Exercise is physical activity that involves repetitive bodily movement done to improve or maintain one or more of the components of physical fitness: cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, flexibility, and body composition. Exercise interventions in patients with cancer have been provided as home-based, patient self-managed programs as well as supervised and unsupervised individual or group exercise sessions of varying duration and frequency. They can include combinations of aerobic and resistance activities. Exercise has been studied in patients with cancer for anxiety, chemotherapy-induced nausea and vomiting, depression, dyspnea, hot flashes, lymphedema, sleep/wake disturbance, pain, and fatigue. It has also been studied for caregiver strain and burden. Users of this information are encouraged to review intervention details in study summaries, as the exercise interventions studied and their timings in the trajectory of cancer care vary and these differences can influence effectiveness.
Arnold, M., & Taylor, N. F. (2010). Does exercise reduce cancer-related fatigue in hospitalised oncology patients? A systematic review. Onkologie, 33, 625–630.
Databases searched were AMED, EMBASE, MEDLINE, and PubMed via the Ovid platform and CINAHL via EBSCO.
Search keywords were oncology, chemotherapy, radiotherapy, strength training, aerobic exercise, walking program, physical activity, and fatigue.
Studies were included if they reported
Studies were excluded if they reported additional diversional interventions.
Initially, 2,954 studies were retrieved. After exclusions, there was a final set of five studies. The PEDro scale was applied for evaluation of study quality.
This review showed no significant effect of aerobic exercise interventions for fatigue outcomes in hospitalized patients with cancer. As this study only included hospitalized patients, the findings may not be applicable in other patient groups.
The study was limited by the small number of included trials, with most having small sample sizes.
Effectiveness of exercise for fatigue may vary greatly depending on the phase of care and time in the cancer disease trajectory at which the intervention is provided. Lack of significant positive findings here may be related to the timing of the intervention with all patients in acute or rehabilitation hospitals.
Brown, J. C., Huedo-Medina, T. B., Pescatello, L. S., Pescatello, S. M., Ferrer, R. A., & Johnson, B. T. (2011). Efficacy of exercise interventions in modulating cancer-related fatigue among adult cancer survivors: a meta-analysis. Cancer Epidemiology, Biomarkers & Prevention, 20, 123–133.
To evaluate the effect of types of exercise on cancer-related fatigue.
Only randomized, controlled trials studying the outcome variable of cancer-related fatigue were included.
Seven thousand two hundred forty-five articles met the initial selection criteria. A final sample of 44 studies was included. Two independent raters collected data, and the intensity of exercise was estimated using metabolic equivalent units (METs). MET values for a given exercise were coded from the Compendium of Physical Activity.
Characteristics of the Interventions
Regression analysis was used to identify factors that were related to the degree of fatigue modulation. Significant factors were
Session length and number of exercise sessions were not significantly related to effects on fatigue.
Overall effect size of fatigue modulation was 0.31 (95% confidence interval [0.22, 0.4]). Effect size was 0.39 among survivors of breast cancer and 0.42 among survivors of prostate cancer. In other cancer types, there were few studies and very small effects, but analysis demonstrated a consistent effect in favor of exercise.
Resistance exercise of moderate intensity appears to be the most effective in reducing cancer-related fatigue. This finding can be useful in planning exercise interventions as well as further research. The report stated a dose response effect on fatigue with exercise; however, the number and length of sessions was not a predictor of the degree of change in fatigue. These two findings seem to be contradictory. This aspect was not discussed by the authors.
The finding that resistance exercise interventions of moderate intensity were more effective than low-intensity or aerobic exercise is contrary to current National Comprehensive Cancer Network (NCCN) and American Cancer Society (ACS) guidelines, which do not mention resistance exercise and emphasize aerobic exercise. Moderate resistance exercise, such as weight machines, resistance bands, or free weights, may be a type that patients can maintain more easily. Use of theoretical models that incorporate issues of exercise behavior and behavior change may be more effective in providing support for the psychological components of adhering to an exercise program.
Carayol, M., Bernard, P., Boiche, J., Riou, F., Mercier, B., Cousson-Gelie, F., . . . Ninot, G. (2013). Psychological effect of exercise in women with breast cancer receiving adjuvant therapy: What is the optimal dose needed? Annals of Oncology, 24, 291–300.
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.
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.
Chang, C.W., Mu, P.F., Jou, S.T., Wong, T.T., & Chen, Y.C. (2013). Systematic review and meta-analysis of nonpharmacological interventions for fatigue in children and adolescents with cancer. Worldviews on Evidence-Based Nursing/Sigma Theta Tau International, Honor Society of Nursing, 10, 208–217.
STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in children and adolescents with cancer
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, CINAHL, PsycINFO, Ovid, MEDLINE, ProQuest Dissertations and Theses, the Electronic Theses and Dissertations System, the Index to Taiwan Periodical Literature, Electronic Thesis and Dissertation System (Chinese)
KEYWORDS: experimental study, random study, quasi-experimental study, children, adolescents, pediatric, cancer, oncology, nonpharmacological interventions, massage, exercise, fitness, physical activity, cognitive-behavioral, stress management, energy conservation, sleep therapy, relaxation, distraction, psychoeducation, fatigue, cancer-related fatigue, loss of energy, levels of tiredness, tired, side effect, symptoms
INCLUSION CRITERIA: RCT or quasi-experimental studies; 1–18 years of age, experiencing cancer-related fatigue; maintenance stage or survivor stage; hospitalized or home; acute lymphoblastic leukemia (ALL)/acute myeloid leukemia (AML)/lymphoma/solid tumor; interventions with descriptions of length, frequency setting, and provider, and including activity enhancement, psychosocial interventions, cognitive behavioral therapy, stress management, relaxation, nutrition consultation, massage, or educational interventions; use of validated scales for cancer-related fatigue in outcomes
EXCLUSION CRITERIA: Written in languages other than English or Chinese
TOTAL REFERENCES RETRIEVED = 76
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Retrieved papers reviewed by two independent reviewers with a third for disagreements about methodologic validity
PHASE OF CARE: Multiple phases of care
Two studies showed no significance in decreasing total fatigue with exercise. Two studies suggested exercise reduced general fatigue (p < .01). No significance was found for sleep/rest fatigue or cognitive fatigue. Study of massage showed no effect on fatigue. Final study used nurse education session on fatigue versus UC with reports that interventions were “effective.”
No study reduced total fatigue in any population. General fatigue was the only fatigue measure with significant improvement in some studies.
The phases of care, tumor type, and age varied. Children may not have had an ability to differentiate fatigue and relaxation, making fatigue perhaps difficult to measure.
Exercise may be a safe intervention for improving general fatigue in children and adolescents experiencing cancer-related fatigue.
Conn, V. S., Hafdahl, A. R., Porock, D. C., McDaniel, R., & Nielsen, P. J. (2006). A meta-analysis of exercise interventions among people treated for cancer. Supportive Care in Cancer, 14, 699–712.
Databases searched were MEDLINE, CANCERLIT, Cochrane Central Register of Controlled Trials (CENTRAL), Dissertation Abstracts, PsycINFO, SPORTDiscus, HealthSTAR, Clinical Evidence, and CINAHL through 2002. The authors also searched the National Institutes of Health (NIH) database of funded studies from 1986 through 2002 and conducted hand searches of selected journals.
Thirty primary study reports (24 in the published literature and the remainder in unpublished dissertations and presentation papers) contained sufficient information to be included in the quantitative analysis. Thirteen studies were designed as single-group pre/post research; the remainder compared at least two groups of patients. Only one two-group study did not randomly assign patients to study arms. Comparisons groups were most often described as having received usual care. Outcomes were quality of life, physical functional ability, fatigue, symptoms other than fatigue, mood, body composition, and exercise behavior.
Twenty-one of 30 studies tested supervised exercise interventions rather than home-based exercise. Supervised exercise was most often scheduled three times per week, and in 16 of the 21 studies of supervised exercise, the exercise program lasted longer than 10 weeks. Supervised exercise generally included aerobic activity (e.g., walking and cycling) and less often included resistance or flexibility exercise. Mixed types of aerobic exercise were used in several studies. The exercise intervention in most studies was of moderate intensity to achieve approximately 30% to 70% of maximum oxygen consumption.
The effect size estimate for the outcome of fatigue in the two-group comparisons was small and not statistically significant (standardized mean difference [SMD] = 0.11). However, the effect size estimate for the outcome of fatigue in the single group comparisons of pre- and posttest was larger (SMD = 0.27) and remained statistically significant under both the assumption that there was no correlation between participants’ pre- and posttest scores and that pre- and posttest scores were strongly correlated (r = 0.80).
Effect sizes among only control group participants were very small but negative; this observation may lend some support to the validity of meta-analytic findings from single-group designs.
The small, nonsignificant effect size for exercise on the outcome of fatigue may have occurred due to heterogeneity in the exercise characteristics and intervention dose, varied samples, diverse measures of outcomes, and variable outcome assessment timing.
Courneya, K. S., & Friedenreich, C. M. (1999). Physical exercise and quality of life following cancer diagnosis: a literature review. Annals of Behavioral Medicine, 21, 171–179.
Databases searched were MEDLINE, CANCERLIT, CINAHL, HERACLES, PsycINFO, and SPORTDiscus through 1997. Studies restricted solely to movement therapy and/or stretching/flexibility exercises for rehabilitation of range of motion were excluded. Studies were also excluded if they presented insufficient detail to allow for critical review.
Eighteen intervention studies (10 quasiexperimental and eight experimental designs) of physical exercise designed to improve cardiovascular and/or muscular fitness were included.
Outcomes were fatigue, health-related quality of life, symptom distress, immune function, physical exercise capacity (maximal oxygen consumption), and other physical performance measures.
Treatment evaluated cycle ergometer (eight studies), walking either alone or in combination with some other exercise mode (six studies), resistance training (one study), and unspecified (three studies).
Length of the intervention was 12 weeks or less in 14 studies, between four and six months in three studies, and one year in one study. Exercise was supervised (13 studies), unsupervised home-based (three studies), and partially supervised (two studies).
The reviewed studies indicated promising effects on both physiological and psychological outcomes. Three studies reported a significant reduction in fatigue. Although effect sizes could not be summarized across studies due to the diversity of outcomes with small numbers of effect sizes, the effects appeared to be robust and clinically significant.
Additional studies are needed to examine the effect of exercise, specifically on the endpoint of fatigue.
Cramer, H., Lauche, R., Klose, P., Dobos, G., & Langhorst, J. (2014). A systematic review and meta-analysis of exercise interventions for colorectal cancer patients. European Journal of Cancer Care, 23, 3–14.
STUDY PURPOSE: To evaluate the effects of exercise on patients with colorectal cancer
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Not specified or not applicable
Meta-analysis of three studies showed no significant overall effect of exercise on fatigue or quality of life. Exercise was associated with improved physical fitness (p = 0.0006).
Exercise was shown to be effective in improving physical fitness; however, physical fitness did not have a significant effect on fatigue in patients with colorectal cancer in this study.
Exercise has been shown to improve fatigue in multiple patient groups. This review was limited by the small number of studies limiting samples to patients with colorectal cancer.
Cramp, F., & Byron-Daniel, J. (2012). Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, 11, CD006145.
To evaluate the effect of exercise on cancer-related fatigue during and after cancer treatment. This was an update of a study from 2008. A secondary objective, subject to available data, was to explore the effect of exercise in different types of cancer populations.
Databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), CINAHL (1982 to March 2011), British Nursing Index (January 1984 to March 2011), AMED (1985 to March 2011), SIGLE (1980 to March 2011), and Dissertation Abstracts International (1861 to March 2011). The authors also searched references of all articles; hand searched the following journals up to April 2011: Cancer, Journal of Clinical Oncology, Psycho-Oncology, Cancer Practice, Oncology Nursing Forum; and searched unpublished literature through searches of conference proceedings up to June 2011.
Appendix 1 details the keywords searched, including expanded neoplasms, leukemia, lymphoma radiation therapy, bone marrow transplantation, exercise, movement, and fatigue.
Studies were included in the review if
Studies were excluded if they explored multidimensional programs in which the effects of exercise alone could not be determined and if a specific exercise program was not described and participants were only given advice or education about the potential benefits of exercise.
Fifty-eight new references plus 28 from the original review were retrieved.
Two independent reviewers reached 100% consensus; they assessed the methodological quality of the studies from the previous review.
Patients were undergoing multiple phases of care.
Statistically significant improvements in fatigue were identified following an exercise program performed either during cancer therapy (standardized mean difference [SMD] = -0.23; 95% confidence interval [CI] [-0.23, -0.33]) or following cancer therapy (SMD = -0.44; 95% CI [-0.79, -0.09]). Statistically significant beneficial effects were identified specific to breast cancer (n = 672) and prostate cancer (n = 239) populations, but not for those with hematological malignancies (n = 114). Statistically beneficial effects were identified following aerobic training but not following resistance training or low-intensity mind-body interventions.
Sufficient evidence exists to support the recommendation of aerobic exercise during and after treatment for patients with breast or prostate cancer. Insufficient evidence exists to support the recommendation of hematological malignancies or other solid tumors. Exercise modalities other than aerobic exercise do not have sufficient evidence to support their recommendation.
Aerobic exercise is recommended for appropriate patients during and after treatment for breast or prostate cancer. Consider recommending exercise for other solid tumors. Research is needed for various cancer types and stages, including palliative care and for types and duration of exercise.
Cramp, F., & Daniel, J. (2008). Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, CD006145.
Databases searched were the Cochrane Controlled Trials Register (CCTR), MEDLINE, EMBASE, CINAHL, British Nursing Index, AMED, SIGLE, and Dissertation Abstracts International through July 2007.
Twenty-eight published randomized, controlled trials investigating the effect of exercise on cancer-related fatigue in adults were identified.
Fatigue was assessed using various self-report measures, including the Functional Assessment of Cancer Therapy-Fatigue (FACT-F), fatigue subscale of the POMS, the Piper Fatigue Scale, and the Brief Fatigue Inventory (BFI). Only three studies incorporated more than one fatigue outcome measure.
Mode, intensity, and timing of exercise differed across studies. Thirteen studies investigated home-based/unsupervised exercise programs, whereas 16 studies investigated supervised, institutionally-based exercise programs. Some studies investigating supervised exercise programs encouraged participants to undertake additional home-based exercise. The mode of aerobic exercise included walking, stationary cycling, or a range of modalities. Three studies included strength training as a component of the exercise program, and two studies investigated the outcomes of resistance training in isolation. Two studies included flexibility training as a component of the exercise program, although several studies incorporated routine stretching as part of the warm-up, cool-down, or both. Yoga was investigated in two trials and seated exercise in one. The intensity of exercise varied greatly across studies, with the comparison complicated by differences in the methods (e.g., heart rate monitoring, predicted oxygen uptake, and patient perceived effort) used to monitor intensity in each study. The length of the intervention also varied greatly, ranging from three to 32 weeks; the largest proportion of studies had an exercise intervention duration of 12 weeks.
Using posttest means and mean change scores from the pre- posttests, exercise was found to be statistically significantly more effective than the control intervention in the management of fatigue. In separate analyses, dividing studies based on whether the intervention was performed during or following cancer treatment, exercise was consistently statistically significantly found to be more effective for fatigue than the control intervention. Similarly, positive results concerning the effects of exercise for fatigue were also found when only those studies performed in women with breast cancer were examined. Quantitative comparison of fatigue intervention outcomes in other disease-specific groupings was not possible due to limitations in the available data. However, two studies of the effects of exercise on fatigue in prostate cancer populations reported mixed results. A four-week, home-based walking program had no significant effect on fatigue, whereas a 12-week supervised resistance training program produced a statistically significant improvement in the exercise group compared to the control group. No statistically significant improvements in fatigue were observed in patients with colorectal cancer who were prescribed a 16-week, home-based cardiovascular and flexibility program; in patients with lymphoma attending a weekly supervised yoga session; or in patients with multiple myeloma receiving an individualized 32-week, home-based strength and aerobic training program. Follow-up assessment of long-term outcomes was limited, with 18 of 28 studies failing to assess outcomes beyond the end of the intervention period. From the remaining ten studies that included a follow-up assessment, three did not present the follow-up data in the original publication.
Methodologic quality of the studies was modest (the majority of the studies assigned an Oxford Quality Score of 2 or 3 on the 0–5 scale, with higher scores indicating better methodologic quality).
Crandall, K., Maguire, R., Campbell, A., & Kearney, N. (2014). Exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer (NSCLC): A systematic review. Surgical Oncology, 23, 17–30.
PHASE OF CARE: Multiple phases of care
Preliminary findings from the review suggest that intervention via exercise compared with usual care pre- and postsurgery may reduce fatigue. The results from the systematic review show the infancy of this particular field of study with very few studies included for analysis, with the majority of studies being of observational methodology. In addition, studies included a wide range of exercise prescriptions.
The field of treatment for fatigue in the surgical NSCLC population is in its infancy. In one study of the reviewer’s expertise, it is noted that the article was labeled as an unsupervised intervention when the article discusses the actual supervision of subjects participating in the exercise intervention.
Additional study of the best exercise prescription for fatigue management is needed related to patients undergoing surgery. The best timing for such interventions is not clear.
Dennett, A.M., Peiris, C.L., Shields, N., Prendergast, L.A., & Taylor, N.F. (2016). Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: A systematic review and meta-regression. Journal of Physiotherapy, 62, 68–82.
STUDY PURPOSE: To evaluate if a dose response effect of exercise on inflammation and fatigue in cancer survivors exists
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
Exercise interventions included aerobic, resistance, flexibility, and combinations of these. Interventions included supervised, unsupervised, home-based, hospital- or other setting–based, and group or individual exercise sessions. Moderate quality evidence that exercise had a positive effect on fatigue compared to usual care existed (standard mean deviation = 0.32, 95% confidence interval [0.13, 0.52]). A combination of aerobic and resistance provided the largest treatment effect. Aerobic intensity was negatively related to treatment effect. No relationships existed between resistance exercise and treatment effect.
Exercise has a beneficial effect on fatigue. Moderate intensity exercise appears to be most beneficial.
Varied study quality and sample sizes
This analysis adds to the body of evidence that exercise has a beneficial effect on fatigue among patients with cancer. This study suggests that moderate level aerobic exercise is more beneficial than more intense exercise. This information can be used to guide patient counseling and teaching to incorporate moderate exercise into daily routines.
Duijts, S.F., Faber, M.M., Oldenburg, H.S., van Beurden, M., & Aaronson, N.K. (2011). Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health-related quality of life in breast cancer patients and survivors—A meta-analysis. Psycho-Oncology, 20, 115–126.
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
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.
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).
Focht, B.C., Clinton, S.K., Devor, S.T., Garver, M.J., Lucas, A.R., Thomas-Ahner, J.M., & Grainger, E. (2013). Resistance exercise interventions during and following cancer treatment: A systematic review. Journal of Supportive Oncology, 11, 45–60.
Pertaining to fatigue outcomes, two randomized, controlled design studies showed insignificant changes in fatigue with BRCA survivors. One nonrandomized trial showed insignificant change in patients with prostate cancer. Two randomized, controlled studies showed moderate to large effect sizes in patients with BRCA and prostate cancer patients over time after three and six months. Large effects were seen in the Schmidt study with BRCA survivors. A moderate effect was seen in the Segal study of patients with prostate cancer receiving androgen deprivation therapy. Small effect sizes were seen in BRCA patients undergoing chemotherapy at a midpoint and post-treatment.
The results of this study suggested that RE may improve fatigue in patients with BRCA undergoing chemotherapy, patients with prostate cancer undergoing androgen deprivation therapy, and in BRCA survivors.
Although methodologic quality was good overall, an increase of intent-to-treat analyses of future randomized, controlled trials is needed.
Few studies examined this type of exercise, and additional study is indicated.
Fong, D.Y., Ho, J.W., Hui, B.P., Lee, A.M., Macfarlane, D.J., Leung, S.S., . . . Cheng, K.K. (2012). Physical activity for cancer survivors: Meta-analysis of randomised controlled trials. BMJ, 344, e70.
STUDY PURPOSE: To evaluate the evidence regarding the effects of physical activity in cancer survivors
TYPE OF STUDY: Meta-analysis and systematic review
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.
Furmaniak, A.C., Menig, M., & Markes, M.H. (2016). Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database of Systematic Reviews, 9, CD005001.
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
PHASE OF CARE: Active antitumor treatment
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.
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.
Galvão, D. A., & Newton, R. U. (2005). Review of exercise intervention studies in cancer patients. Journal of Clinical Oncology, 23, 899–909.
The MEDLINE database was searched through June 2004 to identify experimental and quasiexperimental studies of exercise (cardiovascular and/or resistance training) during and following cancer treatment.
Twenty-six published studies, reflecting 18 experimental or quasiexperimental trials of exercise during cancer treatment and eight studies of exercise after cancer treatment, were identified. Of the 18 trials during treatment, 14 used some type of cardiovascular training; two used mixed training with cardiovascular, resistance, and flexibility exercise; and two applied a structured resistance training program. Of the eight trials of exercise after cancer treatment, all used cardiovascular or cardiovascular plus resistance training. The duration of the intervention ranged from two to 28 weeks, and the frequency of the exercise intervention ranged from daily to two times per week.
