A randomized controlled trial of home-based exercise for cancer-related fatigue in women during and after chemotherapy with or without radiation therapy

Randomised controlled trial on the effectiveness of home-based walking exercise on anxiety, depression and cancer-related symptoms in patients with lung cancer

BACKGROUND

Although exercise has been addressed as an adjuvant treatment for anxiety, depression and cancer-related symptoms, limited studies have evaluated the effectiveness of exercise in patients with lung cancer.

METHODS

We recruited 116 patients from a medical centre in northern Taiwan, and randomly assigned them to either a walking-exercise group (n=58) or a usual-care group (n=58). We conducted a 12-week exercise programme that comprised home-based, moderate-intensity walking for 40 min per day, 3 days per week, and weekly exercise counselling. The outcome measures included the Hospital Anxiety and Depression Scale and the Taiwanese version of the MD Anderson Symptom Inventory.

RESULTS

We analysed the effects of the exercise programme on anxiety, depression and cancer-related symptoms by using a generalised estimating equation method. The exercise group patients exhibited significant improvements in their anxiety levels over time (P=0.009 and 0.006 in the third and sixth months, respectively) and depression (P=0.00006 and 0.004 in the third and sixth months, respectively) than did the usual-care group patients.

CONCLUSIONS

The home-based walking exercise programme is a feasible and effective intervention method for managing anxiety and depression in lung cancer survivors and can be considered as an essential component of lung cancer rehabilitation.

A systematic review of randomized controlled trials for management of persistent post-treatment fatigue in thyroid cancer survivors

BACKGROUND

Fatigue that persists post-treatment is commonly reported by thyroid cancer (TC) survivors.

METHODS

A systematic review of published English language randomized controlled trials (RCTs) on interventions for management of persistent post-treatment fatigue in TC was conducted. This review excluded studies on short-term interventions used in preparation for radioactive iodine diagnostic scans or treatment. An electronic search was executed in six databases and supplemented by a hand search. Two reviewers independently reviewed all citations from the electronic search and relevant full-text studies. Two abstractors independently critically appraised included studies and abstracted the data. The data were qualitatively summarized.

RESULTS

A total of 1086 unique citations and 25 full-text studies were reviewed. Four studies summarizing the results of three RCTs were included. The interventions included: combination triiodothyronine with levothyroxine (L-T4) therapy compared to L-T4 alone (one RCT), reduction in degree of thyrotropin (TSH) suppression using L-T4 compared to maintenance of TSH suppression (one RCT), and supervised exercise compared to inactivity (two RCTs examining different fatigue outcomes in same population). Trial duration ranged from 10 weeks to six months. All trials had limitations, and the number of TC survivors included in respective RCTs ranged from 15 to 36. Hormonal treatment RCTs had mixed fatigue outcome results within respective trials. However, multiple measures suggesting improvement in fatigue were reported following the exercise intervention.

CONCLUSIONS

There is paucity of RCTs to guide evidence-based management of persistent post-treatment fatigue in TC survivors. RCTs of interventions for prevention or treatment of fatigue in TC survivors are needed.

Are exercise programs effective for improving health-related quality of life among cancer survivors? A systematic review and meta-analysis

PURPOSE/OBJECTIVES

To evaluate the effectiveness of exercise interventions on overall health-related quality of life (HRQOL) and its domains among cancer survivors who have completed primary treatment.

DATA SOURCES

11 electronic databases were searched from inception (dates varied) to October 2011. The authors also identified eligible trials through a search of additional sources.

DATA SYNTHESIS

40 trials with 3,694 participants met the inclusion criteria. At 12 weeks, cancer survivors exposed to exercise interventions had greater positive improvement in overall HRQOL (standardized mean difference [SMD] 0.48; 95% confidence interval [CI] [0.16, 0.81]), emotional well-being (SMD 0.33; 95% CI [0.05, 0.61]), and social functioning (SMD 0.45; 95% CI [0.02, 0.87]); and had a significant reduction in anxiety (SMD -0.26; 95% CI [-0.44, -0.07]) and fatigue (SMD -0.82; 95% CI [-1.5, -0.14]).

