Exercise

To investigate the effects of an exercise prescription on fatigue, anxiety, depression, and quality of life in patients with breast cancer receiving adjuvant therapy and to explore the relationships between the volume of targeted exercise and the effects observed on these psychological outcomes.

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: MEDLINE, PsycINFO, Pascal, PSYarticles, and Cochrane

KEYWORDS: anxiety, breast cancer, depression, exercise, fatigue, and quality of life

INCLUSION CRITERIA: Participants were adult women diagnosed with breast cancer. Studies had a randomized, controlled experimental design. Intervention programs involving physical activity (yoga-based) were included, whereas relaxation-based interventions were not. An intervention program was scheduled during adjuvant cancer therapy (chemotherapy and/or radiotherapy). At least one psychological outcome among fatigue, anxiety, depression, and quality of life was observed. Pre- and post-intervention data were included to calculate standardized mean differences.

EXCLUSION CRITERIA: Not given

TOTAL REFERENCES RETRIEVED: N = 1,011

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: A quality score based on 10 methodologic criteria specifically chosen for the evaluation of exercise intervention randomized controlled trials and mostly derived from the PEDro scale was calculated for each included study. Targeted exercise volume was estimated using metabolic equivalent for task (MET), where 1 MET accounts for 3.5 ml O₂/kg/min. Corresponding MET values for a given exercise intervention were coded from the Compendium of Physical Activity. Five and 3.8 METs were, respectively, assigned to moderate- and low-intensity aerobic physical activity; strength-training physical activity was coded 3.5 METs; warm-up and cool-down were estimated 2.5 METs if no more detail related to their content was provided; yoga and stretching activities were coded 2.5 METs.                                                        

• N (studies) = 17
• TOTAL PATIENTS INCLUDED IN REVIEW: 748 subjects, 632 controls
• KEY SAMPLE CHARACTERISTICS: The median age of included patients was 50.5 years old. All patients with breast cancer had been diagnosed with nonmetastatic cancer and were undergoing adjuvant therapy (i.e., chemotherapy and/or radiotherapy during exercise intervention).                                                                                                                     

The methodologic quality of the studies had a median score of 7, ranging from 2–9.

PHASE OF CARE: Active anti-tumor treatment

Controlled comparisons of pre- and post-intervention indicated that exercise intervention significantly reduced fatigue, anxiety, and depression, but only borderline significance was reached for anxiety (P = 0.06). Moreover, exercise intervention significantly improved quality of life. Findings showed that higher dose and duration of exercise targets had greater effectiveness. Effect sizes were modest. When low-quality studies were eliminated, effects for fatigue no longer were significant.

Adapted physical activity programs can be expected to decrease fatigue and depressive symptoms and increase quality of life during chemotherapy and/or radiotherapy for patients with early-stage breast cancer. Reduction in anxiety symptoms also was observed, but the evidence still is limited.

A limitation of the study was the estimation of exercise dose. Targeted aerobic exercise intensity frequently was described within a range such as 50%–80% of the maximal heart rate, which did not enable considering it precisely. Except when it was explicitly stated as light or vigorous, intensity was considered moderate for dose calculation. Only targeted exercise doses were estimated instead of achieved exercise doses.

Exercise intervention may improve fatigue, depression, and quality of life in patients with breast cancer receiving adjuvant therapy, with findings suggesting that a prescription of relatively low doses of exercise (less than 12 MET h/week) consisting of about 90–120 minutes of weekly moderate physical exercise seems more efficacious in improving fatigue and quality of life than higher doses.

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

TYPE OF STUDY: Meta-analysis and systematic review

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

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

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

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

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

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

TYPE OF STUDY: Meta-analysis and systematic review

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

PHASE OF CARE: Active antitumor treatment

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

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

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

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

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

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

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

Studies were included in the review if they

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

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

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

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

The review has clinical applicability for late effects and survivorship.

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

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

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

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

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

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

PHASE OF CARE: Late effects and survivorship

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

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

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

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

This intervention provided telephone-delivered psychosocial interventions. One group received six weeks of telephone-delivered counseling (TIP-C) sessions based on interpersonal psychotherapy/counseling principles, covering the following topics.

• Cancer education
• Social support
• Awareness and management of anxiety symptoms
• Role transitions

The phone calls averaged 34 minutes. Another group received six weeks of telephone-delivered, self-managed exercise protocol information. The exercise protocol consisted of engaging in regular, low-impact exercise (e.g., walking for a prescribed number of minutes at least four times per week). These phone calls averaged 11 minutes. The third group received six weeks of attention control (AC) printed information about breast cancer with brief weekly phone calls averaging 7 minutes. This group did not receive counseling or encouragement to exercise.