Outcomes were fatigue, health-related quality of life, symptom distress, psychological distress, body composition, physical exercise capacity (maximal oxygen consumption), immunologic parameters, and muscle strength. Treatment evaluated cardiovascular and/or resistance exercise.
Five of 18 studies of exercise during cancer treatment specifically found improvements in fatigue, and most of these studies were in women with breast cancer. Of note, a trial of resistance training three times per week in men with prostate cancer undergoing androgen depletion therapy showed improvements in fatigue after a 12-week program. Of the eight studies of exercise following cancer treatment, none reported statistically significant improvements in fatigue, but there were improvements in functional status, quality of life, psychological distress, strength, and capacity.
Although recent evidence supports the use of resistance exercise during cancer management as an exercise mode to counteract adverse effects of the disease and treatment, most of the studies were conducted using cardiovascular training. Promising results in terms of fatigue and other outcomes of a short-term resistance exercise program on patients diagnosed with prostate cancer and undertaking androgen-depletion therapy have been reported.
Jacobsen, P. B., Donovan, K. A., Vadaparampil, S. T., & Small, B. J. (2007). Systematic review and meta-analysis of psychological and activity-based interventions for cancer-related fatigue. Health Psychology, 26, 660–667.
Databases searched were PsycINFO, MEDLINE, and CINAHL through November 2005.
Seventeen randomized, controlled trials of activity-based interventions were included in the meta-analysis. Activity-based interventions included professionally supervised programs and unsupervised, home-based programs designed to promote exercise activity. To be included, a trial must have included a controlled comparison arm with either a no treatment or placebo condition, must have been a study of an activity-based intervention in adults diagnosed with cancer, one of the study outcomes must have been fatigue or the related constructs of vitality or vigor, and the reported results must have included significant testing of differences between an intervention condition and a control condition.
In all 17 studies in which fatigue, vitality, or vigor was assessed as an outcome, more than three-quarters of the studies measured the construct of fatigue. Fatigue, vitality, or vigor was a primary outcome in slightly more than half of all the studies of activity-based interventions, and it was a secondary outcome in the remainder. Activity-based interventions included professionally supervised programs and unsupervised, home-based programs designed to promote exercise activity. There were numerous differences across these studies in the type of exercise (e.g., aerobic or resistance), mode (e.g., walking or cycle ergometer), and intensity of exercise.
Sixteen of the 17 studies used no intervention control groups or wait-list control groups, and one study used a placebo control condition that involved stretching exercises. Sixty-one percent of the studies provided a home-based exercise intervention and 39% provided supervised exercise programs. No study specified the levels of fatigue, vigor, or vitality used as the eligibility criterion.
The effect size for activity-based interventions was not statistically significant (dw = 0.05; 95% confidence interval [CI] [-0.08, -0.19]), and there were no differences in effect sizes as a function of cancer type (breast cancer: dw = 0.12; 95% CI [-0.15, -0.30]) or for all other types (dw = 0.06; 95% CI [-0.11, -0.24]) or intervention modality (home-based: dw = 0.04; 95% CI [-0.13, -0.22]; supervised: dw = 0.16; 95% CI [-0.09, -0.41]).
The current results conflict with the results and conclusions made by other authors who conducted narrative systematic reviews of single studies, with meta-analyses that included both randomized and nonrandomized trials, and with the results of another meta-analysis published more recently. Close comparison of the studies reviewed by the current authors with those reviewed by Cramp and Daniel suggest that the conclusions were different in part because different randomized, controlled trials were examined. Six randomized, controlled trials of activity-based interventions with favorable effects on the outcome of cancer-related fatigue were published after the current authors completed their electronic database searches. In addition, the search strategies used by the current authors excluded two randomized, controlled trials that reported activity interventions (Galantino 2003; Dimeo 2004) that met the criteria for inclusion in their meta-analysis. Moreover, a meta-analysis published in April 2008 by the Cochrane Collaboration that included these more recently published trials together with the two trials that were inadvertently excluded by the current authors concluded that there was a small but statistically significant effect for exercise (standardized mean difference = -0.23; 95% CI [-0.33, -0.13]).
Kangas, M., Bovbjerg, D.H., & Montgomery, G.H. (2008). Cancer-related fatigue: A systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychological Bulletin, 134, 700–741.
STUDY PURPOSE: To conduct a systematic review and meta-analysis on nonpharmacologic interventions (psychosocial and exercise) for cancer-related fatigue (CRF)
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
Both psychosocial interventions and exercise showed benefit in CRF. Psychosocial interventions had a small to moderate effect on fatigue; exercise had a moderate effect. No significant differences existed in the effect of exercise on CRF between psychosocial interventions and exercise. Exercise showed a stronger effect during treatment than post-treatment, whereas psychosocial interventions showed a stronger effect post-treatment.
Both psychosocial interventions and exercise are beneficial in ameliorating CRF. A multimodal approach across all phases of treatment is best.
Provides additional support for psychosocial interventions and exercise for CRF. Because of the heterogeneity of interventions, supporting one type of psychosocial intervention or exercise regime over another is difficult. Nurses can incorporate interventions acceptable to patients.
Keogh, J. W., & MacLeod, R. D. (2012). Body composition, physical fitness, functional performance, quality of life, and fatigue benefits of exercise for prostate cancer patients: a systematic review. Journal of Pain and Symptom Management, 43, 96–110.
To systematically review the literature for benefits of exercise in patients with prostate cancer.
Databases searched were PubMed, CINAHL, and Google Scholar.
Search keywords were exercise, physical activity, prostate cancer, and training and all word derivatives.
Studies were included if they
The total volume of studies retrieved and excluded was not provided. An adaptation of methods reported by Sackett was used to evaluate methodological rigor, involving six criteria. How the criteria were applied by investigators was not described.
Seven studies reported group-based exercise. The authors reported that most of these patients showed significant improvement in some QOL measures and fatigue. Five studies reported home-based exercise. These showed no significant increase in QOL, and two of these reported significant reduction in fatigue. Resistance, aerobic, and combined types of exercise appeared to be similarly effective. The timing of exercise interventions related to cancer treatment were not described. Comparative findings regarding changes in muscle strength and endurance were provided.
There is relatively strong to strong evidence that exercise performed a minimum of two to three days per week can significantly improve physical fitness, functional performance, and QOL and reduce fatigue in patients with prostate cancer.
The context in which the exercise was performed and type of exercise (aerobic, resistance, or combined) may mediate the magnitude of benefit derived. Group-based exercise appeared to offer greater benefit than home-based programs in the studies included.
Findings suggested that exercise recommendations should be a part of care for survivors of prostate cancer for fitness, QOL, and fatigue benefits. Group-based activity may have greater benefit than individual home-based exercise recommendations.
Knols, R., Aaronson, N. K., Uebelhart, D., Fransen, J., & Aufdemkampe, G. (2005). Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials. Journal of Clinical Oncology, 23, 3830–3842.
Databases searched were MEDLINE, CINAHL, Cochrane Library, CANCERLIT, and PEDro through June 2004 to identify randomized, controlled trials and controlled trials (those with a comparison group but without explicit use of randomization for purposes of group allocation).
To be included in the review, the trials had to have examined the effects of physical exercise after surgery or during or after chemotherapy, radiotherapy, and/or hormonal therapy. Only exercise interventions designed to improve endurance or muscular strength were included.
Studies of relaxing exercises (e.g., yoga or tai-chi) were excluded.
The methodologic quality (using the Delphi criteria list—a set of nine criteria for quality assessment of clinical trials) and substantive results of 34 randomized, controlled trials and controlled trials was examined. Of the 34 studies examined, 22 examined the effectiveness of physical exercise during medical treatment, whereas 12 focused on the period after medical treatment.
Outcomes were fatigue, health-related quality of life, symptom distress, psychological distress, body composition, physical exercise capacity (maximal oxygen consumption [VO2] max), self-reported exercise/physical activity level, and other physical performance measures, such as walk time. Various physical exercise modalities were used, differing in type (walking, cycling, swimming, resistive exercises, or combined exercises), intensity (with most programs at 50% to 90% of the estimated VO2 maximum heart rate), frequency (ranging from two times per week to up to two times daily), and duration (ranging from two weeks up to one year). In some studies, the experimental group was compared with a group that received some form of training of a lesser intensity, frequency, and/or duration (e.g., stretching, self-directed exercises, strength exercises, aerobic exercise of a lesser intensity, swimming, behavioral therapy). In other studies, the comparison group did not receive any exercise program or advice, was on a waiting list, or participated in a cross-over trial.
The studies during medical treatment were divided into three subcategories: (1) exercise during breast cancer treatment, (2) exercise during bone marrow and peripheral blood stem cell transplantation, and (3) exercise during medical treatment for mixed solid tumors. The studies after medical treatment were divided into those involving exercise after breast cancer treatment and exercise after medical treatment for other solid tumors. The authors used this strategy to reflect not only differences in cancer diagnosis and the timing of physical exercise programs, but also possible differences in motivation, safety, feasibility and efficacy of exercise. The sample sizes for the intervention groups ranged from 12 to 188 participants.
A clinically significant or statistically significant positive effect of physical activity specifically on fatigue was noted during breast cancer treatment (three studies) or after breast cancer treatment (two studies), and during treatment (three studies) or after treatment (one study) in a mixed solid tumor population. The median quality criteria score on the Delphi list (range 1–7) was four for studies of exercise during and after cancer treatment. Twenty-five of the trials satisfied more than three criteria on the Delphi criteria list. The most commonly observed methodologic problems were with concealment of treatment allocation, blinding of the outcome assessor, and failure to use an intention-to-treat data analysis strategy.
Overall, the authors concluded that the included trials were of moderate methodologic quality, with a trend toward more methodologic rigor in more recent studies.
Kuchinski, A. M., Reading, M., & Lash, A. A. (2009). Treatment-related fatigue and exercise in patients with cancer: a systematic review. Medsurg Nursing, 18, 174–180.
To determine if patients receiving treatment for cancer experienced less treatment-related fatigue if they participated in a regular committed exercise regimen, compared to those who did not exercise regularly.
Databases searched were CINAHL, MEDLINE, Ovid, and ProQuest between January 2000 and October 2006.
Search keywords were fatigue, cancer, and exercise.
Studies were included in the review if
Two unpublished doctoral dissertations were also included.
Initially, 400 articles addressing the topics of fatigue, cancer, and exercise were found. When the inclusion criteria were applied, 10 studies were included. Levels of evidence presented were established using the Priority Symptom Management (PRISM) system developed by the Oncology Nursing Society. No meta-analysis was performed due to differing definitions and methods of measurement of fatigue across studies. All studies demonstrated strong levels of evidence of PRISM level I or II. Brief summaries of study design, exercise regimen, outcomes, limitations, level of evidence, and study recommendations were provided. Studies were identified within two major categories: home-based exercise interventions and out-of-home exercise interventions.
The majority of studies (eight of 10) used home-based exercise interventions.
Eight of the studies had findings that supported exercise during treatment to reduce fatigue. In the two studies that did not show differences in fatigue, one had a very small sample size and one showed poor patient adherence to the exercise regimen.
Exercise was generally well tolerated by participants, and there were no adverse events associated with exercise.
Components of the regimens that were found to be beneficial were
Theoretical foundations of studies were reviewed. These included
The evidence suggested that an individualized exercise program should be included in the treatment of patients receiving chemotherapy and/or radiation therapy. Studies have not shown any adverse effects, such as increased fatigue or falls, as a result of exercise. Studies retrieved were limited to four types of cancer: multiple myeloma, breast, lung, and prostate. Studies reviewed encompassed both early and late stages of disease.
Common limitations found among the studies reviewed included
Use of common definitions and methods of measurement of outcome variables is needed to further advance this area of study. Evidence supports the inclusion of scheduled exercise in the care plan of patients undergoing cancer treatment. It was noted that approximately 50% of healthy Americans have been shown to have difficulty initiating and maintaining an exercise program for more than three months. This suggests that individuals with cancer are likely to need professional support to begin and maintain an exercise program. Nurses’ awareness of the role of exercise can enable better education that benefits patients.
Labourey, J. L. (2007). Physical activity in the management of cancer-related fatigue induced by oncological treatments. Annales de Réadaptation et de Médecine Physique, 50, 445–459.
PubMed was searched to identify English or French language reports of randomized or controlled studies and meta-analyses concerning the benefits of physical activity in patients receiving cancer treatment. The dates encompassed by the search process were not specified.
Eleven randomized or controlled studies that had evaluated the effects of physical exercise on cancer-related fatigue as one of their primary or secondary objectives were identified for analysis. Varied patient-reported outcome measures were used to evaluate fatigue, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Piper Fatigue Scale, Functional Assessment of Cancer Therapy-Fatigue (FACT-F), or the Profile of Mood States (POMS) Fatigue-Inertia subscale. Studies evaluated aerobic exercise, strength training, or a combination of both. Supervised and home-based exercise interventions were studied, and the duration of exercise treatment ranged from only the duration of hospitalization to several months.
Of the seven studies of exercise during active cancer therapy, five studies (all with less than 25 patients) found no significant differences in fatigue across the treatment period. A sixth study in a highly selected population of patients hospitalized for stem cell transplant noted that fatigue increased significantly in the control group but remained steady in the exercise group. The seventh study of men with prostate adenocarcinoma on hormone therapy and receiving strength training noted a statistically significant improvement in fatigue in patients receiving the strength training intervention.
In the posttreatment setting, three studies with small samples suggested that exercise (aerobic exercise of low or moderate intensity) or a motivational counseling intervention to increase home-based exercise and a small study in patients with breast and colon cancer who were three to 15 months posttreatment showed significant improvement in fatigue as a result of either low- or moderate-intensity exercise, compared to controls. An additional study in patients who had completed chemotherapy or surgery within the past month showed an improvement in aerobic fitness in the intervention group but a statistically significant increase in fatigue.
Taken together, these results suggested that there is no clear evidence that exercise during active treatment improves fatigue outcomes, although it may have a favorable effect on cardiorespiratory conditioning. The results of this review point to the possibility that a minimum of rest or mild activity is needed to promote some initial recovery from treatment-related fatigue before residual fatigue is addressed, but current studies provide no guidance on how long the interval should be between the end of chemotherapy and the start of exercise for therapeutic purposes.
Larkin, D., Lopez, V., & Aromataris, E. (2013). Managing cancer-related fatigue in men with prostate cancer: A systematic review of non-pharmacological interventions. International Journal of Nursing Practice.
STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in men with prostate cancer
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: PubMed, PsycINFO, CINAHL, Cochrane Central Trials Register and Embase, PsychExtra, SIGLE, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, World Health Organisation International Clinical Trials Registry Platform, EU Clinical Trials Register, MedNar, and reference lists of articles included in review
KEYWORDS: key concepts of prostate cancer, fatigue, non-pharmacological and nursing management, and various interventions; detailed search for PubMed included as appendix
INCLUSION CRITERIA: Adult men older than 18 years with prostate cancer at any stage of treatment; non-pharmacologic interventions including exercise, exercise with diet and lifestyle modification, education, and cognitive behavioral therapy; comparison to other non-pharmacologic interventions or usual care; experimental studies; fatigue as primary outcome of interest using existing validated tools to measure
EXCLUSION CRITERIA: Not stated
TOTAL REFERENCES RETRIEVED = 1,480
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two independent reviewers appraised studies; validity assessed with Johanna Briggs Institute Critical Appraisal Checklist for Randomised and Pseudo-Randomised Studies
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care
All studies were of high methodologic quality. Four out of five studies measuring physical activity found statistically significant fatigue reduction; the other study showed a trend toward fatigue reduction. Two studies concluded that cognitive behavioral therapy was effective in managing cancer-related fatigue. Two studies looking at education had mixed results. Brief nursing education was not significant in reducing fatigue, but intensive prostate-specific education was significant.
This report supports physical activity for managing cancer-related fatigue. Cognitive behavioral therapy and intensive focused education are also likely to be effective.
Nurses should continue to recommend physical activity for management of cancer-related fatigue. Cognitive behavioral therapy and intensive education may be considered.
Markes, M., Brockow, T., & Resch, K. L. (2006). Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database of Systematic Reviews, CD005001.
Databases searched were Cochrane Breast Cancer Specialised Register, MEDLINE, EMBASE, CINAHL, SPORTDiscus, PsycINFO, SIGLE, ProQuest Digital Dissertations, and Conference Papers Index through July 2004.
Treatment evaluated aerobic (walking or cycle ergometer interval training) or resistance exercise, or a combination of both. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually, or in groups.
To be included in this meta-analysis, the exercise intervention had to be of at least six weeks' duration and had to coincide with the adjuvant treatment regimen rather than follow it. Trials in which the exercise intervention was part of a complex intervention (e.g., complete decongestive lymphatic therapy) and trials restricted to local muscular endurance (e.g., training of shoulders, back, or legs only) instead of including all major muscle groups or restricted to stretching exercises were also excluded.
Seven randomized trials and two nonrandomized, controlled trials involving 452 participants met the inclusion criteria. Five trials, involving 317 participants, were used in the meta-analysis specifically for the outcome of fatigue.
Outcomes were physical fitness, psychological distress, symptoms (pain and fatigue), quality of life, body weight or lean body mass, and immune function. Fatigue was evaluated predominantly using the Piper Fatigue Scale. Meta-analysis of the trials in which fatigue was included as an outcome did not identify a statistically significant improvement in fatigue for participants in the exercise intervention groups compared to the control (nonexercising) groups. Statistically significant improvements for cardiorespiratory fitness, anxiety, sleep disturbance, and nausea relief were found.
The methodologic quality of the studies was overall moderate.
McMillan, E.M., & Newhouse, I.J. (2011). Exercise is an effective treatment modality for reducing cancer-related fatigue and improving physical capacity in cancer patients and survivors: A meta-analysis. Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 36, 892–903.
To determine if exercise interventions can effectively mitigate cancer-related fatigue (CRF)
DATABASES USED: PubMed, CINAHL, PsycINFO, ProQuest, SPORTDiscus
KEYWORDS: exercise, physical activity, exercise therapy, exercise training, aerobic exercise, resistance exercise, physical training, exercise prescription, cancer, oncology, malignancy, neoplasm cancer treatment, chemotherapy, radiotherapy, hormonal therapy, fatigue, CRF, QOL, depression
TOTAL REFERENCES RETRIEVED = 948 articles initially identified
EVALUATION METHOD: No quality scoring of retrieved studies was described.
FINAL NUMBER STUDIES INCLUDED = 16 studies included in meta-analysis
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Study sample sizes ranged from 22–242; 1,426 patients in treatment and control groups
KEY SAMPLE CHARACTERISTICS: Subjects were at various phases in cancer treatment, with some in active treatment of various modes and others post-treatment. Eight trials were in patients with breast cancer. Other studies included prostate cancer, mixed disease types, and acute myelogenous leukemia.
Overall effect of exercise on CRF showed a small but significant effect size with overall reduction in CRF ( SMD = 0.28, 95% CI 0.17–0.38, p <.001).
Subgroup analysis of exercise mode:
Interventions provided in a supervised setting (15 trials) significantly reduced CRF (SMD = 0.29, 95% CI 0.17–0.46, p < .001).
Unsupervised exercise showed a positive trend but no significant difference with exercise.
Effects in phase of treatment:
Effects in patients with cancer other than breast cancer:
Exercise intervention produced improvement in aerobic fitness and musculoskeletal fitness (p < .001).
Findings from meta-analysis provide strong support for the positive effect of exercise on CRF. Effect sizes are small.
Findings suggest that various modes of exercise show a trend toward a positive impact on CRF in patients with breast cancer, as well as patients with other types of cancer.
There may be differences in effect based on mode of exercise.
Findings suggest positive effects in supervised and unsupervised exercise programs, but only those that were supervised demonstrated statistical significance in this study. It is unclear if this represents a real difference in effectiveness, or the fact that there were only four studies of unsupervised exercise included.
Findings support the use of exercise to reduce CRF during and after completion of cancer treatment. Subgroup analyses in this study begin to provide additional useful information regarding the modes and types of exercise interventions that may be most effective. Further research comparing effectiveness of various approaches is warranted.
Effect sizes of exercise are small, suggesting that studies that include patients with very low fatigue or interventions to prevent fatigue may not readily show significant changes.
McNeely, M. L., Campbell, K. L., Rowe, B. H., Klassen, T. P., Mackey, J. R., & Courneya, K. S. (2006). Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. Canadian Medical Association Journal, 175, 34–41.
Databases seached were MEDLINE, CINAHL, EMBASE, PsycINFO, CANCERLIT, Cochrane Library, PEDro, and SPORTDiscus through March 2005.