CONCLUSIONS

Exercise programs have a beneficial effect on HRQOL and most of its domains and can be integrated into the management plans for cancer survivors who have completed treatment. Future research is needed to help understand specific attributes of exercise programs that are beneficial for improving HRQOL within and across cancer types.

IMPLICATIONS FOR NURSING

Evidence presented in this review supports the inclusion of exercise programs in clinical guidelines for the management of cancer survivors who have completed treatment, such as the Oncology Nursing Society's Putting Evidence Into Practice resource.

Healthy Lifestyle Behaviors of Breast Cancer Survivors

The purpose of this secondary analysis was to describe the extent to which women with breast cancer, who participated in a randomized control trial on exercise, adopted American Cancer Society (ACS) guidelines for healthy lifestyle behaviors. Women in the study exercised during cancer treatment and for 6 months after completion of treatment. The sample included 106 women, average age 50.7 years (SD = 9.6). Adherence to guidelines for 5 servings of fruits and vegetables ranged from 36% (n = 28) to 39% (n = 36). Adherence with alcohol consumption guidelines was 71% (n = 28) to 83% (n = 30). Adherence with meeting a healthy weight ranged from 52% (n = 33) to 61% (n = 31). Adherence with physical activity guidelines ranged from 13% (n = 30) to 31% (n = 35). Alcohol and healthy weight guidelines were followed by more than half of the participants, but physical activity and dietary guidelines were followed by far fewer women. Further prospective clinical studies are indicated to determine whether interventions are effective in producing a healthy lifestyle in cancer survivors.

Exercise despite pain--breast cancer patient experiences of muscle and joint pain during adjuvant chemotherapy and concurrent participation in an exercise intervention

Chemotherapy-related pain is a well-known side effect in cancer patient receiving chemotherapy. However, limited knowledge exists describing whether exercise exacerbates existing pain. Aim of the research was to explore muscle and joint pain experienced by women with breast cancer receiving adjuvant chemotherapy with epirubicin and cyclophosphamide followed by docetaxel and factor support and concurrently participating in an exercise intervention. The study used individual semi-structured interviews (pre- and post-intervention). Fifteen women were interviewed. The multimodal group intervention comprised supervised training: high-intensity cardiovascular, heavy resistance and relaxation, massage and body-awareness (9 h weekly, 6 weeks). The analysis revealed five categories: Abrupt pain - a predominant side effect, cogitated pain management, the adapted training, non-immediate exacerbation of pain and summarised into the essence of chemotherapy related muscle and joint pain in exercise breast cancer patients; exercise despite pain. Findings indicate that the patients' perception of sudden onset of chemotherapy-related muscle and joint pain was not aggravated by training. Pain intensity peaked between 2 and 9 days after chemotherapy and is described to be stabbing pain with a feeling of restlessness in the body. The patients demonstrated a high adherence rate to the exercise intervention caused by their own willpower and camaraderie of the group.

Effects of exercise on biobehavioral outcomes of fatigue during cancer treatment: results of a feasibility study

Cancer treatment is associated with decreased hemoglobin (Hb) concentration and aerobic fitness (VO2 max), which may contribute to cancer-related fatigue (CRF) and decreased quality of life (QoL). Endurance exercise may attenuate CRF and improve QoL, but the mechanisms have not been thoroughly investigated. Objectives. To (a) determine the feasibility of conducting an exercise intervention among women receiving treatment for breast cancer; (b) examine the effects of exercise on Hb and VO2 max and determine their association with changes in CRF and QoL; and (c) investigate changes in selected inflammatory markers. Methods. Fourteen women receiving chemotherapy for Stages I-II breast cancer were randomly assigned to exercise (n = 7) or usual care (n = 7). Women in the exercise group performed supervised, individualized treadmill exercise 2-3 times/week for the duration of chemotherapy (9-12 weeks). Data were collected 4 times over 15-16 weeks. Results. Recruitment rate was 45.7%. Sixteen women consented and 14 completed the trial, for a retention rate of 87.5%. Adherence to exercise protocol was 95-97%, and completion of data collection was 87.5-100%. Exercise was well tolerated. VO2 max was maintained at prechemotherapy levels in exercisers but declined in the usual-care group (p < .05). Hb decreased (p < .001) in all participants as they progressed through chemotherapy. Exercise did not have significant effects on CRF or QoL. Changes in inflammatory markers favored the exercise group.