A convenience sample was used.

Data were collected at baseline (T1), one week after final call (T2), and one month after final call (T3).

• The study reported on a sample of 96 women with breast cancer and 96 partners (N = 192).
• The sample was randomized to three groups, stratified by stage and treatment.
  • Group 1 had 38 women and 38 partners.
  • Group 2 had 21 women and 19 partners.
  • Group 3 had 33 women and 30 partners.
• There were no significant differences between groups for treatment, stage, history of depression, participation in support groups or counseling, and use of antidepressants or antianxiety medications.

The study used a three-wave repeated measures design with a between-subjects factor (treatment group).

• Positive and Negative Affect Schedule (PANAS) PLUS Index of Clinical Stress to make eight-item composite index of anxiety
• Mixed-model ANOVAs
• Depression and anxiety treated as separate dependent variables, with T1, T2, and T3 being the within-subject factor
• Three treatment groups act as between-subject factor.
• Group x time
• Paired t tests
• Cronbach’s alphas (reliability) reported across time for women and partners as well as addressing construct validity
• Instruments used have established reliability and validity.

Results showed mixed-model ANOVA significant effect for time (p = 0.001), no significant main effect for treatment group, and significant group x time interaction (p = 0.01).

Both telephone counseling and exercise conditions helped to reduce anxiety in women and their partners, with significant differences (p < 0.001). The AC group did not evidence the same improvement in decreased anxiety, and their partners’ anxiety scores increased.

• The intervention required special training of a psychiatric nurse counselor with oncology expertise to deliver the telephone counseling sessions.
• The 34-minute phone calls (on average) per weekly session (x 2—one for patient and one for partner) required more than one hour per week per couple to deliver the intervention.

To determine if acute exercise reduces state anxiety in breast cancer survivors

Participants recruited were randomly assigned to a light or moderate intensity group and were asked to complete both moderate and light intensity exercise on two different days. Exercise sessions were done by cycling. Prior to exercise, questionnaires for anxiety and self-efficacy were completed. Participants cycled for 20 minutes, staying with standardized heart rate ranges as defined for light and moderate intensity. Questionnaires were repeated after each exercise session following an eight-minute rest.

• The study reported on a sample of 50 participants: 25 breast cancer survivors and 25 age-matched women without a cancer diagnosis.
• Mean participant age was 59 years in the breast cancer survivors and 56 years in the other women.
• Average time since diagnosis of breast cancer was five years.
• Of the sample, 40% had at least a bachelor’s degree and 80% were married or living with a partner.

• Single site
• Canada

The study has clinical applicability for late effects and survivorship.

A randomized, experimental, repeated-measures design was used.

• Spielberger State Anxiety Short Form
• Self-efficacy questionnaire adapted from a previous study: A total efficacy score was calculated by summing confidence ratings by the respondent within a possible score of 100 (reliability – 0.91).

There were no differences between day 1 and 2 for anxiety and self-efficacy. Repeated measures ANOVA on anxiety showed a main effect for time (p < 0.01), with anxiety decreasing across the time of exercise. The intensity of the exercise was not significant. There were no differences between breast cancer survivors and others. Self-efficacy measures showed a main effect for time (p < 0.01), but no differences between breast cancer survivors and others or between exercise intensities. Breast cancer survivors and others reported similar pre-exercise state anxiety levels. There was a significant reciprocal relationship between self-efficacy and state anxiety both pre- and post-exercise (p < 0.05).

Exercise appears to have a short-term effect in reducing anxiety and increasing perception of self-efficacy.

• The study had a small sample, with less than 100 participants.
• The study did not include control observations.
• The study period and intervention was very brief, consisting of only two days of exercise and observations.
• Utility of findings is questionable.
• Participants were generally physically fit and may have been biased toward exercise, limiting applicability of findings.

Studies with longer-term exercise interventions and in participants with higher levels of anxiety may be helpful in exploring these issues. Long-term findings suggest that the specific approach to management of anxiety during the cancer diagnostic phase does not appear to significantly impact anxiety and depression in women with low-risk abnormal findings. The timing of depression might suggest that extended follow-up after diagnostic testing and treatment may be associated with depression for some women. Which of the strategies examined here offer the best balance between benefits and harms is a matter of continuing debate.

The intervention was lower-body aerobic exercise three times a week for 10 weeks in groups. The three groups were low-intensity exercise, moderate-intensity exercise, and control.

The study reported on a sample of 18 patients with cancer recovering from treatment.

A randomized controlled trial design was used.