Fourteen randomized trials were included. Nonrandomized trials, pilot studies, and studies reported only in abstract form were excluded. Therapeutic exercise regimens addressing only specific impairments to shoulder and arm were not included. Studies with an additional treatment arm or combined intervention (e.g., exercise with diet modification) were included only if the effects of exercise could be isolated. Studies were required to have quality of life, cardiorespiratory fitness, or physical functioning as a primary outcome. Secondary outcomes of interest included symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention. Methodologic quality of each included study was evaluated using eight quality criteria specified a priori.
Outcomes were quality of life, cardiorespiratory fitness, physical functioning, symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention.
There was wide variability in the exercise interventions evaluated. Interventions included Tai Chi Chuan, aerobic exercise (walking, cycle ergometer, and arm ergometer), resistance training (weights and resistance bands), and mixed aerobic and resistance exercise. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually or in groups. Overall, study reports provided too little detail concerning the frequency, intensity, time, and type of exercise to allow for determination for an exercise dose-response. Similarly, limited detail about the adherence to the exercise program was provided, and few studies had been designed to include monitoring of activity in the comparison group, so that potential contamination could be gauged.
Six studies involving 319 patients assessed the effect of exercise on symptoms of fatigue. Although all of the studies showed improvements in symptoms of fatigue with exercise, only two reported statistically significant improvements. These two studies were also the only studies performed following breast cancer treatment. The pooled results from all six studies showed that exercise significantly improved symptoms of fatigue (standardized mean difference [SMD] = 0.46; 95% confidence interval [CI] [0.23, 0.70]). The pooled results from the four studies performed during adjuvant cancer treatment showed a nonsignificant effect on fatigue (SMD = 0.28; 95% CI [-0.02, 0.57]). Four studies reported adverse events; in one study, two of 23 participants reported that participation in the home-based exercise program (self-monitored walking program) resulted in worsening of fatigue.
Meneses-Echavez, J.F., Gonzalez-Jimenez, E., & Ramirez-Velez, R. (2015). Effects of supervised exercise on cancer-related fatigue in breast cancer survivors: A systematic review and meta-analysis. BMC Cancer, 15, 77-015-1069-4.
PHASE OF CARE: Multiple phases of care
All trials included aerobic training, and six included resistance training. The average duration of training was 21 weeks, and the average sessions per week was 2.5. Supervised aerobic exercise was more effective than usual care in improving fatigue (SMD = –0.51, 95% confidence interval [CI] [–0.81, –0.21]). SMD for resistance training was –0.41 (95% CI [–0.76, –0.05]). No dose response for training intensity was seen. Studies conducted during active treatment showed a significant benefit in reducing fatigue (SMD = –0.66, p < 0.05). In four studies conducted after cancer treatment, the effects of exercise on fatigue were not significant. Exercise improved physical well-being, but no significant effects were observed for social and emotional domains.
Supervised aerobic training during cancer treatment was associated with a significant improvement in fatigue.
Exercise during cancer treatment has been shown to reduce fatigue. This study suggests that the results may be best with aerobic exercise. The optimum intensity and “dosage” of exercise at various time points in cancer treatment remain unclear.
Meneses-Echavez, J.F., Gonzalez-Jimenez, E., & Ramirez-Velez, R. (2015). Supervised exercise reduces cancer-related fatigue: A systematic review. Journal of Physiotherapy, 61, 3–9.
PHASE OF CARE: Active
The interventions had a mean duration of 17 weeks (SD = 12) with an average of three sessions (SD = 1) per week. The mean session duration was 45 minutes (SD = 29). The interventions included aerobic exercise (i.e., walking, stationary cycling) in all trials, resistance training in six trials (55%), and stretching/flexibility exercises in four trials (36%). Training intensity varied considerably among studies, ranging from 50%–90% of maximum heart rates. All studies reported pre-exercise screening before high intensity physical training. The overall meta-analysis showed that supervised physical activity had a favorable effect on cancer-related fatigue when compared to conventional care. The final analysis of the results revealed that supervised physical activity interventions were effective in the management of cancer-related fatigue for all types of cancer. The favorable effect was no longer significant at the six-month follow-up. However, more participants in the intervention group continued to exercise.
This study provides additional support for exercise in management of cancer-related fatigue during active treatment, in this case supervised activity. It reinforces the role of physiotherapy in the management of cancer-related fatigue.
Publication bias may have been present, but it was not possible to test for it because of the small number of included studies. Heterogeneity was present in most of the meta-analyses. This may be because of the range of sample sizes, the diverse exercise regimens (in terms of length, duration, and intensity) evaluated, and the wide variety in outcome measurement tools used in the included studies
Nurses can continue to recommend exercise as an intervention for cancer-related fatigue. However, additional research is still needed on the type, frequency, intensity, and duration of exercise.
Meneses-Echavez, J.F., Gonzalez-Jimenez, E., & Ramirez-Velez, R. (2015). Effects of supervised multimodal exercise interventions on cancer-related fatigue: Systematic review and meta-analysis of randomized controlled trials. BioMed Research International, 2015, 328636.
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Palliative care
Supervised multimodal exercise programs resulted in an overall reduction of fatigue in cancer survivors (SMD = –0.23, p = 0.001) with low statistical heterogeneity. Slight evidence of publication bias was noted. Length (weeks of training), frequency (sessions/week), and duration (minutes/session) were linearly associated with overall improvement in CRF (Tau squared = 0.04, p = 0.04). Aerobic exercise, resistance training, and stretching were implemented in seven of the nine studies, and the pooled effect estimate showed significant reductions in CRF (SMD = –0.35, p = 0.01). Two studies used resistance training, and the pooled effect estimate showed no significant reductions in CRF (SMD = –0.17, p = 0.3). Reported adverse events occurred infrequently (n = 7 events, one requiring hospitalization). Most studies were conducted during treatment (chemotherapy) and resulted in significant reductions of CRF (SMD = –0.23, p < 0.0001). No significant reductions in CRF were reported after anticancer treatment (p = 0.1).
Supervised multimodal exercise programs implemented during treatment are supported as an intervention for reducing CRF.
Supervised multimodal exercise programs are safe and beneficial for patients receiving anticancer therapy. Referrals to exercise professionals to plan a personalized exercise program for patients with cancer is recommended.
Mishra, S.I., Scherer, R.W., Geigle, P.M., Berlanstein, D.R., Topaloglu, O., Gotay, C.C., & Snyder, C. (2012). Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database of Systematic Reviews, 8, CD007566.
To conduct a meta-analysis of the effectiveness of exercise interventions on health-related quality of life (HRQoL) and domains (e.g., physical, psychological, economic, social, and spiritual well-being) of HRQoL among adult cancer survivors posttreatment.
Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro, LILACS, SIGLE, SPORTDiscus, OTSeeker, Sociological Abstracts, Web of Science, and Scopus.
Search keywords (selected from appendices) were exercise, quality of life, health-related quality of life, pain, and cancer.
Studies were included in the review if they
Studies were excluded if they reported patients with terminal cancer or in hospice care who were receiving active treatment for primary or recurrent cancer.
A total of 1,795 relevant references were retrieved. A total of 1,636 articles were excluded based on the title and abstract. After further review of the abstract, 82 were excluded because they did not meet the inclusion criteria. An additional 13 were excluded from qualitative synthesis because they were ongoing studies.
The review has clinical applicability for late effects and survivorship.
Exercise had a positive effect on change in HRQoL scores at 12 weeks and six months of evaluation, and it improved cancer-specific HRQoL in breast cancer concerns. The effect on HRQoL remained after exclusion of patients who were receiving active treatment. For cancer-specific HRQoL, there was significant improvement in exercise groups compared with controls for breast cancer concerns at baseline to 12 weeks and six months. There was a significant decrease in anxiety in the exercise group compared to controls at 12 weeks only (standardized mean difference [SMD] = -0.26; 95% confidence interval [CI] [-0.44, -0.07]) but not in breast cancer-only analysis. There was a high risk of bias in most of these studies, and when these were removed, the results were not significant. Significant differences were noted in body image at follow-up (12 weeks to six months and beyond) using the Rosenberg Self-Esteem Scale. Significant change scores were noted for cancers other than breast for improving depression scores (SMD = -0.46; 95% CI [-0.72, -0.19]). Significant improvements were noted in emotional well being (12 weeks) and fatigue (12 weeks and 6 months) (SMD = -0.42; 95% CI [-0.83, -0.02]). No effects after six months were seen for fatigue, and effects were not significant when studies involving patients during treatment were excluded. Improvement in pain using follow-up scores (12 weeks) was seen (SMD = -0.29; 95% CI [-0.55, -0.04]), but this was from a single trial. Positive effects were noted in sexuality scores at six months and sleep disturbance at 12 weeks (sleep SMD = -0.46; 95% CI [-0.72, -0.20]). Significant improvements were noted in change scores for social functioning (12 weeks and six months). No significant changes were noted in cognitive function, general health perspective, role function, and spirituality in exercise trials.
Exercise interventions showed beneficial effects on HRQoL and some HRQoL domains, including breast cancer concerns, body image, emotional well being, sexuality, sleep disturbances, social functioning, anxiety, fatigue, and pain at various follow-up time points.
Findings supported the general benefit of exercise for patients with cancer; however, there is further need for research to verify the positive effects of exercise on symptoms of cancer in various patient groups and at various phases of cancer care. These future research studies should determine how to produce larger effect sizes over time and delineate predictors of that effect, such as type of exercise, intensity of the program, timing, and type of cancer and treatment in order to maximize the effect on QoL. It will be important to note that certain questionnaires can affect the outcomes, and consistency would improve this body of research.
Mishra, S.I., Scherer, R.W., Snyder, C., Geigle, P., & Gotay, C. (2014). Are exercise programs effective for improving health-related quality of life among cancer survivors? A systematic review and meta-analysis. Oncology Nursing Forum, 41, E326–E342.
PURPOSE: To evaluate the effectiveness of exercise interventions on several domains of health-related quality of life
PHASE OF CARE: Late effects and survivorship
Studies included those with interventions such as yoga, tai chi, and qigong, as well as more traditional exercises. Moderate to vigorous exercise was associated with positive effects on quality of life (SMD = 0.29, 95% CI = 0, 0.58), but no effect was seen for mild to moderate level exercise. These findings did not differ by type of cancer. Anxiety was reduced in all studies by 12 weeks, but this was not observed at longer follow-up periods. At 12 weeks, more vigorous exercise showed no overall effect on anxiety with pooled data. However, a significant effect was seen with mild to moderate exercise (SMD = -0.26, 95% CI = -0.02,-0.51). For fatigue, there were significant positive effects at 12 weeks and between three and six months, but not at six months
The findings of this review show the benefits of various types of exercise on anxiety, fatigue, and quality of life among cancer survivors. Results varied by exercise intensity and at various time points in patient follow-up. This suggests that benefits exist mainly in the short-term up to six months.
Most studies showed a moderate to high risk of bias. All types of exercise were combined with various mind/body interventions, which would affect the results of the meta-analysis. It is not clear that these various types of interventions are truly equivalent types of interventions. The methods of measurement for the studies included were not provided, and differences in measurement would affect the meta-analysis. The search result volumes differed in two areas of this report. The differences reported by exercise intensity are confusing. It is not clear how more vigorous exercise improved quality of life while less vigorous exercise only affected anxiety.
Overall findings confirm other findings that exercise is beneficial for patients with cancer at various phases of care. This particular analysis was aimed at cancer survivors who completed initial treatment. It is of interest that the benefits of interventions appear to wane around the six-month timeframe. It is not clear if the interventions were done in a group setting for some time period or if social interaction could have influenced the findings that long-term effects were not generally seen if group exercise activity had ceased. Future research in this area should incorporate data to facilitate our understanding of the longevity of effects and mechanisms to maintain improvements long-term.
Oldervoll, L. M., Kaasa, S., Hjermstad, M. J., Lund, J. A., & Loge, J. H. (2004). Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients? European Journal of Cancer (Oxford, England: 1990), 40, 951–962.
Databases searched were PubMed, PsycINFO, CANCERLIT, and Cochrane Library through May 2003.
Twelve randomized trials were included. Nonrandomized trials, pilot studies, and studies in which exercise was combined with other therapies, such as cognitive therapy or diet, were excluded. Outcomes were fatigue, health-related quality of life, physical exercise capacity (maximal oxygen consumption), and other physical performance measures. Treatment evaluated aerobic exercise training (10 studies) and resistance exercise (two studies).
Three studies reported a significant reduction in fatigue. One study observed a significant reduction in fatigue, although this did not reach statistical significance. In another study, no statistical analyses were performed to examine between-group differences.
The reviewed studies indicated promising effects on both physiological and psychological outcomes. However, the reviewed studies differed widely in the length of the exercise program, its intensity, content, and frequency, and the timing of the interventions in relation to the patient’s disease and treatment.
Future exercise intervention studies should also identify fewer and more specific endpoints.
Paramanandam, V.S., & Dunn, V. (2014). Exercise for the management of cancer-related fatigue in lung cancer: A systematic review. European Journal of Cancer Care, 24, 4–14.
Three of the 10 studies showed a significant reduction in fatigue with exercise, one using aerobic exercise, one using chest physiotherapy, and one using pulmonary rehab. The other studies showed improvement but did not reach statistical significance. All studies were level 4 or 5 evidence (low). Studies with significant results, however, were not similar in their exercise intervention. Exercise was safe and feasible for adults with lung cancer. All studies provided exercise under supervision, and most included aerobic and interval training
\"This current review shows that exercise is beneficial and safe in lung cancer-related fatigue; however, the studies are small and, without any control groups, are lacking clinically significant effects. Thus, exercises could be used in the management of cancer-related fatigue in lung cancer in view of the available evidence in other cancer cohorts with due caution. There is an urgent need of further research with adequate sample size, preferably randomized controlled trials, to evaluate the effect of exercise in this cancer cohort” (p. 10).
In light of studies on the effects of exercise in other diseases, exercise can be considered for the management of fatigue in patients with lung cancer with attention to performance status. Patients perhaps should undergo individual testing and exercise prescription. Additional research is needed.
Payne, C., Wiffen, P. J., & Martin, S. (2012). Interventions for fatigue and weight loss in adults with advanced progressive illness. Cochrane Database of Systematic Reviews, 1, CD008427.
To determine the efficacy of interventions used in the management of fatigue and/or unintentional weight loss in adults with advanced progressive illness by reviewing the evidence contained within Cochrane reviews. This overview does not attempt to rereview the literature or provide information on outcomes not reported within the included Cochrane reviews.
The database searched was Cochrane Database of Systematic Reviews.
No keyword or subject heading was searched because it would be unreliable due to the diverse range of interventions and illnesses under review. The authors hand searched the Cochrane Database of Systematic Reviews by title for all reviews that might assess the effect of an intervention on fatigue and/or unintentional weight loss in adults with advanced progressive illness.
Studies were included if they reported interventions with fatigue and/or unintentional weight loss as the primary treatment intent.
Studies were excluded if the treatment of fatigue and/or unintentional weight loss was not a primary indication for the intervention, they were systematic reviews published outside the Cochrane Library, or if they only included children.
Twenty-seven systematic reviews were retrieved. Assessment of Multiple SysTemAtic Reviews (AMSTAR) was used to assess the methodological quality of each systematic review.
The review looked for the following outcomes:
1. Clinically significant improvements in fatigue and/or unintentional weight loss
2. Improvements in quality of life of people who have fatigue and/or unintentional weight loss
3. Withdrawals due to adverse events.
Results relative to fatigue in patients with cancer included identification of five systematic reviews (116 studies with 17,342 participants).
The evidence provided some insight into interventions that may prove beneficial, such as exercise. However, recommendations could not be made for specific exercise interventions that might best manage fatigue. In a systematic review, Cruickshank et al. (2008) reviewed the effect of breast care management strategies on fatigue in women with breast cancer at any stage of their illness. No included study assessed fatigue as an independent outcome, and no conclusions could be drawn. In 2009, Goedendorp reported that for patients undergoing cancer treatment at any disease stage, there was insufficient evidence that psychosocial interventions were beneficial for fatigue management.
Sufficient evidence was not provided for the use of EPA over placebo in patients with advanced cancer. A small but significant improvement with fatigue was found with the use of methylphenidate in 51 studies with 10,296 participants. Use of erythropoietin and darbepoetin showed evidence of an effect over standard of care or placebo for the treatment of cancer-related fatigue. However, increased safety concerns mean they are no longer recommended in practice for this use, especially if the person’s hemoglobin concentration is greater than 12 g/dL. No benefits over placebo were seen for fatigue with the use of antidepressant drug paroxetine, nor with progestational steroids.
There was a lack of robust evidence for interventions for fatigue management in the advanced stage of progressive illness related to cancer.
Extraction of data was limited to Cochrane reviews. Fatigue as an outcome indicator was not always sufficiently reported.
Exercise interventions can lead to an improvement in fatigue in patients with cancer; however, this beneficial effect requires further research for those in the advanced stage.
Persoon, S., Kersten, M.J., van der Weiden, K., Buffart, L.M., Nollet, F., Brug, J., & Chinapaw, M.J. (2013). Effects of exercise in patients treated with stem cell transplantation for a hematologic malignancy: A systematic review and meta-analysis. Cancer Treatment Reviews, 39, 682–690.
STUDY PURPOSE: To evaluate the effectiveness of exercise interventions compared with usual care on physical fitness, fatigue, and quality of life in patients treated with hematopoietic stem cell transplantation (HSCT)
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Active antitumor treatment
Six studies showed a positive effect on cardiorespiratory fitness (effect size [ES] = 0.53, 95% confidence interval [CI] [0.13, 0.94]) compared to usual care. Positive effects were seen in muscle strength. Five studies showed positive effects on quality of life (QOL) in global QOL (ES = 0.41, p = 0.0005), cognitive functioning (ES = 0.36, 95% CI [0.13, 0.59], p = 0.002) from the European Organization of Research on Treatment and Cancer (EORTC) self-report instrument. Compared to usual care, exercise had a moderate and significant positive effect on fatigue (ES = 0.53, 95% CI [0.27, 0.79], p < 0.0001).
Exercise interventions were shown to have a positive effect on cardiorespiratory fitness and fatigue, and might show some benefit in terms of several aspects of health-related quality of life for patients undergoing HSCT.
This review adds to the body of evidence showing the effectiveness of exercise interventions for fatigue among various types of patients with cancer. Exercise may also have an impact on various aspects of health-related quality of life; however, the evidence in this area is weak, and additional research is needed to determine efficacy in this area.
Puetz, T. W., & Herring, M. P. (2012). Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis. American Journal of Preventive Medicine, 43, e1–e24.
In total, 434 records were screened, and 325 were excluded. One hundred nine RCTs were screened further, with 23 excluded due to no primary data being available. Eighty-six studies were assessed for eligibility, and 16 were excluded.
The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Authors extracted data independently and resolved discrepancies via consensus judgment.
Patients were undergoing multiple phases of care.
Exercise significantly reduced cancer-related fatigue during and after treatment. During treatment, patients with lower baseline fatigue scores and higher exercise adherence achieved the greatest improvements. Following treatment, cancer-related fatigue improvement was largest in trials with longer durations between treatment completion and exercise initiation, trials with shorter exercise program lengths, and trials with wait-list comparisons.
Exercise reduces cancer-related fatigue in patients during and after cancer treatment. Exercise is palliative in patients during treatment and recuperative posttreatment.
The study provided evidence for prescribing exercise during and following cancer treatment and recognized the differential effects of exercise on cancer-related fatigue when prescribing exercise.
Schmitz, K. H., Holtzman, J., Courneya, K. S., Masse, L. C., Duval, S., & Kane, R. (2005). Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiology, Biomarkers and Prevention, 14, 1588–1595.
The database searched was MEDLINE through February 2005 to identify intervention studies designed to increase physical activity in adults. Only those studies with a concurrent comparison group with results presented separately for treatment and comparison groups were included.
The quality of 32 studies was assessed using prespecified criteria for internal validity. Twenty-two of 32 studies were rated as being of high methodologic quality and were retained for qualitative and quantitative analysis. The outcomes of physical activity interventions in patients receiving active treatment were analyzed separately from the studies of physical activity after treatment was concluded.
Outcomes were fatigue, health-related quality of life, symptom distress, immune function, hematocrit, body composition, physical exercise capacity (maximal oxygen consumption), and other physical performance measures.
Treatment evaluated aerobic physical activity of moderate to vigorous intensity three to five times per week for 20 to 30 minutes per session. The majority of the interventions lasted between five weeks and three months, with no follow-up at the end of the intervention. The majority of the studies used a control group in which no physical activity or other treatment was prescribed, although a few studies provided an intervention for the comparison group.
Although a consistent positive effect of physical activity on fatigue was noted using qualitative study review techniques, effect size calculations revealed no effect of physical activity on fatigue during treatment (weighted mean effect size = 0.13; 95% confidence interval [CI] [-0.06, 0.33]; p = 0.18) or after treatment (weighted mean effect size = 0.16; 95% CI [-0.23, 0.54]; p = 0.43) or on vigor/vitality during treatment (weighted mean effect size = 0.43; 95% CI [-0.07, 0.94]; p = 0.09). A large positive effect of exercise on vigor/vitality posttreatment was noted (weighted mean effect size = 0.82; 95% CI [0.05, 1.6]; p = 0.04). When fatigue and vigor/vitality were combined into one category (under the assumption that fatigue and vitality are the same attribute) and all studies were combined across treatment timing, the weighted mean effect size was still small (weighted mean effect size = 0.19; p = 0.03).