CONCLUSIONS

Exercise during chemotherapy may protect against chemotherapy-induced decline in VO2 max but not Hb concentration.

Predictors of significant worsening of patient-reported fatigue over a 1-month timeframe in ambulatory patients with common solid tumors

BACKGROUND

Understanding the determinants of fatigue worsening may help distinguish between different fatigue phenotypes and inform clinical trial designs.

METHODS

Patients with invasive cancer of the breast, prostate, colon/rectum, or lung were enrolled from multiple sites. At enrollment during an outpatient visit and 4 or 5 weeks later, patients rated their symptoms on a numerical rating scale from zero to 10. A 2-point change on that scale was considered clinically significant for a change in fatigue. Effects of demographic and clinical factors on patient-reported fatigue were examined using logistic regression models.

RESULTS

In total, 3123 patients were enrolled at baseline, and 3032 patients could be analyzed for fatigue change. At baseline, 23% of patients had no fatigue, 35% had mild fatigue, 25% had moderate fatigue, and 17% had severe fatigue. Key parameters in a model of fatigue worsening included fatigue at baseline (odds ratio [OR], 0.75), disease status (OR, 1.99), performance status (OR, 1.38), history of depression (OR, 1.28), patient perception of bother because of comorbidity (OR, 1.26), and treatment exposures, including recent cancer treatment (OR, 1.77) and receipt of corticosteroids (OR, 1.37). The impact of sex was examined only in patients with colorectal and lung cancer, and it was a significant factor, with men most likely to experience worsening of fatigue (OR, 1.46).

CONCLUSIONS

Predictors of fatigue worsening included multiple factors that were difficult to modify, including the baseline fatigue level, sex, disease status, performance status, recent cancer treatment, bother because of comorbidity, and history of depression. Future fatigue prevention and treatment trial designs should account for key predictors of worsening fatigue.

Consistency of symptom clusters among advanced cancer patients seen at an outpatient supportive care clinic in a tertiary cancer center

OBJECTIVE

Advanced cancer patients often develop severe physical and psychological symptom clusters (SCs), but limited data exist on their consistency or severity after an outpatient interdisciplinary team consultation led by palliative care specialists. The primary aim of the study was to determine the consistency and severity of SCs in advanced cancer patients in this setting.

METHOD

A total of 1373 patients with advanced cancer who were referred to The University of Texas MD Anderson Cancer Center's Outpatient Supportive Care Center between January 2003 and October 2008 with a complete Edmonton Symptom Assessment Scale (ESAS; 0-10 scale) occurred at initial and first follow-up visit were reviewed (median 14 days, range 1-4 weeks). We used a Wilcoxon signed-rank test to determine whether symptoms changed over time, and a principal components factor analysis with varimax rotation to determine SCs at baseline and at first follow-up. The number of factors calculated was determined based upon the number of eigenvalues.

RESULTS

The patients' ratings of the following symptoms (mean, SD) at the initial and follow-up visits, respectively, were: fatigue 6.2 (2.3) and 5.7 (2.5, p < 0.0001), pain 5.4 (2.9) and 4.6 (3, p < 0.0001), nausea 2.2 (2.8) and 2.0 (2.6, p < 0.0001), depression 3.0 (2.9) and 2.5 (2.7, p < 0.0001), anxiety 3.4 (3.0) and 2.8 (2.8, p < 0.0001), drowsiness 4.8 (3.1) and 4.4 (3.1, p < 0.0001), dyspnea 3.0 (2.9) and 2.7 (2.8), p < 0.0001), loss of appetite 4.2 (2.7) and 3.9 (2.7, p < 0.0001), sleep disturbances 4.2 (2.6) and 3.8 (2.6, P < 0.0001), and well-being 4.3 (2.5) and 3.9 (2.3, p < 0.0001). Cluster composition differentiated into physical (fatigue, pain, nausea, drowsiness, dyspnea, and loss of appetite) and psychological (anxiety and depression) components at the initial visit, and these two SCs were consistent upon follow-up.