• Linear Analog Self-Assessment (includes anxiety)
• Quality of Life Index for patients with cancer
• Physiologic capacity measures

There was significant decrease in anxiety pre- and post-study (p = 0.011) but not compared to the control group versus findings of decreased anxiety in the exercise group.

• The study had a small sample.
• No reliability for the instrument measuring anxiety was provided.
• Group interactions may have influenced anxiety.

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

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

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

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

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

Parallel, randomized, controlled, single-center trial

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

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

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

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

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

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

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

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

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

Randomized controlled trial

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

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

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

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

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

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

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

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

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

• PHASE OF CARE: Active antitumor treatment

Randomized trial

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

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

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

• Risk of bias (no blinding)

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

Primary aim: To determine if prior research findings of improvement in patient outcomes with exercise during adjuvant chemotherapy would be maintained at six-month follow-up

Secondary aim: To determine if patients who reported regular exercise during the follow-up period would report better outcomes at six-month follow-up

Participants who had initially been in a three-armed randomized controlled trial were recruited to participate in this study. Prior study groups were aerobic exercise, resistance exercise, and control. Exercise groups were supervised. Participants were mailed questionnaires to determine the frequency of exercise and to rate their quality of life, self-esteem, fatigue, anxiety, and depression. Participants were asked to recall their exercise of the past six months using a questionnaire, and were then categorized into meeting or not meeting current guidelines for aerobic exercise (>/= 60 minutes of vigorous or 150 minutes of moderate exercise per week).

• The study reported on a sample of 201 female patients with breast cancer.
• Mean patient age was 49 years, with a range of 25–78 years.
• Patients received adjuvant chemotherapy with or without radiation therapy.
• Of the sample, 21% were obese, 61% had stage II disease, 59% had breast-conserving surgery, 31% received taxane-based chemotherapy, and 25% had reported recent exercise in the initial study.

• Multisite
• Other setting
• Alberta, Ottawa, and British Columbia, Canada

Patients were undergoing the transition phase of care after initial treatment.

This was a descriptive study for follow-up from a previous randomized controlled trial.

• Functional Assessment of Cancer Therapy–Anemia scale (FACT-A)
• Rosenberg Self-Esteem Scale
• Center for Epidemiologic Studies–Depression scale (CES-D)
• Spielberger State-Trait Anxiety Inventory
• Godin Leisure-Time Exercise Questionnaire

Of the sample, 20.9% reported meeting both aerobic and resistance exercise guidelines, 8% reported meeting only resistance exercise guidelines, 28.9% reported meeting only aerobic guidelines, and 42.3% reported not meeting any exercise guidelines. Those who originally were in a group given supervised aerobic exercise training (AET) had fewer reporting that they met exercise guidelines during follow-up (p = 0.034). Those who had received resistance exercise training (RET) reported higher self-esteem at six months (p = 0.032). The AET group reported significantly lower anxiety at six months than either the control or RET group members (p = 0.049). All other changes in self-reported outcomes at six months favored the exercise groups, but were not statistically significant. Those who reported that they met exercise guidelines reported higher quality of life (p = 0.025) and less fatigue (p = 0.013). They also reported less anxiety, but this difference was not significant. At six months, those in the AET group reported that anxiety was lower by 4.7 points and depression was reduced by 2.7 points.

Exercise training during chemotherapy treatment may have longer-term effects on anxiety and self-esteem. Consistent exercise meeting recommended guidelines appears to benefit patients in terms of a positive effect on symptoms of fatigue and general quality of life.

• There was a higher loss to follow-up in the original study’s control group, which may have skewed study results comparing exercise groups to controls.
• Findings are based on self-report only, which may have affected findings related to consistency of exercise.

Findings suggest that ongoing exercise according to guidelines appears to have positive effects on patients’ quality of life, fatigue, anxiety, and self-esteem. Nurses can educate patients about these potential benefits.

The three-armed study reported on an exercise intervention with supervised aerobic exercise (AET) and supervised resistance exercise (RET) versus usual care (UC). The exercise sessions were started one to two weeks after starting chemotherapy and ended three weeks after completion of chemotherapy. Exercise trainers administered the intervention.

• AET group participants (n = 78) exercised three times per week on a cycle, a treadmill, or an elliptical machine, beginning at 60% of their maximal oxygen consumption for weeks 1–6 and then progressing to 70% during weeks 7–12, and 80% beyond week 12. Exercise duration began at 15 minutes for weeks 1–3 and increased by five minutes every three weeks until the duration reached 45 minutes at week 18.
• RET group participants (n = 82) exercised three times per week, performing two sets of 8–12 repetitions of nine different exercises at 60%–70% of their estimated one-repetition maximum. Resistance was increased by 10% when participants completed more than 12 reps.
• UC group participants (n = 82) were asked not to initiate an exercise program and were offered a one-month exercise program after postintervention assessments.