The results supported the conclusion that physical activity has a large positive effect on vigor/vitality after treatment is complete. There is some support from qualitative analysis of a consistent effect of physical activity on fatigue, although the magnitude of this effect may be too small to be clinically meaningful. The study findings also supported a preliminary conclusion that physical activity is generally well tolerated during and after cancer treatment, although the available literature does not allow conclusions to be drawn regarding adverse events from participation.
Speck, R.M., Courneya, K.S., Mâsse, L.C., Duval, S., & Schmitz, K.H. (2010). An update of controlled physical activity trials in cancer survivors: A systematic review and meta-analysis. Journal of Cancer Survivorship, 4, 87–100.
PHASE OF CARE: Multiple phases of care
The majority of studies demonstrated a positive effect on upper and lower body strength and self-esteem with physical activity during treatment. The majority of studies also demonstrated a positive effect on aerobic fitness, lower body flexibility, lean body mass, quality of life, trial outcome index, breast cancer subscale, vigor and vitality, fatigue, immune parameters, pain, symptoms, and side effects post-treatment. Twenty-nine of 36 studies reporting on aerobic exercises reported no side effects from physical activity. Significant WMES were found post-treatment for fatigue (-0.54, p = 0.003).
In general, physical activity is well-tolerated during and after cancer treatment. More studies are needed on specific kinds of exercise and the structure of delivery. Physical activity studies with fatigue as an outcome have increased from five to 14 since 2005 for post-treatment interventions with 93% of studies showing positive results and 50% of them being statistically significant.
Patients can be educated that physical activity after a cancer diagnosis can be safe with modifications as necessary.
Stevinson, C., Lawlor, D. A., & Fox, K. R. (2004). Exercise interventions for cancer patients: systematic review of controlled trials. Cancer Causes and Control, 15, 1035–1056.
Databases searched were MEDLINE, EMBASE, Cochrane Controlled Trials Register, CANCERLIT, CINAHL, PsycINFO, and SPORTDiscus through December 2003.
Thirty-three studies (25 randomized trials and eight nonrandomized studies) reported in 40 articles were included in the review. Data were pooled for 10 trials that assessed physical functioning and 12 trials that assessed fatigue.
Trials were included if they tested interventions involving regular exercise of any type (e.g., aerobic, resistance, and flexibility). Exercise could be the sole intervention or could be combined with other interventions (e.g., diet counseling). Only prospective trials with a control arm were included. Based on an a priori decision, both nonrandomized and randomized trials were included. There were no restrictions on the outcomes assessed in trials. Nineteen studies tested aerobic exercise interventions, of which eight used cycle ergometers and eight used walking programs. Three trials tested resistive exercise, 10 had combined aerobic and resistive programs, and one was based on team sport activities. Most trials compared an exercise intervention with no intervention; six that did not used information training, psychological therapies, stretching, or tai chi as comparison arms.
Trials of single exercise sessions that measured acute effects were excluded, as were trials that only investigated the effects of physiotherapy. Control arms could not comprise an intervention (e.g., usual care), an alternative intervention (e.g., counseling, relaxation), or a different type of exercise (e.g., aerobic versus flexibility exercises). Trials with healthy or historical control groups were excluded.
Exercise interventions lasted for 10 weeks or longer in 17 trials and two weeks or less in four studies. The longest intervention period of any trial was 26 weeks. Trial quality was assessed by recording whether the following features were incorporated in the study design: randomization, allocation concealment, blinding of the main outcome assessment, and intention-to-treat analysis.
Reductions in cancer-related fatigue were reported in 10 studies, although statistical significance was not reached or not tested for in three of them. No differences between groups were reported for fatigue in six trials immediately after the intervention or several months later. Pooling the data from the 12 trials that assessed fatigue suggested that there was no overall effect of exercise on symptoms of fatigue (standardized mean difference [standard deviation (SD)] in fatigue = -0.15 [-0.38, 0.09]). Heterogeneity between studies was not related to randomization, allocation concealment, intention-to-treat analysis, or choice of control. However, the effect appeared to vary by population type. Some evidence existed that no effect was found of exercise on fatigue symptoms in trials that recruited patients with any type of cancer and that those that recruited patients with breast cancer found a modest reduction in symptoms of fatigue among those allocated to exercise (standardized mean difference [SD] = -0.52 [-0.95,-0.09]). There was no strong evidence of small study bias in this meta-analysis by the Beggs and Egger tests.
The authors generally concluded that there were methodologic limitations associated with many of the studies and that these limitations may have contributed to the inconsistencies among the results.
Two studies may have included participants in the control group who had declined to undertake the intervention; in five other studies, it was unclear whether eligibility (including willingness to participate) was determined prior to group allocation or whether the control group may have solely or partly consisted of those who declined to be allocated to exercise.
Strasser, B., Steindorf, K., Wiskemann, J., & Ulrich, C.M. (2013). Impact of resistance training in cancer survivors: A meta-analysis. Medicine and Science in Sports and Exercise, 45, 2080–2090.
STUDY PURPOSE: The purpose of this article was to review published literature on impact resistance training (RT) in adults with cancer.
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: Clinical Trial Register, Cochrane Trial Register, MEDLINE, and EMBASE
KEYWORDS: cancer, resistance training, muscle function, muscle strength, body mass, fatigue
INCLUSION CRITERIA: RCT comparing RT with an exercise or non-exercise control group in adult patients with cancer. Evaluation and report on strength, body composition, or fatigue comparing RT to no exercise, usual care, or alternative treatment.
EXCLUSION CRITERIA: Single RT intervention, intervention less than six weeks, recommendation of interventions with no further detail, indirectly or poorly documented RT, clinical co-intervention not applied to control, concomitant aerobic endurance training not applied to control
TOTAL REFERENCES RETRIEVED = 261
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Assessed by Jadad score (randomization, double-blinding, follow-up, intention to treat). Scores higher than two considered.
PHASE OF CARE: Multiple phases of care
Four studies provided FACT-fatigue data. Improvement was seen in pooled fatigue scores (p = .05; WMD 1.86; CI -.03–3.75). Individually, two studies showed significant improvement. The therapeutic dose necessary to reduce fatigue was unable to be determined. No significant difference was seen in participant characteristics. No significant side effects were reported.
Low-to-moderate intensity RT may improve cancer-related fatigue described as muscle fatigue within 15–20 repetitions.
RT may have benefits for fatigue with a certain subset of patients with cancer with low risk for side effects. Further studies are needed to establish dose and to validate improvement for certain populations.
Stricker, C. T., Drake, D., Hoyer, K. A., & Mock, V. (2004). Evidence-based practice for fatigue management in adults with cancer: exercise as an intervention. Oncology Nursing Forum, 31, 963–976.
Databases searched were MEDLINE, CINAHL, and Database of Abstracts of Reviews of Effects (DARE) through October 2003. Proceedings of the annual meetings of the American Society of Clinical Oncology, American College of Sports Medicine, and Oncology Nursing Society were also searched.
Twenty experimental studies (nine randomized, clinical trials and 11 quasiexperimental studies) were included. The outcome was fatigue. Treatment evaluated physical activity or group or individual exercise.
There is strong evidence to support the effectiveness of home-based exercise programs performed by middle-aged women undergoing adjuvant chemotherapy or radiation therapy for nonmetastatic breast cancer and some evidence that exercise may be equally beneficial in other cancer populations, including individuals with solid tumors and hematologic malignancies and cancer survivors. Based on current evidence, low-intensity exercise individualized to patient comfort is the only type of exercise that can be considered safe for patients in palliative care settings. Evidence supports the efficacy of aerobic laboratory-based interval training in individuals receiving peripheral blood stem cell transplantation.
All studies had some design limitations, including
Thorsen, L., Courneya, K. S., Stevinson, C., & Fosså, S. D. (2008). A systematic review of physical activity in prostate cancer survivors: outcomes, prevalence, and determinants. Supportive Care in Cancer, 16, 987–997.
Databases searched were MEDLINE, PubMed, EMBASE, Allied and Complementary Medicine (AMED), and PsycINFO. The dates encompassed by the search process were not specified by the authors.
Trials that provided data on the outcomes of physical activity in survivors of prostate cancer were identified. Studies that did not disentangle the effects of physical activity from a package of multiple interventions (e.g., physical activity combined with diet, counseling, etc.) were excluded. Studies that included survivors of prostate cancer among other cancer survivors without presenting separate results for survivors of prostate cancer were also excluded.
Six studies that examined the effects of physical activity in survivors of prostate cancer were identified. Of these studies, the physical activity interventions were performed during radiotherapy in one study and during androgen depletion therapy in five. Four studies were randomized trials, whereas two were uncontrolled trials.
Outcomes were physical functioning, body composition, fatigue, and quality of life.
Four studies examined the effects of supervised exercise programs, whereas two investigated the effects of home-based exercise programs. Three studies tested a resistance exercise program; one tested a home-based walking program; one tested a group-based lifestyle program designed to increase physical activity; and one used a home-based intervention with walking, stretching, and resistance activities with biweekly supervised group-based booster sessions. The length of the exercise programs ranged from four weeks to six months, with a median of 12 weeks.
Sample sizes ranged from nine to 155 participants (median sample size = 48).
In four of the six studies in which fatigue was measured and reported, statistically significant improvements in fatigue were noted. All studies demonstrated that physical activity was safe and feasible for survivors of prostate cancer receiving treatment.
Tian, L., Lu, H.J., Lin, L., & Hu, Y. (2016). Effects of aerobic exercise on cancer-related fatigue: A meta-analysis of randomized controlled trials. Supportive Care in Cancer, 24, 969–983.
PHASE OF CARE: Active antitumor treatment
Exercise was supervised or home-based, 15–50 minutes in length, two to five times per week for 6–24 weeks. Overall aerobic exercise had a small but significant effect (p = 0.01). Studies with patients past active treatment had a moderate effect on fatigue compared to usual care (p < 0.01). Professionally led exercise led to significant improvements in fatigue (p = 0.02). Professionally led exercises lasted 20–30 (p < 0.01) or 50 minutes (p < 0.02), two to three (p < 0.01, p = 0.01) times per week for eight weeks (p < 0.01). No significant difference by exercise type existed.
Structured exercise can have a positive effect on CRF. The effect may be greater when activity is professionally led and after active treatment.
Consistent physical activity should be discussed with patients with cancer to lessen the effects of CRF.
Tomlinson, D., Diorio, C., Beyene, J., & Sung, L. (2014). Effect of exercise on cancer-related fatigue: A meta-analysis. American Journal of Physical Medicine and Rehabilitation, 93, 675–686.
PHASE OF CARE: Multiple phases of care
There was a moderate effect on fatigue, sleep disturbance, and depression with exercise in the intervention groups (p < 0.001) compared to the control group. The benefits of exercise did not differ by type of exercise intervention (P = 0.85 for interaction). However, the effect of exercise on fatigue reduction may differ by underlying malignancy type with a stronger effect in solid tumors versus hematologic and mixed-malignancy types (P = 0.01 for interaction). There was a stronger effect on depression in females (p = 0.03). Patients with solid tumors seemed to experience a greater benefit.
Exercise can have an effect on fatigue despite the type of exercise and phase of care when delivered.
The clinical effect of what is considered a significant reduction in Functional Assessment of Cancer Therapy - Fatigue was questioned. The terms physical activity and exercise were used interchangeably, and the meaning of structured exercise was not well-explained.
Patients may be given several options for kinds of exercise to improve fatigue based on their preference while still receiving the benefit of improved fatigue.
van Haren, I.E., Timmerman, H., Potting, C.M., Blijlevens, N.M., Staal, J.B., & Nijhuis-van der Sanden, M.W. (2013). Physical exercise for patients undergoing hematopoietic stem cell transplantation: Systematic review and meta-analyses of randomized controlled trials. Physical Therapy, 93, 514–528.
STUDY PURPOSE: To summarize and analyze the evidence provided by randomized, controlled trials (RCTs) on physical exercise interventions among patients with cancer undergoing HSCT
TYPE OF STUDY: Systematic review and meta-analysis
TOTAL REFERENCES RETRIEVED: 232 originally retrieved; 180 excluded by title and abstract
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane collaborative tool for assessing for risk of bias used for bias; two of the authors scored articles. If a disagreement occurred, a third author reviewed.
Only six of the studies examined the effect of exercise on fatigue. In meta-analysis of 115 patients (two studies), exercise significantly reduced fatigue at discharge (n = 115; SMD = 0.53; 95% CI [0.16, 0.91], p = .005). The meta-analysis indicated that training during hospitalization has a positive effect on fatigue in patients receiving an allogeneic HSCT.
Results of meta-analysis could not be confirmed through individual review of the other four studies, as only two showed statistically significant effect for fatigue in favor of the exercise group.
Physical functioning could not be evaluated by meta-analysis due to differences in study design and outcomes, but the majority of the studies did suggest a positive effect of exercise on functioning.
Exercise intervention during hospitalization can have a positive effect on fatigue at discharge for patients undergoing HSCT.
Best outcomes were seen at discharge, suggesting that starting interventions before or just after transplantation are most effective. Further research into the optimal exercise program is needed.
van Vulpen, J.K., Peeters, P.H., Velthuis, M.J., van der Wall, E., & May, A.M. (2016). Effects of physical exercise during adjuvant breast cancer treatment on physical and psychosocial dimensions of cancer-related fatigue: A meta-analysis. Maturitas, 85, 104–111.
STUDY PURPOSE: To investigate the effects of exercise on physical and psychosocial dimensions of fatigue during adjuvant treatment for breast cancer
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Active antitumor treatment
Analysis showed that exercise had significant benefit for general fatigue (ES = –0.22), physical fatigue (ES = –0.35), reduced activity (ES = –0.22), and reduced motivation (ES = –0.18) (p = 0.05) but no effect on cognitive or affective dimensions of fatigue. Five studies included resistance exercises. Two studies compared resistance and aerobic exercise.
Exercise was shown to have beneficial effects on the physical dimensions of fatigue with low to moderate effect sizes. No apparent effects on emotional and cognitive components of fatigue were observed.
Limited number of studies included
This analysis adds to the large body of evidence showing the beneficial effects of exercise on fatigue. In this study, only the physical aspects of fatigue were affected. Additional interventions may be needed to address the psychosocial dimensions of fatigue.
Velthuis, M. J., Agasi-Idenburg, S. C., Aufdemkampe, G., & Wittink, H. M. (2010). The effect of physical exercise on cancer-related fatigue during cancer treatment: a meta-analysis of randomised controlled trials. Clinical Oncology (Royal College of Radiologists (Great Britain)), 22, 208–221.
To evaluate short- and long-term effects of different exercise parameters during adjuvant treatment on cancer-related fatigue.
Databases searched were CINAHL, EMBASE, MEDLINE, Scopus, PEDro, and Cochrane Library to 2008. Hand searching was performed using reference lists from articles obtained.
Search keywords were cancer (and related terms), chemotherapy, radiotherapy, hormone*, exercise, cycle, train*, walk, and fatigue.
Studies were included in the review if
No exclusion criteria were specified.
Initally, 1,097 articles were identified. A final set of 18 articles met the inclusion criteria. The PEDro scale was used to rate the methodological quality of the research. Fifteen studies were considered to be of high quality, with a score 4 or greater (range 2–8).
Overall Findings in Breast Cancer
Exercise was home-based and self-monitored in seven studies. Interventions consisted of walking for 10 to 45 minutes per week and for three to six times per week. In one study, the participants also performed resistance exercises. Cancer treatments and timing of the programs varied. Adherence ranged from 70% to 100%.
Supervised Exercise Programs
Supervised programs were used in five studies. Three involved aerobic exercises, and the others included groups with stretching and/or resistance exercises. Most were performed for 10 to 30 minutes three times per week. Programs were completed by 39% to 100% of partcipants.
Overall Findings in Prostate Cancer
Four studies were performed in patients with prostate cancer; three were supervised and one was home-based.
Findings in Multiple Myeloma and Acute Myeloid Leukemia
One study was performed in each of these patient groups. One was of low quality. Both had nonsignificant reductions in fatigue.
Only short-term effects could be analyzed because only one study described any longer-term effects of physical exercise. No significant adverse effects overall were seen. Supervised aerobic exercise programs were more effective in reducing fatigue than home-based programs. There were significant positive effects during breast cancer treatment, with small to moderate effect sizes. The most effective frequency intensity or duration of exercise could not be determined. Reported adherence to the exercise program varied widely.
Findings showed that exercise had at least a small beneficial effect in reducing fatigue for patients during adjuvant treatment. Supervised programs may be more effective than self-managed home-based programs. More research on the effects of resistance exercise, home-based exercise, and most effective exercise parameters are needed. Longer-term outcomes and patient adherence need to be examined further. Research on the effects of exercise in other patient types is also needed.
Wanchai, A., Armer, J. M., & Stewart, B. R. (2011). Nonpharmacologic supportive strategies to promote quality of life in patients experiencing cancer-related fatigue: a systematic review. Clinical Journal of Oncology Nursing, 15, 203–214.
To review the literature on nonpharmacologic supportive strategies to enhance quality of life (QOL) among patients with breast cancer experiencing cancer-related fatigue.
Databases searched were MEDLINE and CINAHL (2000–2010).
Search keywords were breast cancer patient, oncology patient, fatigue, cancer-related fatigue, quality of life, health-related quality of life, physical activity, and exercise.
Studies were included in the review if they
Eighty-nine articles were identified, of which 28 met the inclusion criteria. No method of quality rating of the studies was described.
Supervised exercise was used in eight studies. Four of these showed that exercise significantly improved QOL and reduced fatigue. Two studies showed that supervised exercise improved QOL but not fatigue; they had noted study limitations and intervention contamination. One large multi-site study showed that supervised aerobic exercise improved self-esteem, fitness, etc., but had no significant effect on QOL, depression, anxiety, or fatigue
Home-based exercise was used in six studies. All of these confirmed a positive effect of participation in exercise on fatigue. Fatigue levels either decreased, or those who exercised had significantly less increase in fatigue over time.
Telephone-based encouragement in activity was used in one study (25 patients). At 12 weeks, there were significant increases in activity, QOL, and fatigue.
One study used print materials and step pedometers along with physical activity recommendations. Those who received all three of these strategies had improved QOL and fatigue.
Education and counseling was used in five studies. Mixed results were seen across studies, with a positive effect on fatigue that was significant in three of these studies.
Sleep therapy was examined in three studies. Two of these demonstrated a significant positive effect on fatigue with cognitive behavioral therapy and insomnia treatment. One large study using cognitive behavioral therapy showed improvement in sleep quality but no effect on fatigue.
Other interventions were yoga in one study, tai chi in one study, and physical therapy in one study. Yoga was associated with an improvement in fatigue, and physical therapy was also associated with improvement, although this was only studied in 11 patients.
This review generally showed that supervised exercise and supervised exercise and other strategies to promote exercise can reduce cancer-related fatigue and improve QOL in women with breast cancer. Findings were limited by several studies with small sample sizes and variations in the phases of care in which the interventions were provided. There was insufficient evidence to draw conclusions about the complementary therapies included.
Based on current evidence, exercise, educational counseling, and sleep therapy appear to be helpful methods to improve QOL and reduce fatigue. Because of methodological limitations of many of these previous studies, further well-designed research is needed to confirm these conclusions.
Zou, L.Y., Yang, L., He, X.L., Sun, M., & Xu, J.J. (2014). Effects of aerobic exercise on cancer-related fatigue in breast cancer patients receiving chemotherapy: A meta-analysis. Tumour Biology, 35, 5659–5667.
PHASE OF CARE: Active
The Revised Piper Fatigue Scale (RPFS) scores for patients with breast cancer were significantly lower in the intervention group than the control group. However, there was no significant difference in the Functional Assessment of Chronic Illness Treatment Fatigue (FACIT-F) scale scores between the intervention and control groups. A subgroup analysis by ethnicity indicated that there were significant differences in RPFS and FACIT-F scores between the intervention and control groups among Asian populations.
This study provided additional support for aerobic exercise as an intervention for CRF in women receiving chemotherapy for breast cancer, especially Asian women. However, it did not help determine the frequency, intensity, or duration of aerobic exercise that is most beneficial for CRF.
Nurses can continue to recommend aerobic exercise for women receiving chemotherapy for breast cancer. However, additional research is needed regarding the frequency, intensity, and duration of exercise.
Alibhai, S.M., Durbano, S., Breunis, H., Brandwein, J.M., Timilshina, N., Tomlinson, G.A., . . . Culos-Reed, S.N. (2015). A phase II exercise randomized controlled trial for patients with acute myeloid leukemia undergoing induction chemotherapy. Leukemia Research, 39, 1178–1186.