SIGNIFICANCE OF RESULTS

We conclude that SCs remain constant between baseline and near-term follow-up but that the severity of those symptoms lessened during that interval. This knowledge may allow palliative care teams to provide more targeted and higher-quality care, but further studies are needed.

Cancer, physical activity, and exercise

This review examines the relationship between physical activity and cancer along the cancer continuum, and serves as a synthesis of systematic and meta-analytic reviews conducted to date. There exists a large body of epidemiologic evidence that conclude those who participate in higher levels of physical activity have a reduced likelihood of developing a variety of cancers compared to those who engage in lower levels of physical activity. Despite this observational evidence, the causal pathway underlying the association between participation in physical activity and cancer risk reduction remains unclear. Physical activity is also a useful adjunct to improve the deleterious sequelae experienced during cancer treatment. These deleterious sequelae may include fatigue, muscular weakness, deteriorated functional capacity, and many others. The benefits of physical activity during cancer treatment are similar to those experienced after treatment. Despite the growing volume of literature examining physical activity and cancer across the cancer continuum, a number of research gaps exist. There is little evidence on the safety of physical activity among all cancer survivors, as most trials have selectively recruited participants. The specific dose of exercise needed to optimize primary cancer prevention or symptom control during and after cancer treatment remains to be elucidated.

Update on interventions focused on symptom clusters: what has been tried and what have we learned?

PURPOSE OF REVIEW

Although clinicians and researchers acknowledge symptom clusters, the focus has been on relieving a single symptom. This review summarizes the recent literature on interventions that focus on relief of symptom clusters in patients with cancer.

RECENT FINDINGS

Twelve intervention studies meeting inclusion criteria were published in 2011-2012. The timeframe was expanded to 2009-2012 and 24 studies met the criteria: 18 in early stage and 6 in advanced-stage cancer patients. Several cognitive behavioral therapy, complementary therapy, and exercise interventions demonstrated positive outcomes in relieving a variety of symptom clusters in several cancer types. Most psychoeducational interventions using traditional formats or those combined with automated clinician alerts demonstrated effectiveness in reducing a variety of clusters. Clusters that included fatigue and anxiety or depression were reduced by exercise in early stage patients and by methylphenidate in advanced-stage patients. Current NIH R01 funded studies verified the trends in the types of interventions being tested.

SUMMARY

Few interventions have been tested and found to be effective in relieving the specific symptom clusters in early and advanced-stage cancer patients. Future research needs to expand our understanding of the mechanisms that initiate co-occurring symptoms. Mechanism-targeted interventions need to be identified and tested in homogeneous samples with specific symptom clusters. Interventions need to be replicated before guidelines can be established.

Self-management programme for cancer patients: a literature review

BACKGROUND

With increased cancer survivorship, cancer, in its chronic form, self-management among cancer patients has become an international research focus. Self-management programmes are used to guide the self-care process. Over the past 10 years, six self-management programmes for cancer patients (Taking CHARGE, Expert Patients Programme, Living with Cancer Education Program, Focus Program, PRO-SELF Program and Oncologist-referred exercise self-management programme) were used in a variety of self-management studies for cancer patients.

AIM

The aims of this paper are to describe, compare and critique these six self-management programmes that are commonly used to guide self-management for cancer patients, and propose directions for new self-management programme development among cancer patients.