Data were collected at three time points: baseline (one to two weeks after starting chemotherapy), midpoint (three to four weeks after starting chemotherapy), and at six-month follow-up.

The study reported on a sample of 242 women with breast cancer receiving adjuvant chemotherapy.

Multiple centers in Canada

A randomized controlled trial (RCT) design was used.

• Functional Assessment of Cancer Therapy–Anemia scale (FACT-A)
• Rosenberg Self-Esteem Scale
• Center for Epidemiologic Studies–Depression scale (CES-D)
• Spielberger State Anxiety Inventory (STAI)
• Peak oxygen consumption
• Expired gases
• Body weight and height
• Dual x-ray absorptiometry scan for assessment of whole body fat and lean tissue
• Lymphedema measurements
• Chemotherapy completion rate assessed as the average relative dose intensity for the originally planned regimen based on standard formulas

Mixed-model analysis measured at three time points compared the differences across groups in changes over time. Neither AET nor RET interventions significantly improved cancer-specific quality of life, fatigue, depression, or anxiety, although the trends favored the exercise groups. AET improved self-esteem, aerobic fitness, and percent of body fat. RET improved self-esteem, muscle strength, lean body mass, and chemotherapy completion rates.

The study is an RCT with an adequate sample size but null findings for anxiety levels.

The intervention required exercise trainers.

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

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

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

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

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

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

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

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

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

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

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

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

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

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

Three-group trial with a repeated-measures design

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

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

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

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

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

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

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

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

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

PHASE OF CARE: Active anti-tumor treatment

• Randomized, controlled trial
• Four groups

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

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

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

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

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

A group exercise training (GET) intervention was delivered in a structured format three times per week for 16 weeks. The one-hour GET training sessions emphasized physical activities that promote aerobic fitness, strength, and flexibility. The warm-up period lasted 10–15 minutes, the aerobic training phase lasted 20 minutes, and the resistance training and cool-down phase lasted 20 minutes. Exercise intensity and duration were prescribed on an individual basis using the results from baseline fitness assessments. Two exercise physiologists provided each session. Data were collected at baseline, week 8, and week 16.

• The study reported on a sample of 40 sedentary women, aged 45 or older, who had been diagnosed and surgically treated for stage I, II, or III breast cancer.
• Most women were within 12 months of diagnosis, and all were postsurgery.
• Most women were concurrently undergoing adjuvant therapies.

A quasi-experimental design was used.

• Beck Depression Inventory (BDI)
• State-Trait Anxiety Inventory (STAI)
• Positive and Negative Affect Schedule (PANAS)
• Hamilton Rating Scale for Depression (HRSD)
• Functional Assessment of Cancer Therapy (FACT)
• Cancer Rehabilitation Evaluation System (CARES)
• Global Assessment Scale (GAS)
• Life Functioning Scales (LFS)
• Physiologic measures
  • Heart rate and blood pressure, height and weight
  • Body fat through skinfold fat thickness
  • Single-stage submaximal treadmill walking test
  • Sit-and-Reach Test to measure flexibility
  • Variable resistance equipment to measure body strength

BDI, PANAS, and HRSD were significantly improved from baseline to week 16. There was no statistically significant change in anxiety, as measured by STAI, after the exercise intervention. At baseline, participants were not experiencing high levels of distress.

Anxiety levels were not changed significantly from this exercise program, although other health benefits were reported.

• The study had a small sample.
• Outcomes were conceptualized and measured multidimensionally rather than unidimensionally (e.g., aerobic capacity or mood/distress only).
• The sample included patients with breast cancer only.
• The study had special costs or training due to use of exercise physiologists.
• The study required individual tailoring of intervention.

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

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

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

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

PHASE OF CARE: Transition phase after active treatment

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

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

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

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

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

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

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

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

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

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

• PHASE OF CARE: Late effects and survivorship

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

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

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

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

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

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

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

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

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

• Single site
• Outpatient setting
• Germany

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

A randomized controlled trial design was used.

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

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

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

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

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

The intervention was a six-week, nine-hour weekly group intervention of high (exercise) and low (massage) intensity. “Talking time” also was included. A trained nurse and physiotherapist administered the intervention.

• The study reported on a sample of 91 patients.
• The sample was comprised of a heterogeneous cancer population receiving chemotherapy.

Denmark

A prospective follow-up design was used (one group, pre/post-test).