To determine if a multimodal exercise program for patients during induction chemotherapy is feasible, safe, and beneficial for fatigue, quality of life, and fitness
Patients were randomized to the exercise or usual care groups. Usual care generally included suggestions to walk on a regular basis, without further instruction. Those in the exercise group were approached 4–5 days per week during hospital admission to participate in light-to-moderate–intensity exercise for 30–60 minutes. Exercise sessions included combined aerobic, resistance, and flexibility training. Aerobic intensity was encouraged at an exertion equivalent to 50%–75% of heart-rate reserve. The resistance exercises targeted large muscle groups using resistance bands and free weights. Flexibility was incorporated into each session via static stretching. Exercise sessions were directly supervised by a certified exercise physiologist. Study assessments were completed at baseline, post induction, and within two weeks of discharge, post cycle 2 (4–6 weeks post discharge).
Exercise group participants completed 514.2 minutes of exercise on average during an average admission of 36.5 days. The most common reported reason for not exercising was fatigue. Adherence to exercise sessions was 54%. Control group patients exercised an average of 510.4 minutes over 35.8 days. Participants in both groups demonstrated an improvement in global quality of life. Fatigue scores improved only in the exercise group, with a between group difference of 3.6 points, which was not statistically significant. The six-minute walk improved in both groups but improved significantly more in the exercise group (p = 0.005). No significant adverse event occurred. During over 1,000 patient days of observation, four musculoskeletal events were reported. No differences existed between groups in length of stay or other resource utilization.
This study demonstrated that the provision of an exercise program is feasible for patients during induction chemotherapy and may help manage fatigue in these patients. Patients who participated in the multimodal exercise program demonstrated improved physical fitness.
Participation in an exercise program of moderate intensity was shown to be feasible for patients who were hospitalized and receiving induction chemotherapy for AML.
Alibhai, S.M., O'Neill, S., Fisher-Schlombs, K., Breunis, H., Timilshina, N., Brandwein, J.M., . . . Culos-Reed, S.N. (2014). A pilot phase II RCT of a home-based exercise intervention for survivors of AML. Supportive Care in Cancer, 22, 881–889.
To examine the feasibility (recruitment, retention, and adherence), preliminary efficacy, and safety of a 12-week, home-based exercise program for middle-aged and older acute myeloid leukemia (AML) survivors
Phase II randomized controlled trial with an exercise group and a wait-list control group that could cross over to the exercise group at week 12.
Recruitment and retention rates were 31% and 91%, respectively. The adherence rate was 28%. The analyses did not suggest statistically significant or clinically important benefits in QOL, fatigue, or physical fitness between groups. There were no adverse events.
Successful recruitment with low adherence and limited effects on clinical outcomes including fatigue.
Further study is needed in this population including how to enhance exercise adherence.
Al-Majid, S., Wilson, L.D., Rakovski, C., & Coburn, J.W. (2015). Effects of exercise on biobehavioral outcomes of fatigue during cancer treatment: Results of a feasibility study. Biological Research for Nursing, 17, 40–48.
To determine the feasibility of an exercise intervention among women receiving treatment for breast cancer and to examine the effects of exercise on hemoglobin (Hb) and maximum oxygen volume (VO2MAX) and their association with changes in cancer-related fatigue (CRF) and quality of life (QOL) while investigating changes in selected inflammatory markers
The intervention consisted of a supervised, progressive treadmill exercise program two to three times times per week delivered in a rehabilitation center for the duration of chemotherapy (9–12 weeks).
Random assignment with repeated measures
Feasibility: The recruitment rate was 45.7%, the retention rate was 87.5%, the adherence rate was 95%–97%, and the tolerance rate was 93%.
Efficacy: There were no differences in VO2MAX at baseline between the groups. The exercise group maintained pretreatment VO2MAX levels throughout chemotherapy, and the usual-care group showed a significant decline of as much as 6.3 ml/kg per minute that continued three to four weeks after treatment. CRF outcomes favored the exercise group, and QOL, physical well-being, and functional well-being declined significantly in both the experimental and usual-care groups.
Recruitment to exercise interventions is difficult. The type of exercise, location, and the choice of a self-lead or a supervised intervention may influence the decision to participate. Retention may be influenced by flexibility in scheduling and the allowance of make-up sessions. Exercise did not have a significant effect on CRF or QOL. Changes in the inflammatory markers favored the exercise group. Exercise may protect against a decline in VO2MAX but not Hb concentrations.
This study addressed exercise dose in terms of intensity, duration, and frequency when prescribing exercise as an intervention. The inclusion of inflammatory markers is a potential benefit that future research could use to quantify the effects of an exercise intervention.
Banzer, W., Bernhorster, M., Schmidt, K., Niederer, D., Lungwitz, A., Thiel, C., . . . Vogt, L. (2014). Changes in exercise capacity, quality of life and fatigue in cancer patients during an intervention. European Journal of Cancer Care, 23, 624–629.
To explore the interdependence of changes in oxygen uptake, quality of life (QOL), and cancer-related fatigue (CRF) during a four-month exercise intervention
Aerobic exercise capacity was determined by a physician-supervised cardiopulmonary exercise test on an electrically braked cycle ergometer. An initial watt load of 0 watts was increased by 25 watts every three minutes until exhaustion. The results were used at an initial exercise counseling session to individualize exercise plans (i.e., frequency of three to five times per week, intensity, type of exercise, opportunity to participate in a Nordic walking training session once per week). Subjects attended a second counseling session four weeks into the intervention to adjust home-based exercises to fit their conditions. An exercise counselor was available by phone, via email, or in person at any time during the intervention. Assessments were repeated at the end of 16–20 weeks. Self-reported measures of adherence to exercise plans were obtained by diaries.
Repeated measures pre- and postintervention
Subjects were active (i.e., hiking, biking, walking, bicycling) three to six times per week for 60–300 minutes at 60%–100% of individual anaerobic thresholds. At baseline, the groups differed in QOL scores but not CRF or VO2PEAK scores. Subjects with complete data sets had a significant increase in VO2PEAK and QOL scores, and their fatigue decreased significantly over the course of the intervention. No significant effect for diagnosis or time since diagnoses occurred.
A relationship between exercise capacity enhancement, QOL improvement, and fatigue symptom reduction exists during and shortly after cancer treatment.
The data in this study support the role of individualized exercise planning based on baseline exercise capacity with respect to frequency, time, and intensity as well as the importance of patient choice in the type of exercise in which to participate.
Baruth, M., Wilcox, S., Der Ananian, C., & Heiney, S. (2013). Effects of home-based walking on quality of life and fatigue outcomes in early stage breast cancer survivors: A 12-week pilot study. Journal of Physical Activity and Health [Epub ahead of print].
To examine the effects of a home-based walking program on quality of life and fatigue.
Women were randomized to the usual care, wait list control, or intervention groups. Those in the intervention group received a 30 minute in-person counseling session and follow-up telephone counseling calls in weeks 1, 2, 4, 7, and 10. Counseling calls applied constructs of social cognitive therapy, discussing specific behavior change principles that could be used to increase walking, using a semi-structured script. Walking plans were designed for gradual increases in frequency, duration, and intensity. Women in the usual care group were asked to maintain their usual activity levels. Those in the intervention group were asked to keep daily activity logs and were given pedometers.
Fatigue declined in all patients. There was a greater decline among the intervention group, but the difference was not significant. Estimated activity level of walking METs was not significantly different between groups at baseline, but levels post-intervention are not reported. Overall, participants in the intervention group completed 86% (range = 62%–100%) of prescribed walking sessions.
Findings suggest relatively good adherence to home-based walking prescriptions and suggest that this activity may improve fatigue symptoms.
Findings suggest that a prescription for a home-based walking program can be a practical way to improve or maintain physical activity among women with breast cancer after initial treatment, and that this activity can improve symptoms of fatigue. There were multiple limitations to this study; however, multiple studies have shown that exercise is effective to reduce fatigue. Previous findings regarding self-managed exercise programs have been mixed. This pilot study suggests that a prescription for exercise, patient counseling and follow-up contacts may facilitate performance of home-based exercise.
Baumann, F.T., Zopf, E.M., Nykamp, E., Kraut, L., Schüle, K., Elter, T., . . . Bloch, W. (2011). Physical activity for patients undergoing an allogeneic hematopoietic stem cell transplantation: Benefits of a moderate exercise intervention. European Journal of Haematology, 87, 148–156.
To demonstrate the effects of an exercise program on endurance, strength, lung function, and quality of life in patients undergoing allogeneic transplantation.
Forty-seven patients undergoing allogeneic transplantation during a three-year period were recruited and randomized into either the exercise group (EG) or the control group (CG). The EG received daily aerobic endurance training with a cycle and ADL training, involving relaxation, stair climbing coordination, and strengthening. Exercise was done 20–30 minutes per day, twice daily. CG patients received standard physiotherapy for 20 minute five days per week, consisting of active and passive mobilization with low intensity. Fatigue measurement was conducted two days after admission and one day before discharge. Exercise began the first day after transplantation.
Increase in the experience of fatigue in the CG. Deterioration of physical function was seen in both study groups. There was improved emotional state for patients in the EG (p = .028). Relative endurance improved in EG both groups. There was no significant group by time effect on fatigue. No effect for strength, lung function, or anthropometric assessments reached significance in either group.
The only significant difference between the two groups was found in relative endurance in favor of EG.
Physical activity during acute phase of transplantation appears safe and can improve physical endurance and strength.
Bourke, L., Thompson, G., Gibson, D. J., Daley, A., Crank, H., Adam, I., . . . Saxton, J. (2011). Pragmatic lifestyle intervention in patients recovering from colon cancer: a randomized controlled pilot study. Archives of Physical Medicine and Rehabilitation, 92, 749–755.
To investigate the feasibility of an intervention aimed at increasing exercise participation and improving dietary behavior in survivors of colon cancer and obtain preliminary data on the effect of the intervention on fatigue, exercise, and dietary outcomes.
Patients were randomly assigned to intervention or standard care control groups. The 12-week intervention included supervised and home-based exercise and dietary advice. During the first six weeks, the experimental group attended two group supervised exercise sessions of 30 minutes of aerobic exercise. Participants were asked to continue the same time of activities at home once a week during the same period and were asked to keep an exercise log. During the last six weeks, participants attended a supervised session once a week and were to perform two weekly home-based exercise sessions. Participants were given a dietary advice information pack and periodically attended healthy eating seminars encouraging reduction in saturated fat, increased fiber intake, reduction in refined carbohydrates, and limited alcohol intake.
Patients were undergoing the transition phase after initial treatment.
This was a randomized, controlled trial that was single-blinded for some outcome measures.
There was an overall 90% attendance rate at supervised exercise sessions and a 77% attendance rate at dietary seminars. Of those in the intervention group, 66.6% returned exercise logs, and among these, there was a 94% rate of adherence to independent aerobic exercise for 25 to 30 minutes. There was no significant difference between groups in exercise behavior. Fatigue scores improved significantly in the intervention group (p = 0.005) compared to controls. There was a significant increase in dietary fiber intake (p = 0.044), with no other differences in dietary habits. Compared to controls, there were significant improvements in chair sit to stand performance (p = 0.003) and aerobic exercise tolerance (p = 0.01).
Combined supervised group and home-based individual exercise with dietary education was shown to be feasible and demonstrated preliminary positive effects on fatigue and dietary fiber intake.
Findings suggested that an intervention combining some group supervised exercise and some home-based exercise is feasible and can be effective in reducing fatigue. Further research in this area is warranted as researchers attempt to determine the most effective ways to provide exercise interventions that patients will adhere to. The combination of some group periodic supervised sessions may improve patient motivations to adhere to a program, given the relatively low dropout rate seen here. This study was performed after completion of cancer treatment.
Broderick, J.M., Guinan, E., Kennedy, M.J., Hollywood, D., Courneya, K.S., Culos-Reed, S.N., . . . Hussey, J. (2013). Feasibility and efficacy of a supervised exercise intervention in de-conditioned cancer survivors during the early survivorship phase: The PEACH trial. Journal of Cancer Survivorship: Research and Practice, 7, 551–562.
To evaluate the feasibility and efficacy of an eight-week, supervised exercise program in deconditioned cancer survivors within two to six months of chemotherapy completion
Twice-weekly, aerobically-based group sessions in a hospital setting for a duration of eight weeks plus a home exercise program.
Prospective, two-arm, randomized controlled trial
Feasibility: 81% eligible patients were recruited to the study. Conflicting data on drop-outs were presented. Exercise intervention was positively received as noted in exit interviews with subjects. Adherence to supervised and home-based exercise intervention was good (76% to 105%, respectively). There were no statistically significant differences between the groups for any health-related fitness outcomes. Total FACIT and fatigue subscale scores were better in the exercise group at three months (mean difference = 6.2, 95%, CI 1.4–11.0).
Data support the benefit of exercise to address cancer-related fatigue in the early survivorship period. However, sample was “healthy” with few co-morbidities and, although deconditioned, did not include older adults (> 65 years of age), which raises questions about safety and which type and dose of exercise should be recommended to the large group of cancer survivors who continue to experience cancer-related fatigue.
Buss, T., de Walden-Gałuszko, K., Modlińska, A., Osowicka, M., Lichodziejewska-Niemierko, M., & Janiszewska, J. (2010). Kinesitherapy alleviates fatigue in terminal hospice cancer patients-an experimental, controlled study. Supportive Care in Cancer, 18, 743–749.
To evaluate the effect of physical exercise on terminally ill patients with cancer.
Patients in the exercise group exercised three times a week for 20 to 30 minutes for a three- to four-week period. The schedule of exercises was individually planned by a physiotherapist. Study outcome measures were obtained at baseline, weekly, and at the end of the study. No information was provided regarding the control group procedures.
Patients were undergoing end of life care/end of life and palliative care phase of care.
This was a two-group comparative trial – no information was provided on whether patients were randomly assigned.
There were no apparent effects on outcomes during the first two weeks. By week 3, mean VAS intensity of fatigue declined in the exercise group from 6.5 to 5.5. In the control group, fatigue increased from 6.5 to 7.5 (ANOVA; p < 0.001). Physical symptoms tended to decline slightly in the exercise group and increase slightly in the control group, with changes ranging from 0.1 to .05 (p < 0.05). There were no observable effects on quality of life scores from the symptom checklist data.
Results suggested that individualized exercise can be beneficial for fatigue in terminal patients with cancer.
The study did not provide strong evidence for the effectiveness of exercise due to multiple issues in this report and the small measured changes seen. Findings suggested that exercise may be beneficial in terminally ill patients and showed that there were no apparent adverse effects from the activity provided to these patients.
Cantarero-Villanueva, I., Fernández-Lao, C., Cuesta-Vargas, A. I., Del Moral-Avila, R., Fernández-de-Las-Peñas, C., & Arroyo-Morales, M. (2013). The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 221–230.
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.
Patients were undergoing the transition phase after active treatment.
This was a single-blind, randomized, controlled trial.
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 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.
Cheville, A.L., Kollasch, J., Vandenberg, J., Shen, T., Grothey, A., Gamble, G., & Basford, J.R. (2013). A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: A randomized controlled trial. Journal of Pain and Symptom Management, 45, 811–821.
To report the effects of a strength training and walking program in patients with stage IV lung and colorectal cancer.
Patients were given usual care or 1.5 hours of training by a physical therapist on rapid, easy, strength training exercises (REST) and pedometer-based walking using an instruction manual, resistance bands, an exertion rating scale, and a study log. They were then followed bimonthly by telephone for eight weeks.
Patients were undergoing the end of life phase of care.
The study was a single-blinded, randomized, controlled trial.
Mobility, fatigue, and sleep measures were statistically significant between the intervention and control groups from baseline to week 8 (p = 0.002, p = 0.03, and p = 0.002, respectively), in favor of exercise. Other measures did not show significance. The number of REST sessions and weeks logged with step counts were associated with changes in the mobility score. Survival and withdrawals did not differ significantly between the groups.
A home-based intervention using walking and strength exercises may improve mobility, fatigue, and sleep quality in patients with stage IV colorectal or lung cancer.
The teaching of walking exercises and strength routines may improve functioning in this patient population in terms of mobility, sleep quality, and fatigue. The one-time education session may be appealing to nurses looking for a timely intervention to help improve these symptoms.
Coleman, E. A., Goodwin, J. A., Kennedy, R., Coon, S. K., Richards, K., Enderlin, C., . . . Anaissie, E. J. (2012). Effects of exercise on fatigue, sleep, and performance: a randomized trial. Oncology Nursing Forum, 39, 468–477.
To compare usual care with a home-based individualized exercise program (HBIEP) in patients receiving intensive treatment for multiple myeloma (MM) and epoetin alfa therapy.
This was a randomized trial with repeated measures of two groups (one experimental and one control) and an approximate 15-week experimental period for the HBIEP. The control group received a recommendation to walk 20 minutes three times per week. In the HBIEP, patients were given color-coded stretch bands and materials to illustrate exercises to be used, and they were to perform aerobic walking to reach 65% to 80% of the maximal heart rate. Patients mailed in weekly activity summaries. Assessments were performed at baseline, 10 to 12 weeks later prior to the second chemotherapy cycle, and three to four weeks later when finishing stem cell collection.
This was a randomized, controlled trial with repeated measures of two groups and a 15-week experimental period.
No statistically significant differences existed among the experimental and control groups for fatigue, sleep, or performance (aerobic capacity). Statistically significant differences (p < 0.05) were found in each of the study outcomes for all patients as treatment progressed, and patients experienced more fatigue and poorer nighttime sleep and performance.
The effect of exercise seemed to be minimal on decreasing fatigue, improving sleep, and improving performance. Exercise is safe and has physiologic benefits for patients undergoing MM treatment and, when combined with epoetin alfa, helped to alleviate anemia.
Although the results might indicate no derived benefit, patients became more fatigued, slept less, and experienced a decline in performance with more treatment. The HBIEP group required fewer red blood cell transfusions to maintain a similar hemoglobin level, less platelet transfusions, and fewer days to collect stem cells. When combined with epoetin alfa therapy, exercise had an effect in decreasing cancer-related anemia and improving cell count recovery after high-dose chemotherapy. These are benefits to patients and the healthcare economy. Cancer rehabilitation exercises may result in improved performance. Having fatigue prior to treatment might predict having fatigue after treatment. Energy conservation measures should be considered with endurance and resistance exercises. Rehabiltation therapy might be needed for deconditioned patients. Exercise should be tailored individually based on the patient's disease stage, presence of bone lesions, and values. The HBIEP may have helped to alleviate anemia, but there is no evidence that HBIEP combining muscle strengthening and aerobic walking exercises decreases fatigue.
Cormie, P., Galvao, D.A., Spry, N., Joseph, D., Chee, R., Taaffe, D.R., . . . Newton, R.U. (2015). Can supervised exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: A randomised controlled trial. BJU International, 115, 256–266.
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.
Randomized controlled trial
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.
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.
Do, J., Cho, Y., & Jeon, J. (2015). Effects of a 4-week multimodal rehabilitation program on quality of life, cardiopulmonary function, and fatigue in breast cancer patients. Journal of Breast Cancer, 18, 87–96.
To examine effects of a rehabilitation program
Patients were randomly assigned to an early exercise group or a delayed exercise group. Participants attended rehabilitation sessions five times per week for four weeks. Sessions involved the use of upper and lower extremity stretching, aerobic, and strengthening exercises. During weeks 1–4, the early exercise group participated, and during weeks 4–8, the delayed group participated. Patients were evaluated at baseline and at two, four, six, and eight weeks.
Randomized, parallel group trial with repeated measures
Patients in both groups showed significant improvements in all measures except body image (p < 0.001). The greatest improvements were shown during the period of time that individuals were participating in the exercise sessions in both groups. There was no significant difference between groups.
The exercise combinations used here were effective in reducing fatigue and improving quality of life among participants
The findings of this study add to the already extensive body of evidence that various forms of exercise are beneficial to reduce fatigue in patients with cancer. This study showed effects specifically during the time in which participants were exercising, suggesting the need for ongoing involvement in activity to maintain effectiveness
Ergun, M., Eyigor, S., Karaca, B., Kisim, A., & Uslu, R. (2013). Effects of exercise on angiogenesis and apoptosis-related molecules, quality of life, fatigue and depression in breast cancer patients. European Journal of Cancer Care, 22, 626–637.
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.
PHASE OF CARE: Transition phase after active treatment
Prospective, randomized controlled study
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.
Nurses encouraging patients with breast cancer to stay physically active and adopt a moderate exercise program is important to improve quality of life and help with symptoms of depression.
Eyigor, S., Karapolat, H., Yesil, H., Uslu, R., & Durmaz, B. (2010). Effects of Pilates exercises on functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer patients: a randomized controlled study. European Journal of Physical and Rehabilitation Medicine, 46, 481–487.
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 phase of care was late effects and survivorship.
This was a prospective, randomized two-group, pre-/post study.
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.
