness of referrals from nurses or medical providers to a 12-week exercise program compared to usual care for the outcome of self-reported physical activity among men after completion of active prostate cancer treatment.

Participants were randomly assigned to the intervention or to the control: The intervention was a 12-week exercise program that included two gym sessions and one home-based session per week beginning 3–12 months after active treatment for prostate cancer was completed. Intervention participants were given a referral slip stating that the clinician recommended participation in the exercise program. The 12-week exercise program was at a local community gym, supervised by exercise physiologists, and followed exercise guidelines for cancer survivor exercises by the American College of Sports Medicine and the Exercise and Sport Science Australia. The exercise intervention also used social cognitive theory. The control group had usual care, which included a recommendation to exercise.

• N = 131  
• MEAN AGE: 65 years (range = 39-84)
• MALES: 100%  
• KEY DISEASE CHARACTERISTICS: 3-12 months after completion of treatment with curative intent for prostate cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: A majority of participants had stage I (15%) or stage II (16.5%) prostate cancer, and there were no significant between-group differences except for the disease stage (p < 0.01) and treatment (p < 0.05) between groups. English language ability to read and complete surveys

• SITE: Single site     
• SETTING TYPE: Outpatient        
• LOCATION: Melbourne, Australia

• PHASE OF CARE: Late effects and survivorship

• Prospective, multicenter, cluster, randomized controlled trial with two arms

• Godin-Shepherd Leisure Time Exercise Questionnaire: A monthly self-report of number of minutes of moderate-to-vigorous physical activity in a typical week in the past month. Measures were zero minutes, light intensity, moderate intensity, vigorous intensity, and minutes greater than 150 per week, with definitions of each level.
• ActiGraph for T1 (7 days at the baseline) and T2 (immediately after the 12-week exercise program) with the same time period of measures in the control group. Freedson adult cut points for light-intensity and average daily activity: used in the activity calculations but not reported. 
• Quality of life: Measured by the European Organization for Research and Treatment of Cancer Quality-of-Life Core-30 questionnaire (QLQ-C30, which has a cognitive functioning subscale) and prostate tumor–specific module (QLQ-PR25). 
• Prostate cancer–related anxiety: Memorial Anxiety Scale for Prostate Cancer (MAX-PC).
• Depressive symptoms: 20-item Center for Epidemiological Studies-Depression Inventory, with mean and total scores calculated.
• Satisfaction: Measured in the intervention group using a survey to assess the acceptability, convenience, and feasibility of the clinician referral and exercise program. 

Intervention participants indicated positive reports about clinician referral influencing participation in the exercise program.  Prostate cancer-related anxiety declined more in the control group (d = 0.42, p = 0.02).  Effects on depression were not significant, but there was greater decline in the intervention group (d = -0.35, p = 0.06). There was no significant change in the cognitive subscale of the QOL measure. A higher percentage of those in the intervention group reported achievement of aerobic exercise guidelines.

Clinician referral from doctor or nurse care provider influences decision to participate in a tailored exercise program among men who have completed prostate cancer treatment. Exercise program supervision helps to ensure that exercise is tailored to each individual, risk of injury is reduced, and potential for adherence is improved.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Activity level may have been higher at baseline due to time after completion of treatment; activity measures may not have been as accurate as desired or may have been worn at different times than desired.

Nurse clinicians may influence participation in an exercise program for men who have completed radiation, chemotherapy, or surgery for prostate cancer, touting benefits of improved physical activity, cognition, QOL, and other health outcomes, including significant reduction of anxiety self-report and moderate reduction of depression symptoms. A specific referral or prescription for exercise may enhance exercise participation and activity that meets current national recommendations.

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

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

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

• Single site
• Outpatient setting
• Germany

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

A randomized controlled trial design was used.

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

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

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

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

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

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

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

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

• Multisite
• Denmark and Sweden

Prospective pre/post-test one-group design

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

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

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

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.

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.

• 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

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

PHASE OF CARE: Late effects and survivorship

Single arm, pre-/post-test design

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

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).

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.

• 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)

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.

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

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

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

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

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

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

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

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

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

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

To determine the effects of a supervised group exercise intervention on aerobic capacity, anxiety, depression, and quality of life in patients with advanced lung cancer

The intervention consisted of physical and relaxation training in groups of 10–12 patients provided twice weekly for six weeks. Exercises included cycling and strength training supervised by a physiotherapist. Study assessments were done at baseline and at six weeks.

• N = 71
• MEAN AGE = 66 years (range = 31–88 years)
• MALES: 42.8%, FEMALES: 57.2%
• KEY DISEASE CHARACTERISTICS: All patients had advanced inoperable lung cancer and were receiving chemotherapy. Most were receiving carboplatin-based treatment.
• OTHER KEY SAMPLE CHARACTERISTICS: The majority of participants were employed full- or part-time

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

• PHASE OF CARE: Active antitumor treatment

Quasi-experimental

• Peak VO₂ for aerobic capacity
• 6-Minute Walk Test (6MWT)
• FEV₁
• Functional Assessment of Cancer Therapy (FACT) general and L for quality of life
• Hospital Anxiety and Depression Scale (HADS)

There were significant reductions in anxiety scores (ES 0.21, -0.9 change, p = 0.007). There was no effect on depression scores. Aerobic capacity, functional capacity, and muscle strength improved significantly.

The findings of this study suggest that group exercise sessions may benefit the managing anxiety and increase functional capacity among patients with advanced lung cancer. Changes were statistically significant; however, actual change scores were small. The clinical relevance of these changes is not clear.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: Although significant effects were seen, actual changes scores were small, calling into question the actual clinical relevance of findings. There was a withdrawal rate of about 50%, suggesting that this program may not be practical. Patients self-selected to participate in the program, so the sample was potentially biased. The intervention was provided in a group setting, so it is possible that the change in anxiety was related to participating in a group of individuals with the same problems rather than the exercise itself. An analysis of drop-outs showed that baseline functional capacity was significantly higher among those who remained in the program.

The findings of this study suggest that group exercise sessions can improve function and might reduce anxiety among patients with advanced lung cancer. This type of approach may not be feasible or acceptable for patients with very poor baseline functional capabilities. Additional well-designed research in this area would be helpful, and studies should include attentional control conditions to differentiate the affects of group support versus other aspects of the intervention.

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

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.

• 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.

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

PHASE OF CARE: Late effects and survivorship

Randomized control trial

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

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.

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

Intervention expensive, impractical, or training needs

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.

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 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 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.

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

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

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

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

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

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

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

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

Objectives were to

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

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

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

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

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

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

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

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

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

Treatment Strategies:

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

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

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

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

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

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

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

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