• Hospital Anxiety and Depression Scale (HADS) – depression and anxiety subscales
• Aerobic capacity

Anxiety and depression scores improved (p < 0.001). Patients who were physically nonactive improved more on the HADS anxiety subscale than those in the active group. Women improved more on the HADS anxiety subscale than men.

• The study was not randomized.
• The study did not include pharmacologic assessment.
• The sample was 70% female.

To investigate the effect of a six-week intervention program including exercise, relaxation, massage, and body awareness training on anxiety and depression in patients undergoing chemotherapy

Patients were randomly assigned to the intervention group or a wait list control group. Patients in the intervention participated in group supervised exercise sessions for six weeks. Sessions involved fitness training on stationary bicycles of 10.5 metabolic equivalents (MET) and heavy resistance training. Warm up and cool down exercises and stretching were also done. All patients received usual care. Control group patients were not restrained from increasing physical activity and participating in available supportive care activities. Data on depression and anxiety were obtained at baseline and were repeated at week 6.

• The study reported on a sample of 209 patients.
• Mean patient age was 47.5 years, with a range of 20–65 years.
• The sample was 75% female and 25% male.
• Patients had a variety of tumor types; the most frequent were breast and bowel cancers.
• Most patients (71%) were married or living together in a relationship.
• About 17% had a usual activity level of “sedentary” at baseline, and 34% had baseline activity levels of regular physical exercise of at least three hours per week or more.
• Baseline HADS anxiety scores ranged from 0 to 19, and baseline HADS depression scores ranged from 0 to 14; 23.4% were identified as moderate for anxiety, and 11.5% were suspicious or definite cases of depression.

• Multisite
• Outpatient setting
• Denmark

Patients were undergoing the active treatment phase of care.

The study design was post-hoc analysis of data from a randomized controlled trial.

Hospital Anxiety and Depression Scale (HADS)

The intervention group depression score declined a mean of 0.7 points, compared to a decline of 0.24 points on average in the control group (p = 0.015). Patients defined by HADS as borderline or definite cases of depression (n = 24, HADS score ≥ 8) had a mean reduction of –2.53 points, while controls declined an average of 0.25 points (p = 0.021). There were no significant changes or differences between groups in anxiety scores either in the whole sample or in the subgroup defined as baseline borderline or moderate anxiety. Adherence to the exercise sessions was 73.1%.

Exercise may be helpful to reduce depression in patients receiving cancer chemotherapy. No effect on anxiety was observed.

• The study did not have an appropriate control group.
• There was no attentional control.
• Intervention participants worked in groups and had the opportunity for group discussion, etc., so it is unclear what aspects of this multicomponent program contributed to effects seen.
• There is no information about the activity level of control patients.
• No information is provided regarding the use of any medications for anxiety or depression.
• In the overall intervention group, mean score changes were below those identified as clinically relevant for HADs.
• Only 24 patients had baseline scores indicating probable depression, so analysis showing an effect for the intervention was only in a very small group.

Findings suggest that the intervention tested here, including exercise, group support, massage, and body awareness interventions, may be helpful to combat depression, but may not be helpful for anxiety. However, clinically relevant effects were only seen for depression in those patients who had clinically relevant levels of depression scores at baseline. This suggests that such a program may not be useful to prevent depression, but may be helpful in the situation of actual depression. Screening for depression may be useful to identify those individual patients who are most likely to benefit from this type of approach. Further research is needed to test whether combinations of pharmacotherapy, exercise, and psychotherapy are better than separate approaches to manage anxiety and depression.

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

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

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

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

• PHASE OF CARE: Active antitumor treatment

Quasi-experimental

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

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

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

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

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

The exercise intervention was a supervised, home-based, flexible training program in young and middle-aged patients with cancer shortly after curative chemotherapy. An exercise instructor designed the training program. The exercise period lasted approximately 14 weeks, with a minimum of two exercise sessions per week of at least 30 minutes. All types of activities were chosen, based on the patients’ wishes and opportunities. The intensity of the exercise was adjusted according to the patient’s subjective experience of tiredness. Data were collected at baseline and at three weeks (approximately 14 weeks).

The study reported on a sample of 111 patients (59 in the intervention group and 52 in the control group).

A randomized controlled trial design was used.

• Cardiorespiratory fitness (CRF)
• European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire
• Hospital Anxiety and Depression Scale (HADS)

CRF increased and fatigue scores decreased in the intervention group. There were no significant intergroup differences in mental distress or health-related quality of life. There were no statistically significant decreases in anxiety levels as measured by HADS.

The intervention required an exercise instructor.

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

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

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

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

• PHASE OF CARE: Active antitumor treatment

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

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

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

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

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

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

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

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

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

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

Randomized, controlled trial

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

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

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

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

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