This study provides some evidence that exercise can be of benefit to patients in managing depression. The study has multiple limitations.
Galiano-Castillo, N., Cantarero-Villanueva, I., Fernandez-Lao, C., Ariza-Garcia, A., Diaz-Rodriguez, L., Del-Moral-Avila, R., & Arroyo-Morales, M. (2016). Telehealth system: A randomized controlled trial evaluating the impact of an internet-based exercise intervention on quality of life, pain, muscle strength, and fatigue in breast cancer survivors. Cancer. Advance online publication.
To evaluate the effectiveness of a the telehealth-delivered exercise intervention on symptoms among breast cancer survivors
Patients were randomized to the telehealth intervention or usual care. After baseline assessment, those in the study group received instructions on how to access the private area of the system. The intervention consisted of three sessions per week of exercise following recommendations of the American College of Sports Medicine for cancer survivors. Each session was delivered online. The system allowed participants to send messages and set up video conferencing, participants to write questions or comments, and research staff to comment and monitor performance remotely. Participants received phone calls from research staff if needed. The intervention lasted eight weeks. Usual care patients received basic written recommendations for exercise. After six months, they were offered the opportunity to participate in the telehealth program. Assessments were done at baseline, at completion, and at six months.
After the intervention, the telehealth group reported lower pain severity (p = 0.001) and interference (p = 0.045). The telehealth group reported improved total fatigue perception compared to controls (p = 0.001). This improvement was maintained at the six month follow-up (ES d = –0.75, p = 0.002). Adherence rate for exercise sessions was 93.9%. Muscle strength and quality of life (QOL) were also improved in the telehealth group compared to controls. There were no technical issues or adverse effects of the intervention observed.
An online exercise and interaction approach was effective in reducing pain and fatigue and improving QOL and muscle strength. The program had good patient adherence.
The online delivery of an interactive exercise intervention was shown to be effective. An Internet-based intervention may be a useful alternative to traditional approaches to deliver such interventions, particularly in the setting of barriers such as distance and time. The comparative costs for staff time to deliver and maintain this type of intervention need to be evaluated.
Gokal, K., Wallis, D., Ahmed, S., Boiangiu, I., Kancherla, K., & Munir, F. (2016). Effects of a self-managed home-based walking intervention on psychosocial health outcomes for breast cancer patients receiving chemotherapy: A randomised controlled trial. Supportive Care in Cancer, 24, 1139–1166.
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.
PHASE OF CARE: Active antitumor treatment
Randomized, controlled trial
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.
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.
Hayes, S. C., Rye, S., DiSipio, T., Yates, P., Bashford, J., Pyke, C., . . . Eakin, E. (2013). Exercise for health: a randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer. Breast Cancer Research and Treatment, 137, 175–186.
To evaluate two modes of delivery of an exercise intervention: provided either face-to-face or via the telephone.
Women were randomized to one of three groups: face-to-face exercise, telephone exercise intervention, or usual care. For those in the exercise interventions, the intervention involved 16 sessions, starting weekly and tapering to monthly contact after four months. The exercise prescription was provided in sessions to progress to exercising 45 minutes at least four days per week, incorporating both aerobic and strength-based exercise. Assessments were performed at baseline and six weeks, six months, and 12 months postsurgery.
Patients were undegoing the active antitumor treatment phase of care.
This was a single-blind, randomized, controlled, longitudinal study.
Upper body function and adverse effects, such as menopausal symptoms, pain, anxiety, and depression, improved over time for all patients, with no differences between groups. The adherence rate was 88% in the face-to-face exercise group and 81% in the telephonic intervention group. Patients in both exercise intervention groups showed greater improvement in fatigue symptoms over time (p = 0.032). At the end of the study, fatigue scores improved by 4.9 points in the face-to-face intervention and by 6.8 points in the telephonic group. In the usual care group, fatigue initially got worse; however, scores improved by 4.6 points by 12 months. Sixty-six percent of those in the usual care group also participated in at least 180 minutes of physical activity per week and had an increased level of activity from baseline. Quality of life improved significantly more in the intervention groups over time (p = 0.03)
Findings suggested that delivery of an exercise prescription and instruction via the telephone can be an effective method of delivering an exercise intervention for women with breast cancer. Results of this study support those of others demonstrating improvement in symptoms in all patients over time, but significantly greater improvement in fatigue with exercise interventions.
Findings suggested that providing an exercise prescription might be an effective way to engage patients in exercise, which can reduce symptoms of fatigue. This study demonstrated that providing an exercise program intervention via telephone contact can be as effective as engaging patients in a face-to-face intervention. This suggests that telephonic contact to teach and motivate patients to exercise may be an effective and practical way to deliver an intervention.
Hoffman, A. J., Brintnall, R. A., Brown, J. K., Eye, A. v., Jones, L. W., Alderink, G., . . . Vanotteren, G. M. (2013). Too sick not to exercise: using a 6-week, home-based exercise intervention for cancer-related fatigue self-management for postsurgical non-small cell lung cancer patients. Cancer Nursing, 36, 175–188.
To evaluate the feasibility, safety, acceptability, and effects of a home-based exercise intervention.
Patients were screened for inclusion, and baseline measures were obtained prior to surgery. Each patient was assigned a primary nurse for the duration of the study to ensure continuity of care. Prior to surgery, participants were taught approaches to increase self-efficacy in self-management of fatigue and were prepared to participate in the exercise intervention after surgery. Within three days of hospital discharge, patients were contacted by telephone and screened for readiness to start exercise. When ready, a home visit was scheduled to set up the exercise equipment (the Nintendo Wii Fit Plus), the particpant was educated in the exercise intervention, and teaching for self-management was reinforced. The exercise intervention provided a virtual reality scenario for walking. After week 2, another home visit was performed, and telephone contacts were made at three and six weeks. Patients completed study tools at the end of six weeks via mail.
Patients were undergoing the active antitumor treatment phase of care.
This was a prospective, single-group, feasibility trial.
Mean adherence to the exercise intervention was 96.6% (range 90%–100%). Participants reported a high level of satisfaction with the exercise intervention. Overall decline in fatigue was seen from postsurgery to the end of the study. All participants stated that the intervention helped them to manage their fatigue. Fifty percent of those approached for participation consented and completed the study.
Use of the Nintendo Wii Fit Plus sytem for a home-based exercise intervention was shown to be feasible and effective in helping patients self-manage fatigue in this small study.
Findings suggested that use of home virtual reality exercise programs, such as the Nintendo Wii Fit Plus system, can be a feasible and effective way to promote exercise for the self-management of cancer-related fatigue.
Hoffman, A. J., Brintnall, R. A., Brown, J. K., von Eye, A., Jones, L. W., Alderink, G., . . . Vanotteren, G. M. (2014). Virtual reality bringing a new reality to postthoracotomy lung cancer patients via a home-based exercise intervention targeting fatigue while undergoing adjuvant treatment. Cancer Nursing, 37, 23–33.
To explore the efficacy of a virtual reality home-based exercise program for managing fatigue during adjuvant therapy in patients with postthoracotomy lung cancer.
Patients were initially provided self-management education for fatigue and a Nintendo Wii system for walking and balance exercise in the home. Nurses initiated the program in a home visit, performed follow-up at two weeks, and contacted patients via telephone for reinforcement at three and six weeks in the initial study. This report involved extension of the initial study for an additional 10 weeks while patients were receiving adjuvant therapy. Patients wore a pedometer to record the number of steps per day and were to use the program five days per week.
Patients were undergoing the active antitumor treatment phase of care.
This was a prospective trial.
Adherence to the exercise protocol declined slightly from the previous six-week study to an overall adherence of 87.6% (range 59%–100%). All patients reported unmanaged symptoms unrelated to the exercise at some point in the 10 weeks. Fatigue scores increased slightly from weeks 6 to 14 and then declined further. Self-efficacy for walking and self-management were relatively stable. There was high variability in the average walking steps per day from the pedometers.
Results suggested continued feasibility and overall efficacy of the virtual reality home-based exercise and balance program tested. Findings showed that, over longer periods of time, program adherence declined and was more variable. Some of this variability in exercise adherence and fatigue scores may be associated with periods of adjuvant chemotherapy and radiation therapy.
The use of a home virtual reality–based approach to facilitate exercise among patients with cancer is a promising approach for self-management of fatigue. Larger well-designed research using this approach is warranted.
Hoffman, A.J., Brintnall, R.A., Given, B.A., von Eye, A., Jones, L.W., & Brown, J.K. (2016). Using perceived self-efficacy to improve fatigue and fatigability in postsurgical lung cancer patients: A pilot randomized controlled trial. Cancer Nursing, 40, 1–12.
To design and test the feasibility and acceptability of a postsurgical intervention with exercise for patients with non-small cell lung cancer to promote perceived self-efficacy for fatigue self-management targeting cancer-related fatigue (CRF) severity and its associated fatigability
Participants performed warm-up exercises designed for the patient population. Wii walking was self-paced and comfortable for participants with the Wii exercise equipment, creating a virtual environment in a town of happy people providing encouragement to continue. Patients started walking five minutes each day for five days during week 1 and increased by five-minute intervals per day until a goal of 30 minutes per day of Wii walking was reached by week 6. The nurse assessed each participant’s readiness to advance the walking prescription. Participants also completed balance exercises five days a week from weeks 1 to 6 from a menu of predetermined Wii balance exercises, which used a gaming format. Data were recorded in the participants' daily diaries and confirmed by research staff as recorded in the Wii Fit Plus.
Two-arm, randomized, controlled trial to compare the impact of a six-week rehabilitative CRF self-management exercise intervention post-surgical hospital discharge. The control group used a Wii-based walking and balance home program at home.
Feasibility: Rates of recruitment, adherence, retention, and monitoring of adverse events
Acceptability: 15-item acceptability questionnaire developed by the researchers
Feasibility and acceptability: Recruitment, vulnerable population, adherence, and acceptability goals were exceeded. No adverse events were reported.
Efficacy: At week 6, interval scores for CRF, CRF self-management, walking, balance, and fatigability were significantly different (p < 0.001) between the intervention group and control group. Participants exceeded minimum walking-balance exercise behaviors during the six-week study period. Functional performance decreased postsurgery in both the control and intervention groups. Improvement occurred in weeks 1–6 for both groups but improved more slowly in the control group versus the intervention group.
A home- and Wii-based exercise and balance program for patients with lung cancer postsurgery is a feasible, acceptable, safe, and effective method to improve fatigue and fatigability in this patient population.
Early rehabilitation exercise and balance interventions for patients undergoing surgery for non-small cell lung cancer are feasible, acceptable, and safe. Additional research is needed to determine factors to enhance adherence to exercise and balance interventions beyond the immediate postsurgical period (six weeks) and to determine their effects on prognosis and functional (physical and mental) capacity.
Hoffman, A.J., Brintnall, R.A., von Eye, A., Jones, L.W., Alderink, G., Patzelt, L.H., & Brown, J.K. (2014). Home-based exercise: Promising rehabilitation for symptom relief, improved functional status and quality of life for post-surgical lung cancer patients. Journal of Thoracic Disease, 6, 632–640.
To describe the effects of a postsurgical home exercise intervention implemented immediately after hospital discharge on cancer-related fatigue (CRF), other symptoms, functional status, and quality of life (QOL) in individuals with non-small cell lung cancer (NSCLC)
Patient education in a hospital regarding exercise was followed by a home visit from a nurse educated on warm-up exercises, light intensity exercise such as walking, and balance exercises with a Wii. Patients were instructed to increase walking to goal of 30 minutes a day in week 6.
Cancer-related fatigue decreased below presurgery levels after six weeks of exercise intervention.
Home-based exercise may reduce cancer-related fatigue in patients with NSCLC postsurgery.
Hsieh, C. C., Sprod, L. K., Hydock, D. S., Carter, S. D., Hayward, R., & Schneider, C. M. (2008). Effects of a supervised exercise intervention on recovery from treatment regimens in breast cancer survivors. Oncology Nursing Forum, 35, 909–915.
To investigate the effects of supervised exercise training on cardiopulmonary function and fatigue in cancer survivors undergoing various clinical treatments.
Patients were divided into four groups based on specific type of treatment: surgery alone (n = 22); surgery and chemotherapy (n = 30); surgery and radiation (n = 17); and surgery, chemotherapy, and radiation (n = 27). Following comprehensive screening and medical examination, cardiovascular endurance, pulmonary function, and fatigue were assessed. Individualized exercise prescriptions and six-month exercise interventions were developed. Participants attended supervised exercise sessions two to three days per week for six months.
This was a pre-/posttest quasiexperimental study.
Cardiopulmonary function (predicted maximal oxygen consumption and time on treadmill) significantly increased in all groups after exercise training. In addition, resting heart rate and forced vital capacity significantly improved in those undergoing surgery, chemotherapy, and radiation. Psychologically, the exercise intervention resulted in significant reductions in behavioral, affective, sensory, cognitive, mood, and total fatigue scale scores in all three groups who received treatment with surgery. The breast cancer survivors in the surgery alone group showed significant reductions in behavioral, affective, and total fatigue scale scores but not in sensory, cognitive, and mood fatigue scale scores.
The results suggested that moderate-intensity individualized exercise maintains or improves cardiopulmonary function with concomitant reductions in fatigue, regardless of treatment type. Moreover, cancer survivors receiving combination chemotherapy and radiotherapy following surgery appear to benefit to a greater extent as a result of an individualized exercise intervention.
Symptom management recommendations should be given to cancer survivors concerning the effectiveness of exercise throughout the cancer continuum, and the importance of participating in a cancer rehabilitation exercise program should be emphasized.
Husebo, A.M., Dyrstad, S.M., Mjaaland, I., Soreide, J.A., & Bru, E. (2014). Effects of scheduled exercise on cancer-related fatigue in women with early breast cancer. The Scientific World Journal, 2014, 271828.
To compare the effects of a scheduled, home-based exercise intervention to the effects of advising patients to exercise on fatigue, physical fitness, and physical activity level
Patients who had surgical treatment and were receiving adjuvant chemotherapy for breast cancer were randomly assigned to the scheduled exercise or control comparison groups. The intervention combined resistance and aerobic exercise with resistance bands and strength training three times per week along with 30 minutes of brisk walking daily. Those in the experimental group received motivational phone calls every two weeks. Patients in the control group were advised to continue their regular activity levels and had one follow-up phone call. Study measures were obtained at baseline, prior to chemotherapy, 8–24 weeks at the end of chemotherapy, and about six months after completing chemotherapy.
Randomized controlled trial (RCT)
Fatigue scores increased significantly from baseline to the end of chemotherapy for all patients (p = .003) with no difference between groups. Fatigue returned to baseline levels after the end of chemotherapy with no difference between groups. A similar pattern was shown for all patients in physical fitness. There were no differences between groups in mean levels of physical activity per week, though there was a slight trend toward more exercise in the intervention group.
There were no additional effects of a scheduled home exercise program to reduce fatigue compared to individuals who were simply encouraged to maintain appropriate exercise levels.
Study findings show a pattern of fatigue such that fatigue increases significantly during chemotherapy and then declines after the end of treatment. Both groups of patients in this study performed exercise at general recommended levels, which likely accounts for the lack of differences in fatigue found. These results suggest that patients do not necessarily need to have scheduled approaches to exercise, and that encouraging patients to maintain at least moderate exercise levels can be effective. Nurses can encourage patients to maintain exercise and choose approaches that they prefer in order to maintain motivation for regular activity.
Jensen, W., Baumann, F.T., Stein, A., Bloch, W., Bokemeyer, C., de Wit, M., & Oechsle, K. (2014). Exercise training in patients with advanced gastrointestinal cancer undergoing palliative chemotherapy: A pilot study. Supportive Care in Cancer, 22, 1797–1806.
To investigate the feasibility of two different training programs including resistance and aerobic exercise in a small cohort of patients with advanced gastrointestinal cancer undergoing palliative chemotherapy; the study aimed to investigate potential effects of these programs on quality of life according to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) as well as on physical performance, biological parameters, and activities of daily living
Two-group randomized trial
The postinterventional fatigue level decreased in both subgroups, suggesting that both programs seem to have positive effects on fatigue in patients undergoing palliative chemotherapy.
Further prospective, controlled trials with larger sample sizes are needed to adequately analyze the efficacy of these programs in patients with advanced gastrointestinal cancer currently undergoing palliative chemotherapy.
Kampshoff, C.S., Chinapaw, M.J., Brug, J., Twisk, J.W., Schep, G., Nijziel, M.R., . . . Buffart, L.M. (2015). Randomized controlled trial of the effects of high intensity and low-to-moderate intensity exercise on physical fitness and fatigue in cancer survivors: Results of the Resistance and Endurance Exercise After ChemoTherapy (REACT) study. BMC Medicine, 13, 275-015-0513-2.
To evaluate the effectiveness of a high-intensity (HI) and low-to-moderate–intensity (LMI) resistance and endurance exercise program compared with a wait-list control (WLC) group on physical fitness and fatigue in a mixed group of cancer survivors who completed primary cancer treatment, including chemotherapy
The HI (β = 2.2, 95% confidence interval [CI] [1.2, 3.1]) and LMI (β = 1.3, 95% CI [0.3, 2.3]) groups showed significantly larger improvements in peak VO2 compared to the WLC group. Improvement in peak VO2 was larger for the HI group than the LMI group (β = 0.9, 95% CI [−0.1, 1.9]), but the difference was not statistically significant (p = 0.08). Relative improvements in peak VO2 were 20% and 15% for the HI and LMI groups, respectively, which is in line with the relative improvements in healthy adults after a 12-week exercise program. No significant intervention effects were found for grip strength and 30-second chair-stand tests. Compared to the WLC group, both the HI and LMI groups showed significant improvements in general fatigue (HI: β = −1.3, 95% CI [−2.2, −0.4] and LMI: β = −1.1, 95% CI [−2, −0.2]), physical fatigue (HI: β = −2, 95% CI [−2.9, −1.1] and LMI: β = −1.4, 95% CI [−2.3, −0.5]), and reduced activity (HI: β = −1.1, 95% CI [−1.9, −0.2] and LMI: β = −1.2, 95% CI [−2.1, −0.3]), with no significant differences between both interventions. The HI group showed a beneficial effect on motivation compared to the LMI group (β = −0.8, 95% CI [−1.5, −0.03]) and WLC group (β = −1.2, 95% CI [−1.9, −0.4]), with no significant differences between the LMI and WLC groups. Furthermore, the HI group showed a significant reduction in mental fatigue compared to the WLC group (β = −0.9, 95% CI [−1.7, −0.2]). The effects on peak VO2 were modified by age (HI: βinteraction = −0.2, 95% CI [−0.3, −0.1], p = 0 and LMI: βinteraction = −0.1, 95% CI [−0.2, −0.01], p = 0.03), indicating larger effects for younger participants. No significant interaction effects for gender or diagnosis were found for physical fitness or fatigue.
Supervised HI exercise can be safely recommended to cancer survivors shortly after their completion of cancer treatment. HI and LMI exercise were equally beneficial in counteracting general and physical fatigue.
Advising patients to exercise or referring them to exercise specialists to exercise under supervision is beneficial when possible.
Leach, H.J., Danyluk, J.M., Nishimura, K.C., & Culos-Reed, S.N. (2016). Benefits of 24 versus 12 weeks of exercise and wellness programming for women undergoing treatment for breast cancer. Supportive Care in Cancer, 24, 4597–4606.
Litterini, A. J., & Fieler, V. K. (2008). The change in fatigue, strength, and quality of life following a physical therapist prescribed exercise program for cancer survivors. Rehabilitation Oncology, 26, 11–17.
To determine if there was an improvement in fatigue, strength, and quality of life (QOL) in individuals within one year of treatment for an individualized physical therapist–prescribed exercise intervention.
Cancer survivors participated in an exercise class (one hour two times weekly) that included instruction and supervision in cardiovascular, strength training, and flexibility exercises. Measurement of fatigue, strength, and repetition of prescribed exercises occurred. The individualized exercise program was prescribed by a single therapist and was based on the patient’s medical history, diagnosis, age-related changes, treatment stage, and goals. Flexibility, strength, and balance assessments were conducted, and participants were retested at the conclusion of the program. Patients were encouraged to exercise two times weekly.
This study included a pre- and posttest and a two-tailed t test.
Overall fatigue improved significantly (p = 0.004). Overall lower-extremity anaerobic endurance increased significantly (p = 0.000). Overall nondominant grip strength increased significantly (p = 0.000). Overall QOL improved significantly (p < 0.01). The intervention was well tolerated in all of the diagnostic, stage, and age groups with no adverse events. The 81- to 90-year-old group had the highest completion rate, followed by the 71- to 80-year-old group. Survivors with stage IV disease had statistically significant improvement in lower extremity anaerobic endurance and QOL, whereas survivors of lung cancer had statistically significant reductions in their fatigue.
Virtually all patients with various cancer diagnoses and stages of disease, as well as a wide age range and both genders, can safely participate in and will benefit from a strength training program in terms of less fatigue, improved QOL, and increased strength. Oncology rehabilitation is necessary for survivors of cancer.
Exercise can be performed safely with careful planning. Exercise programs do not need to be restricted to those who are relatively well. Oncology rehabilitation is as necessary for survivors as cardiac rehabilitation. This study is supportive of a comprehensive exercise program.
Litterini, A.J., Fieler, V.K., Cavanaugh, J.T., & Lee, J.Q. (2013). Differential effects of cardiovascular and resistance exercise on functional mobility in individuals with advanced cancer: A randomized trial. Archives of Physical Medicine and Rehabilitation, 94, 2329–2335.
To compare effects of cardiovascular and resistance exercise on functional mobility in people with advanced cancer
Individuals were randomly assigned to either resistance or cardiovascular exercise groups. Exercise sessions were held in a hospital-based fitness facility twice weekly for 10 weeks. Both groups participated in flexibility exercises. Sessions lasted 30–60 minutes and were supervised by oncology-trained exercise specialists. Participants completed the study assessments at baseline and one week after study completion.
On average, participants attended 70% of exercise sessions. SPPB scores improved in all over time (p < .001), but improved slightly more in the cardiovascular group (p = .045). Intent-to-treat analysis did not confirm this difference between groups. Fatigue declined over time in all (p = .05), with no difference between groups. There were no significant changes in pain by group or by time.
Findings show improved functional mobility and reduced fatigue over time. This study did not show a difference associated with the type of exercise provided.
This study suggests that both cardiovascular and resistance exercise can be used in appropriate patients with advanced disease, and findings showed that there were no significant changes in pain or fatigue with these interventions.
Mayo, N.E., Moriello, C., Scott, S.C., Dawes, D., Auais, M., & Chasen, M. (2014). Pedometer-facilitated walking intervention shows promising effectiveness for reducing cancer fatigue: A pilot randomized trial. Clinical Rehabilitation, 28, 1198–1209.
To contribute preliminary evidence for the feasibility and potential effectiveness of a structured walking intervention on reducing cancer-related fatigue in order to plan for a full-scale study of effectiveness
The study consisted of an eight-week program with three intervention groups: one with the STEPS (a walking program using a pedometer) during rehabilitation, one with STEPS after rehabilitation, and one group with only the rehabilitation program for people with advanced cancer and a > 4 fatigue level on a Visual Analog Scale (VAS).
A pilot randomized trial. The STEPS program was based on the participants’ current walking status and progressed according to fatigue level.
Instruments chosen to measure fatigue and symptoms of anxiety and depression included the following.
Results demonstrated that the pedometer-facilitated walking intervention adapted to fatigue levels (STEPS program) showed promise as an intervention to decrease cancer-related fatigue.
Compared to rehabilitation alone, the eight-week adaptive walking intervention reduced fatigue and improved physical function and well-being over a 16-week period and was sustained to six months.
Walking intervention is associated with a trend toward less fatigue; however, this study needs replication in the advanced cancer population. Effectiveness not established.
Naraphong, W., Lane, A., Schafer, J., Whitmer, K., & Wilson, B.R. (2015). Exercise intervention for fatigue‐related symptoms in Thai women with breast cancer: A pilot study. Nursing and Health Sciences, 17, 33–41.
To test the feasibility and provide a preliminary evaluation of the effects of an exercise program for fatigue, sleep disturbance, mood, and symptoms in patients with cancer
Participants randomly were assigned to the treatment or control group. Patients in the control group received usual care, an educational booklet and DVD, and weekly telephone calls. Patients in the experimental group received initial one-on-one training sessions and were given exercise program kits containing written instructions, a pedometer, and an exercise log. Patients were to choose activities that provided low to moderate intensity exercise and perform these daily for at least 20 minutes. Participants also were asked to walk three to five days per week. Weekly phone calls to the experimental group were made to monitor participation and make adjustments to the walking prescription as needed. The program was planned for 12 weeks.
Randomized, controlled trial
Patients in the experimental group demonstrated a nonsignificant improvement in fatigue (d = -0.48). There were no significant group by time effects for other measures. Data were not collected after week 10 because of loss of subject follow-up.
The findings of this study support the known effect of exercise on cancer-related fatigue; however, the small sample in this study limits the strength of these findings.
This study provides minimal additional support for the benefits of exercise among women with breast cancer during active treatment. Exercise has been shown to be effective in reducing multiple symptoms, and nurses should encourage patients to be active.
Oechsle, K., Aslan, Z., Suesse, Y., Jensen, W., Bokemeyer, C., & de Wit, M. (2014). Multimodal exercise training during myeloablative chemotherapy: A prospective randomized pilot trial. Supportive Care in Cancer, 22, 63–69.
To evaluate the effects of combined aerobic and strength exercise on physical performance and symptoms in patients who are hospitalized while receiving myeloablative therapy
Patients were randomly assigned to the exercise intervention or usual care. Usual care patients were allowed to undergo physical therapy as medically indicated according to standard practice. The intervention group included ergometer endurance training for 10–20 minutes and resistance exercises for main muscle groups for 20 minutes. Exercises were done five days per week during the entire hospital stay, and training intensity was individually adjusted based on spiroergometry at study entry. Training was suspended if patients experienced fever, infection, thrombocytopenia (platelet < 20,000) cardiac arrhythmia, or life-threatening clinical complications. Neutropenic patients wore masks when they left their rooms. Follow-up assessment was done at 12 months.
Randomized controlled trial
The median duration of exercise training was 15 days with the median hospital stay being 21 days. The control group’s lung function as measured by oxygen consumption increased. Treatment group oxygen consumption and expiratory minute ventilation volume was significantly higher at the end of the study compared to controls (p < .05). EORTC physical functioning was significantly higher in the treatment group compared to controls (p = .04). There were no other differences in symptoms between groups. The treatment group complained of fatigue for fewer days than those in the control group (p = .04). Self-report of overall condition at 12 months indicated no significant difference between groups. There were no exercise-related adverse events.
This study demonstrated that exercise training during myeloablative chemotherapy is feasible, well-tolerated, and may improve physical performance during treatment.
Findings suggest that exercise training during hospitalization for myeloablative chemotherapy is generally well-tolerated. The study was underpowered to show any effect on symptoms of fatigue; however, exercise training was associated with improved physical performance measures. Nurses can advocate for exercise programs for this group of patients.
Oldervoll, L. M., Loge, J. H., Lydersen, S., Paltiel, H., Asp, M. B., Nygaard, U. V., . . . Kaasa, S. (2011). Physical exercise for cancer patients with advanced disease: a randomized controlled trial. The Oncologist, 16, 1648–1657.
To test the hypothesis that physical exercise reduces fatigue and improves physical performance in patients with advanced cancer.
Patients were randomly assigned to physical exercise (PE) or usual care (UC) groups. The PE group had two exercise sessions per week that lasted 50 to 60 minutes after a 10-minute warm-up. Exercise was performed in groups of two to eight and was supervised by a physiotherapist. Sessions included circuit training and stretching/relaxation. Focus was on muscle strength, balance, and aerobic endurance. Pre- and postintervention were performed at baseline at immediately after the intervention period.
This was a randomized, controlled trial.
Median survival times for all included patients were 11.1 months in the PE group and 12.3 months in the UC group. In the PE group, exercise adherence was 69% on average (11 of 16 sessions). Regression analysis showed no significant between-group effect in physical fatigue (estimated mean difference = -0.3; confidence interval [-1, 1.0]; p = 0.62). There were significant differences between groups in shuttle walk test (p = 0.008) and grip strength (p = 0.01) results. There were no apparent effects of the exercise intervention on mental or total fatigue, including mental and physical fatigue.
Findings showed that such an exercise program is feasible in patients with advanced disease and limited life expectancy. Findings did not provide support for the hypothesis that exercise reduces fatigue in this group of patients.
Exercise programs are feasible for patients with advanced disease. Study findings did not show that the intervention improved the symptom of fatigue, but it did improve some physical performance.
Owens, B., Jackson, M., & Berndt, A. (2009). Pilot study of a structured aerobic exercise program for Hispanic women during treatment for early-stage breast cancer. Medsurg Nursing, 18, 23–29.
To evaluate the feasibility of a structured aerobic exercise intervention during treatment in a predominately Hispanic population of women.
A convenience sample of women who met the criteria at the time of their outpatient appointments were included. Patients were weighed and measured and completed tests regarding side effect burden and fatigue. Patients were given a sports outlet gift card for walking shoes and a six-month membership to the community health club. They were instructed to make an appointment with a physical therapist and a community health club for exercise. The research intervention was exercise three times a week for one hour with a goal to continue for six months. Exercises involved 10 minutes of warm-ups, 30 minutes of resistance training to improve muscle tone, 20 minutes of brisk walking to improve heart strength, and 10 minutes of cool-down. Assessments occurred at three and six months.
The study used a mixed qualitative and quantitative, repeated measure, quasiexperimental design.
Fatigue was significantly correlated with age (p = 0.05), fasting blood glucose (p = 0.05), and weight gain (p = 0.01). Mean weight gain was 15 lb. No changes were seen in fatigue. Qualitative analysis identified physical limitations, family responsibilities, lack of transportation, return to work, and lack of habit development as factors that influenced adherence to the exercise program. Sources of support for adherence included family, peers, employer, and health care providers. Several patients indicated that they preferred to exercise in an area that had only women. Self-report of exercise adherence was 66% at the first follow-up and 7% at the study conclusion.
Social, physical, and psychosocial factors influenced the women’s exercise adoptions. The provision of a gift card and recommendations did not have an effect on fatigue in these individuals.
A structured exercise program appears to facilitate recovery from cancer. These Hispanic women had difficulty setting aside time to exercise. Support from health care providers was identified as a facilitator of adherence to exercise, suggesting that encouragement to exercise may be helpful. Concrete barriers, such as lack of transportation and dealing with family responsibilities, need to be addressed if patients are to be able to participate in exercise programs. Interventions need to fit lifestyle needs and preferences of the individual.
Payne, J. K., Held, J., Thorpe, J., & Shaw, H. (2008). Effect of exercise on biomarkers, fatigue, sleep disturbances, and depressive symptoms in older women with breast cancer receiving hormonal therapy. Oncology Nursing Forum, 35, 635–642.
The primary aim was to determine if a home-based walking exercise program is more effective than usual care in reducing fatigue, sleep disturbances, and depressive symptoms in older women receiving hormonal treatment for breast cancer as a feasibility study. The secondary aim was to examine the extent to which symptoms and biomarkers of cortisol, serotonin, interleukin-6 (IL-6), and bilirubin are related and change over time.
Participants were recruited from breast cancer clinics and randomized to usual care or a prescribed walking exercise program. Participants were followed over a 14-week period. At an initial clinic visit, demographic data were collected and participants completed study instruments. Study instruments were again completed two weeks later via mail, 12 weeks after baseline at a clinic visit, and at 14 weeks via mail. Cortisol, serotonin, IL-6, and bilirubin were collected at the initial clinic visit and at 3 months. Blood samples were carefully handled to ensure appropriate handling for radioimmunoassay and other laboratory testing. At visit 1 and at 12 weeks, patients were asked to wear a sleep watch actigraph for 72 continuous hours. A study coordinator or investigator explained the walking exercise intervention, which was a moderate walking activity for 20 minutes, four times a week. Participants in the exercise group were shown how to use a pedometer that was provided to them but were not required to use it. Participants were given a log to record the duration and frequency of walking activity.
Participants were included if they
Individuals were excluded if they had a history of neurologic deficits or mental illness in the past year or had neuromuscular deficits that would contraindicate use of a walking program.
This was a longitudinal, repeated measures, randomized, clinical trial.
Levels of fatigue over time and between groups were not significantly different. PSQI scores decreased significantly over time in the exercise group (p = 0.007) and did not change in the usual care controls. Actigraphy analysis after 12 weeks showed a shorter wake time (p = 0.02), sleep time (p = 0.05), and less movement during sleep (p = 0.002) in the exercise group. There was no difference between groups in sleep efficiency, the ratio of total sleep time while in bed. There were no differences in cortisol levels over time or between groups. ANOVA showed a significant difference between groups and across time in serotonin levels, with an intervention effect of exercise (p = 0.009). Serotonin levels were correlated with actual wake time, but correlations were not statistically significant. There were no significant differences in IL-6 or bilirubin between groups or over time. Bilirubin levels in both groups were at or above the upper limit of normal range. Correlation analysis for cortisol, IL-6, and bilirubin were not reported. There were no differences between groups or over time in depressive symptoms. Actual patient adherence to prescribed exercise was not reported. Authors reported that the walking exercise intervention was accepted in this population.
Home-based walking intervention appears to be feasible and acceptable to older women receiving hormonal therapy for breast cancer. The decline in PSQI scores in the exercise group suggests that this type of intervention may be helpful in improving sleep quality in this population. Effects of the exercise intervention on biomarkers are unclear. There was no observed effect of the exercise intervention on fatigue.
A walking exercise program may be helpful to patients receiving hormonal treatment for breast cancer, but actual effects on fatigue, sleep, and depressive symptoms are unclear.
Rajotte, E. J., Yi, J. C., Baker, K. S., Gregerson, L., Leiserowitz, A., & Syrjala, K. L. (2012). Community-based exercise program effectiveness and safety for cancer survivors. Journal of Cancer Survivorship, 6, 219–228.
To determine the effectiveness and safety of a disseminated community-based exercise program for cancer survivors who completed cancer treatment.
Twice weekly over a period of 12 weeks, YMCA personal trainers supervised groups of seven to 14 study participants during 90-minute exercise sessions at 13 YMCA sites. Study measures were administered at baseline and after the 12-week exercise program. The standardized protocol included aerobic warm-up (10 minutes), resistance training (50 minutes), and community building time (e.g., sharing personal experiences, didactic and experiential training in breathing, relaxation, stress management, and nutrition). Precautions or contraindicated movements were noted for each participant, and resistance training was individualized. YMCA personal trainers had at least one year of personal training experience and received a specialized 16-hour group training by a cancer rehabilitation physical therapist. Additional training to address emotional issues for participants and trainers was provided by a licensed clinical psychologist with expertise in cancer survivorship. Participants and immediate family received access to YMCA facility branches and were encouraged to exercise outside of the sessions.
Patients were undergoing long-term follow-up postcancer treatment.
This was a prospective pre/post (nonrandomized) study design.
Validated patient-reported outcomes measures included
The study indicated that the community-based exercise program has important beneficial effects on physiologic, symptom, and quality of life health outcomes for cancer survivors and is safe to implement. Findings suggested that the program is helpful for improving fatigue, insomnia, physical function, overall musculoskeletal symptoms, mental health, social support, and physical activity in cancer survivors. Average baseline insomnia ratings of 1.63 (SD = 0.93) differed significantly from postintervention ratings of 1.43 (SD = 0.85) (p < 0.001). Additionally, the exercise program indicated notable improvements in physiologic measures (blood pressure, upper and lower body strength, walking endurance, and flexibility).
Community-based exercise groups for cancer survivors of mixed diagnoses and ages, who have completed active treatment, have physiologic and psychosocial benefits and appear to be safe. Because the participants self-selected to be part of the study and were screened for their ability to participate, findings cannot be generalized to the larger cancer survivor population.
Survivors may benefit from participating in a community-based exercise program tailored to meet their individual needs as a survivor; however, exercise programs should be preceded by consultation with health care providers. Additional nursing research is needed to determine the effect of resistance training and other exercise protocols in more diverse cancer survivor populations.
Reis, D., Walsh, M.E., Young-McCaughan, S., & Jones, T. (2013). Effects of Nia exercise in women receiving radiation therapy for breast cancer [Online exclusive]. Oncology Nursing Forum, 40, E374–E381.
To compare a 12-week Nia-based exercise program to usual care on cancer-related fatigue, quality of life, aerobic capacity, and shoulder flexibility in women receiving radiation therapy for breast cancer
Participants randomized to the intervention were instructed in Nia techniques as well as given a DVD for home use. They were instructed to perform the exercises for 20–60 minutes at least three times a week and maintain a log. The control group were instructed to maintain their usual exercise regime and maintain a log. The principle investigator met individually with both groups at the beginning and at 6 and 12 weeks. At the end of the 12 weeks, control group participants were given the opportunity to take part in a Nia group.
Both groups reported increased fatigue at week 6 (completing therapy) with improvement at week 12. Repeated measures of covariance noted statistically significant differences in the Nia and control groups between weeks 6 and 12; the Nia group had a greater increase in FACIT-F scores (p = 0.05).
Sample size and study limitations make it difficult to draw conclusions; however, Nia exercise can be beneficial to women with breast cancer receiving radiation therapy to reduce cancer-related fatigue.
Nia exercise can be beneficial to women with breast cancer receiving radiation therapy, particularly those who favor a holistic or complementary approach.
Rogers, L.Q., Anton, P.M., Fogleman, A., Hopkins-Price, P., Verhulst, S., Rao, K., . . . Robbins, K.T. (2013). Pilot, randomized trial of resistance exercise during radiation therapy for head and neck cancer. Head & Neck, 35, 1178–1188.
To determine the feasibility of conducting a randomized, controlled trial of exercise in patients with head and neck cancer receiving radiation therapy
Patients were randomly assigned to the intervention group or a control group. Control patients received only nutritional counseling from a registered dietician. Patients in the intervention group received nutritional counseling plus the exercise intervention. Exercise included twice-weekly, supervised exercise sessions for six weeks followed by six weeks of twice-weekly home-based sessions supported by weekly telephone counseling, written materials, and a DVD.
Pilot randomized, controlled trial
Over the first six weeks, fatigue increased in both groups with no significant difference between groups. Between weeks 6 and 12, fatigue declined in both groups but showed a greater decline in the intervention group. Exercise adherence was 87% in the first six weeks and 57% weeks 7–12.
Less than one half of patients offered the study consented to participate, suggesting low interest and limited feasibility. The final sample size was very small, so no firm conclusions about effects can be drawn.
This study provides minimal support for the feasibility and efficacy of implementing an exercise intervention among patients with head and neck cancer undergoing radiation therapy. These findings are not in concert with findings from other similar studies.
Rogers, L.Q., Vicari, S., Trammell, R., Hopkins-Price, P., Fogleman, A., Spenner, A., . . . Verhulst, S. (2013). Biobehavioral factors mediate exercise effects on fatigue in breast cancer survivors. Medicine and Science in Sports and Exercise, 46, 1077-1088.
To examine mediators of fatigue effects of an exercise intervention
Patients were randomized to an exercise intervention or control group. The intervention combined walking and strength training with resistance bands. Walking was gradually increased by week 9 to 40 minute sessions of moderate intensity, four times per week, and participants attended 26 individual exercise sessions supervised by an exercise specialist. Resistance training was two times per week in the last 10 weeks of the study with the supervised aerobic walking sessions. Resistance was advanced as tolerated. Six group meetings with a psychologist also were provided every other week to provide support and improve exercise adherence. The control group was instructed to maintain usual exercise behavior.
Adherence to supervised exercise sessions was 91%–93%. Exercise goals for at home were met in 65% of the weeks during the study. General fatigue declined significantly in the intervention group compared to controls (d = –0.49, p < .01). Fatigue interference (d = –0.38, NS) declined in the intervention group. Fatigue intensity increased in the intervention group and declined in controls (d = 0.3, NS). There were no significant differences in depression. Anxiety declined in the intervention group (d = –0.54, p < .05). Sleep/wake dysfunction declined in both groups over time, but more in the intervention group (d = –0.054, p < .01). Positive effects in fatigue intensity were significantly mediated by IL-6, IL-10, IL-6:IL-10, and TNF alpha:IL-10.
The exercise program used here showed a small to medium non-significant effect on fatigue intensity and interference, as measured in this study. Effects of exercise on fatigue were mediated by some cytokine system responses.
Although this study has limitations, findings do provide additional support for positive effects of exercise on cancer-related fatigue among cancer survivors. Findings here show evidence of potential effects through the cytokine system. Adherence to the exercise program in this study was very good, using a support group interaction and the combination of supervised exercise sessions and home-based exercise recommendations. This type of additional support may help many patients adhere to an exercise program.
Saarto, T., Penttinen, H. M., Sievänen, H., Kellokumpu-Lehtinen, P. L., Hakamies-Blomqvist, L., Nikander, R., . . . Luoma, M. L. (2012). Effectiveness of a 12-month exercise program on physical performance and quality of life of breast cancer survivors. Anticancer Research, 32, 3875–3884.
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.
This was a randomized, controlled trial.
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 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.
Schmidt, M.E., Wiskemann, J., Armbrust, P., Schneeweiss, A., Ulrich, C.M., & Steindorf, K. (2015). Effects of resistance exercise on fatigue and quality of life in breast cancer patients undergoing adjuvant chemotherapy: A randomized controlled trial. International Journal of Cancer, 137, 471–480.
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.
Randomized, controlled trial
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.
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.
Schmidt, T., Weisser, B., Jonat, W., Baumann, F. T., & Mundhenke, C. (2012). Gentle strength training in rehabilitation of breast cancer patients compared to conventional therapy. Anticancer Research, 32, 3229–3233.
To evaluate the effect of gentle strength training on endurance and psychological outcomes in patients with breast cancer.
Patients were randomized to the intervention or control study groups. Patients in the control group participated weekly in gymnastic exercises, such as chair or floor exercises with various sports equipment. Those in the intervention group were trained with strength endurance training, according to individualized training plans based on a training load of 50% of one repetition maximum on a weekly basis. Both groups continued the weekly training program for six months. Data were collected at baseline, after three months, and after six months.
Patients were undergoing the transition phase after active treatment.
This was a randomized, two-group prospective study.
There was a significant reduction in BMI in both groups. QOL and fatigue scores showed a significant improvement in both groups at three and six months (p < 0.01). There were no significant differences between groups. The pattern of fatigue change showed decline in both groups by three months. At the six-month time point, the intervention group continued to experience a decline, whereas those in the control group showed increased fatigue, although this level was still below that at baseline.
Both conventional gymnastic exercise and gentle strength training were associated with weight reduction and improvement in fatigue and QOL in women with breast cancer.
Findings suggested that both types of exercise were beneficial to patients with breast cancer. Further research in this area would be beneficial to determine those types of exercise and the timing of exercise related to cancer treatment that are most effective for the prevention and management of fatigue.
Schuler, M.K., Hentschel, L., Kisel, W., Kramer, M., Lenz, F., Hornemann, B., . . . Kroschinsky, F. (2016). Impact of different exercise programs on severe fatigue in patients undergoing anticancer treatment-A randomized controlled trial. Journal of Pain and Symptom Management, 53, 57–66.
To compare partially supervised, structured exercise to standard of care for patients with advanced cancer. The primary outcome was general fatigue.
Patients were randomized into three groups. Group A received treatment as usual; participants in group B were taught a structured, individual sports program; and group C received additional ambulatory physiotherapeutical supervision. Exercises were defined based on expert consensus with physical therapists and physicians. Included as “possible exercises” into a catalog and a patient information sheet. For groups B and C, a physical therapist selected applicable exercises from this catalog. Patients were instructed to complete three sessions of endurance and two sessions of strength each week for 20-30 minutes per session. Patients were contacted at weeks 4 and 8, during which groups B and C could ask specific questions and adherence was encouraged. Patients were then followed up with in person at 12 and 24 weeks.
PHASE OF CARE: Active antitumor treatment
Randomized, controlled trial into three groups
No difference in general fatigue was observed. Significant difference was found with mental fatigue (p = 0.03). Over time, all groups experienced an increase in fitness, with group C experiencing the most improvement.
No effects on fatigue were seen.
This study did not find any effect of interventions. The study was underpowered to identify significant differences between groups.
Steindorf, K., Schmidt, M.E., Klassen, O., Ulrich, C.M., Oelmann, J., Habermann, N., . . . Potthoff, K. (2014). Randomized, controlled trial of resistance training in breast cancer patients receiving adjuvant radiotherapy: Results on cancer-related fatigue and quality of life. Annals of Oncology, 25, 2237–2243.
To evaluate the efficacy of resistance training to treat fatigue
Single, blinded, randomized, controlled trial
This study adds to the already extensive evidence supporting that exercise improves fatigue. This study showed this to be the case for patients receiving radiation therapy treatment and demonstrated that group interaction and attention alone were not responsible for the changes seen by including an attention control group in the study design. Nurses should recommend that patients participate in exercise to combat fatigue during cancer treatment.
Travier, N., Velthuis, M.J., Steins Bisschop, C.N., van den Buijs, B., Monninkhof, E.M., Backx, F., . . . May, A.M. (2015). Effects of an 18-week exercise programme started early during breast cancer treatment: A randomised controlled trial. BMC Medicine, 13, 121.
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.
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.
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.
van Waart, H., Stuiver, M.M., van Harten, W.H., Geleijn, E., Kieffer, J.M., Buffart, L.M., . . . Aaronson, N.K. (2015). Effect of low-intensity physical activity and moderate- to high-intensity physical exercise during adjuvant chemotherapy on physical fitness, fatigue, and chemotherapy completion rates: Results of the PACES randomized clinical trial. Journal of Clinical Oncology, 33, 1918–1927.
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.
Randomized, controlled trial
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
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.
Wenzel, J. A., Griffith, K. A., Shang, J., Thompson, C. B., Hedlin, H., Stewart, K. J., . . . Mock, V. (2013). Impact of a home-based walking intervention on outcomes of sleep quality, emotional distress, and fatigue in patients undergoing treatment for solid tumors. The Oncologist, 18, 476-484.
To evaluate the impact of a home-based walking program on patient symptoms of fatigue, sleep disturbances, and mood.
Patients were randomly assigned to the walking program or a usual care control group. The exercise intervention included a walking prescription based on the American College of Sports Medicine guidelines. The targeted exercise prescription included a brisk 20- to 30-minute walk with five-minute warm-ups and cool-downs five days per week. Exercise participants wore pedometers. Usual care patients wore pedometers during the first two weeks only. Throughout the study, patients in both groups received telephone contact on a biweekly basis to discuss physical activity and any concerns. For those in the exercise program, adjustments to the program were made, barriers to walking were discussed, and strategies for resolution were planned.
Patients were undergoing the active antitumor treatment phase of care.
This was a randomized, controlled trial.
Analysis of dropouts showed that significantly more ethnic minorities and those with lower educational levels withdrew (p < 0.03). There were no differences at the end of the study in sleep quality. There were no differences between groups in overall mean emotional distress scores; however, dose-response analysis showed that those who exercised more had less emotional distress (p = 0.03). There were no between-group differences in fatigue; however, analysis showed that those who exercised more had lower fatigue scores (p = 0.03). Subgroup analysis among patients with prostate cancer showed that exercise group members had better sleep quality (p < 0.001), less emotional distress (p = 0.048), and less fatigue (p = 0.009). PAQ findings were moderately correlated with pedometer results, suggesting that the PAQ may be a reasonable measure of exercise dose (Spearman = 0.37; p = 0.002).
Findings suggested that a home-based exercise program can be beneficial in patients receiving cancer treatment to reduce fatigue. Among patients with prostate cancer, the program resulted in improved sleep quality and less emotional distress and fatigue.
A home-based walking program is a simple intervention that can be beneficial to patients, and study findings showed that patients who exercised more had less fatigue and improved mood. In patients other than patients with prostate cancer, it did not appear that exercise improved sleep quality. This study included biweekly telephone follow-ups. Other studies have not shown the same level of results with home-based walking, suggesting that the follow-up component is probably important to maintain patient exercise program use. Of interest, patients who were less educated and of ethnic minorities were more likely to drop out of the study. This suggests that these groups of patients need to be examined more in order to see what interventions will be most likely to appeal to them.
Wiskemann, J., Dreger, P., Schwerdtfeger, R., Bondong, A., Huber, G., Kleindienst, N., . . . Bohus, M. (2011). Effects of a partly self-administered exercise program prior to, during, and after allogeneic stem cell transplantation. Blood, 117, 2604–2613.
The primary aim was to identify the benefits of exercise performed during the entire hematopoietic stem cell transplantation (HSCT) time period. The secondary aim was to explore endurance performance via six-minute walk test (6MWT), isometric muscle strength, functional performance status, physical activity levels via pedometer step count, health-related quality of life, and psychological well-being and distress.
A self-administered exercise intervention was compared to a social contact pedometer-wearing control group. Exercise began one to four weeks prior to hospital admission. Exercise included three endurance (outpatient: walking; inpatient: bicycling and treadmill) and two resistance (color-coded bands with different levels of resistance focused on extremities, entire body, and bed exercises) training sessions per week (up to five sessions during hospitalization). Exercise continued six to eight weeks after discharge. The control group reported that moderate physical activity was helpful without instruction, wore step counters, and received thirty minutes of physiotherapy and access to bicycles and treadmills during hospitalization. Both groups received the same number of visits by study personnel.
This was a prospective, multicenter, randomized, controlled trial.
All assessments were measured at four time points: baseline, admission, discharge, and six to eight weeks after discharge.
Significant group differences at the end of the intervention were: general fatigue (p = 0.009); physical fatigue (p = 0.01); and POMS fatigue scale (p = 0.004). The exercise group was superior to the control group in all subscales. Physical capacity increased in the exercise group (p = 0.02) and was inversely correlated with general fatigue (p ≤ 0.01). The Intervention significantly improved the strength of the lower extremities (p = 0.03) (maybe due to walking and biking). The exercise group was significantly more anxious than the control group (p = 0.007). All benefits were observed most predominantly during hospitalization.
This partly supervised exercise intervention was beneficial for patients undergoing allogeneic (allo)-HSCT.
The allo-HSCT patient population should be encouraged to exercise. An exercise intervention is feasible and can alter cancer-related fatigue in the allo-HSCT patient population. Use of preadmission exercise in concert with findings of differences in fatigue between individuals who have higher baseline activity levels suggests that further research in improving capacity and activity levels prior to treatment in various patients is worth investigating.
Wu, H., Dodd, M. J., & Cho, M. H. (2008). Patterns of fatigue and effect of exercise in patients receiving chemotherapy for breast cancer. Oncology Nursing Forum, 35, E90-E99.
To examine daily fatigue patterns during the third cycle of chemotherapy in women with breast cancer and predict whether fatigue trajectories differ by exercise or chemotherapy regimens.
Patients completed a daily fatigue diary that included a fatigue rating and items to determine whether they were exercisers or nonexercisers. Patients were asked to complete the diary daily. Weekly telephone calls from an exercise physiologist were used to determine exercise adherence. Adherence was determined as either a yes or no based on whether the patient exercised at least three days per week for 20 minutes per session and at a “somewhat hard” intensity. Measures obtained during the third course of chemotherapy were used in this analysis.
Patients were undergoing the active treatment phase of care.
This was a prospective, longitudinal, repeated-measure design primary study; a secondary analysis of these data was performed.
Average levels of fatigue reported were moderate for the first eight days and mild for the rest of the cycle. Highest levels of fatigue were observed on days 1 to 3 for average and worst fatigue. Five distinct trajectory patterns of cancer-related fatigue (CRF) were identified: immediate and sharp increase followed by a gradual decline; early peak, a decline, and a sharp increase toward the end of the cycle; small variations among daily scores; chaotic pattern; and step-up evaluation followed by a gradual decline. Nonexercisers had higher average and worst fatigue (p < 0.01). In exercisers and nonexercisers, fatigue declined in severity over time, and the rate of decline was not significantly different between the two groups; however, fatigue levels were consistently higher among nonexercisers.
CRF peaked in the days immediately after intravenous chemotherapy and declined gradually over time. Fatigue tended to be lower in those who exercised as described.
Nurses should provide anticipatory guidance to patients so that they can plan for the days when they are at most risk for fatigue. Continued exercise during the course of chemotherapy may be helpful in mitigating the severity of fatigue.
Yang, C. Y., Tsai, J. C., Huang, Y. C., & Lin, C. C. (2011). Effects of a home-based walking program on perceived symptom and mood status in postoperative breast cancer women receiving adjuvant chemotherapy. Journal of Advanced Nursing, 67, 158–168.
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.
Patients were undergoing the active treatment phase of care.
This was a randomized, controlled trial.
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.
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.
Yang, T.Y., Chen, M.L., & Li, C.C. (2015). Effects of an aerobic exercise programme on fatigue for patients with breast cancer undergoing radiotherapy. Journal of Clinical Nursing, 24, 202–211.
To evaluate the efficacy of an aerobic exercise program for fatigue in women receiving radiotherapy for breast cancer
Patients were recruited to an intervention group and to a comparison group. The intervention consisted of aerobic exercise using a treadmill with mild to moderate intensity defined as 40%–65% of maximum heart rate. Exercise was done for 20–30 minutes three days per week during six weeks of radiation therapy. Fatigue was assessed prior to radiation therapy and then weekly for six weeks.
Two-group, nonrandomized, quasi-experimental study
Fatigue trends over time showed a consistent decline in the intervention group and an increase over time in the comparison group. With the intervention, the change in fatigue was -1.09 (p < 0.0001), and in the control group, fatigue increased by 1.45 points by week 6 (p = 0.002). The same pattern was shown for fatigue interference with daily life measures.
The findings of this study suggest that aerobic exercise can reduce and prevent fatigue during radiation therapy. The study's design limits its generalizability and the strength of these findings.
This study adds to the body of evidence regarding the efficacy of exercise to combat fatigue during active cancer treatment. This study was conducted during radiation therapy, showing that aerobic exercise can be helpful during this treatment.
Yeh, C. H., Man Wai, J. P., Lin, U. S., & Chiang, Y. C. (2011). A pilot study to examine the feasibility and effects of a home-based aerobic program on reducing fatigue in children with acute lymphoblastic leukemia. Cancer Nursing, 34, 3–12.
To examine the feasibility of a home-based aerobic exercise intervention on reducing fatigue in children with acute lymphoblastic leukemia (ALL).
Institutional review board approval, parental consent and child assent, verbal and written explanations, and baseline assessments were completed. Maximal exercise tests were completed for all, and those in the intervention group were provided with a video and instructions on achieving target heart rate. Parents and patients were instructed on exercise guidelines, safety and health condition assessment, and monitoring. Heart rate monitors were worn and documented.
The home-based aerobic exercise intervention consisted of following the steps in an exercise video three days a week, for 30 minutes each session, for six weeks. The content of the intervention included three sections: a warm-up for five minutes, aerobic exercise for 25 minutes, and a cool-down for five minutes. The warm-up and cool-down were aimed to increase 10% to 30% of the heart rate reserve. This was recommended by the American College of Sports Physicians. The aerobic section was designed to increase the heart rate reserve to 40% to 60%. The exercise prescription was individualized after baseline assessment, and the duration ranged from 10 to 30 minutes, gradually increasing to 30 minutes by the third week and after. Patients were instructed to complete the exercise three times per week for six weeks.
This was a quasiexperimental control study with multivariate analysis on self-reported levels of fatigue at posttest and one-month follow-up.
For the PP analysis, children who received the exercise intervention reported lower general fatigue subscale scores than those in the control group at one-month follow-up (p = 0.03). There were no significant differences between groups at any other study timepoint. For intent-to-treat (ITT) analysis, there was no intervention and time effect for any of the three fatigue subscales at posttest or one-month follow-up. Descriptive statistics were collected, and the intervention effects of the home exercise and data were measured using the mixed-effects model (mixed procedure in SAS). This included fixed-effects for time and group. ITT (for all patients) and PP (for those who adhered to exercise) analyses were used. The mean adherence rate for the six-week intervention was 76% in the ITT analysis and 90% in the PP analysis.
This exercise program was feasible. Children who received the home-based aerobic exercise intervention reported lower “general fatigue” than those in control group at one-month follow-up. There was structured parental involvement, which might have played a role in adherence. Motivating children with cancer to exercise will require additional study.
A home-based aerobic intervention program might reduce fatigue in children with ALL who are undergoing maintenance chemotherapy. This study demonstrated a high level of adherence, which the authors attributed to parental involvement. Larger, well-designed clinical trials should be performed to further examine the role of exercise in managing fatigue in these patients, as well as the importance and degree of parental involvement needed for success.
Yeo, T. P., Burrell, S. A., Sauter, P. K., Kennedy, E. P., Lavu, H., Leiby, B. E., & Yeo, C. J. (2012). A progressive postresection walking program significantly improves fatigue and health-related quality of life in pancreas and periampullary cancer patients. Journal of the American College of Surgeons, 214, 463–475.
To evaluate the effects of a home-based walking program in postresection patients on cancer-related fatigue, physical function, and quality of life.
Consenting patients were randomly assigned to the walking group or usual care group while in the hospital after surgery. Baseline measures were obtained either in the physician's office prior to surgery or in the hospital. Patients in the intervention group were given a prescription for a graduated walking program and were asked to record the number of minutes or approximate distance walked and any adverse symptoms in a weekly diary. They also received monthly telephone calls to assess their current status and adherence to walking and remind them to mail in their diary information. The intervention group was given a modified “Every Step Counts” booklet, modified to cover a six-month period recommending increasing brisk walking time to 20 minutes in the second month and to 25 to 30 minutes in the third month. Patients in the usual care control group did not receive monthly calls but received one follow-up call at three months. Outcome measures were assessed via the follow-up telephone calls in all groups.
Patients were undergoing the active treatment phase of care.
This was a randomized, controlled trial.
Patients in the exercise group had improved fatigue scores by both VAS and FACIT measures (p < 0.05). Mean change in VAS fatigue score was 1.2, and mean change in the FACIT subscale was 9 points. FACIT scores tended to correlate with disease stage. All patients had a significant reduction in pain. Physical function score changes on the SF-36 were mixed, with the individual subscale score improving more in the exercise group but the composite score improving more in the usual care group. There were no differences between groups in other symptoms observed. Analysis demonstrated a fatigue-related symptom cluster of fatigue, bodily pain, depression, weakness, and anxiety at an average of three months.
Findings supported the benefits of a home-based progressive walking program for patients postsurgical resection.
Findings suggested that a self-managed home-based walking prescription can be helpful to patients with cancer postoperatively. This study adds to the body of evidence related to exercise and fatigue by using a sample of patients who had diagnoses and treatments not previously studied in this area.
Bower, J.E., Bak, K., Berger, A., Breitbart, W., Escalante, C.P., Ganz, P.A., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical Oncology clinical practice guideline adaptation. Journal of Clinical Oncology, 32, 1840–1850.
PHASE OF CARE: Late effects and survivorship
Adapted from three guidelines by multidisciplinary experts using supplementary evidence and clinical experience. Most recommendations listed verbatim but some modified to include updated evidence or current practice beliefs.
Recommendations focused on patients who have completed active treatment or are considered in clinical remission. Treat underlying causes, moderate physical activity after cancer treatment with PT and lymphedema referrals as needed (meta-analysis, systematic review, [randomized controlled trial [RCT]; 10 cited), cognitive behavioral therapy (meta-analysis, RCT, systematic reviews; 6 cited), psychoeducational therapies (systematic, RCT; 3 cited), psychosocial services, mindfulness-based interventions (RCT; 3 cited), yoga (RCT; 2 cited), acupuncture (RCT; 2 cited), psychostimulants/wakefulness agents (limited evidence in patients who are post-treatment disease-free). Additional areas in which research needed include biofield therapies, massage, music therapy, relaxation, Reiki, Qigong, ginseng, and vitamin D.
Guidelines were tailored to survivors with current evidence as not all evidence done is survivors.
Screening, assessment, and treatment guidelines summarized for use in cancer survivors.
National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue [v.1.2016]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf
PHASE OF CARE: Multiple phases of care
Two hundred two references were retrieved. The total number of references included and reviewed for updating was not provided. No quality rating is identified.
The guidelines provide suggestions for screening and identify some tools for fatigue assessment and some key interventions for the management of fatigue. They provide an overview of relevant evidence for multiple types of interventions. Major suggestions are identified in the recommendations section of this summary.
Schmitz, K. H., Courneya, K. S., Matthews, C., Demark-Wahnefried, W., Galvão, D. A., Pinto, B. M., . . . American College of Sports Medicine. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise, 42, 1409–1426.
To synthesize the literature on the safety and efficacy of exercise training during and after cancer treatment and provide guidelines for exercise for patients with and survivors of cancer. Adults with cancer during and after adjuvant cancer treatment were addressed. The guidelines state that the focus is on sites where the most evidence exists: breast, prostate, colon, hematologic, and gynecologic cancers.
Evaluation of evidence was based on categories from the National Heart, Lung and Blood Institute (A–D levels). Panel member reviews were presented and discussed at the roundtable, and guidelines were developed by consensus. Specific strategy and terms were not described. Guidelines were developed by an expert roundtable in which members were asked to review relevant literature. The guidelines were limited to an adult population and provided an overview of a volume of evidence in multiple outcome areas related to exercise.
A comprehensive and detailed set of guidelines for exercise approaches applicable for survivors of breast, prostate, colon, hematologic, and gynecologic cancers was provided in the guidelines, as well as some of the issues of exercise training timing related to phases of care. The guidelines also provided a summary of evidence used per cancer site and identified gaps in research because of the small number of studies in some cases and small sample sizes in many of the studies.
Recommendations for exercise testing were as follows:
Recommendations for exercise prescription were as follows:
General activity guidelines were as follows:
No participant associations were described.
The guidelines concluded that there was consistent evidence that exercise is safe during and after cancer treatment, with consideration of specific risks that are associated with various types. Exercise training can be expected to improve aerobic fitness, muscular strength, quality of life, and fatigue. Resistance training can be performed safely in patients with and at risk for lymphedema with breast cancer. Some exercise is recommended for all types of patients. Further study is needed in the areas of dose-response effects of exercise training. The guidelines provided additional evidence-based and expert support for the incorporation of various types of exercise in the care of patients with cancer during and after adjuvant treatment. Continued research is needed in this area in terms of research in other cancer types and determination of dose-response relationships for various outcomes.