METHODS

Medline, Pubmed and Embase, Springer, Elsevier, EBSCO and ProQuest were searched for literatures on self-management programmes for cancer patients from 2000 to November 2010. Search terms such as 'self-management' or 'self-care' or 'patient education' or 'self-management' or 'self-care' or 'self-efficacy', 'intervention' or 'program*' 'cancer' or 'carcinoma' or 'neoplasms' were used.

RESULTS

Comparison and critique of these programmes revealed important limitations of cancer self-management programmes including lack of the facilitators' training process, failure to assess the cultural differences and failure to cover all of the outcome measures.

CONCLUSION

Researchers and clinicians need to build more individualized and dynamic self-management programmes that parallel advances in clinical research and practice for cancer patients.

Prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer

Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.

Exercise for the management of cancer-related fatigue in adults

BACKGROUND

Cancer-related fatigue is recognised as an important symptom associated with cancer and its treatment. A number of studies have investigated the effects of physical activity in reducing cancer-related fatigue. This is an updated version of the original Cochrane review published in The Cochrane Library (2008, Issue 1). The original review identified some benefits of physical activity on fatigue in cancer both during and after adjuvant treatment. We identified a number of limitations in the evidence, providing clear justification for an updated review.

OBJECTIVES

To evaluate the effect of exercise on cancer-related fatigue both during and after cancer treatment.

SEARCH METHODS

We searched 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) using key words. We also searched reference lists off all studies identified for inclusion and relevant reviews. In addition, we handsearched relevant journals and contacted experts in the field of cancer-related fatigue.

SELECTION CRITERIA

We sought and included randomised controlled trials (RCTs) that investigated the effect of exercise on cancer-related fatigue in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of studies and extracted data based upon predefined criteria. Where data were available we performed meta-analyses for fatigue using a random-effects model.

MAIN RESULTS

For this update we identified a total of 56 studies (4068 participants) for inclusion (28 from the original search and 28 from the updated search), with the majority carried out in participants with breast cancer (28 studies). A meta-analysis of all fatigue data, incorporating 38 comparisons, provided data for 1461 participants who received an exercise intervention and 1187 control participants. At the end of the intervention period exercise was seen to be statistically more effective than the control intervention (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.37 to -0.17). Benefits of exercise on fatigue were observed for interventions delivered during or post-adjuvant cancer therapy. In relation to diagnosis, we identified benefits of exercise on fatigue for breast and prostate cancer but not for those with haematological malignancies. Finally, aerobic exercise significantly reduced fatigue but resistance training and alternative forms of exercise failed to reach significance.

AUTHORS' CONCLUSIONS

The findings of the updated review have enabled a more precise conclusion to be made in that aerobic exercise can be regarded as beneficial for individuals with cancer-related fatigue during and post-cancer therapy, specifically those with solid tumours. Further research is required to determine the optimal type, intensity and timing of an exercise intervention.

The effects of a six-week supervised multimodal exercise intervention during chemotherapy on cancer-related fatigue

PURPOSE

Cancer related fatigue (CRF) is a common problem for cancer patients across diagnoses during chemotherapy and is associated with physical inactivity, lower functional level and lack of energy. Few RCT exercise intervention studies have included cancer patients undergoing chemotherapy. The objective of this study is to evaluate whether a six-week supervised multimodal exercise intervention, adjunct to chemotherapy and standard care, can reduce the patient's CRF level.

METHODS

Data is based on analyses of a prospective randomised controlled trial 'The Body & Cancer Trial'. 213 cancer patients with different diagnoses were randomised into an intervention group or wait-list control group. The primary outcome, Fatigue score (CRF), was evaluated by the Functional Assessment of Cancer Therapy-Anaemia Questionnaire (FACT-An-) (FACT-G score & FACT-An Anemia subscale).

INTERVENTION

Supervised exercise, comprising high-intensity cardiovascular and heavy resistance training, relaxation- and body awareness training and massage, 9 h weekly for 6 weeks.

RESULTS

CRF was significantly reduced in the intervention group, corresponding to a Fatigue score reduction of 3.04 (effect size of 0.44, 95% CI 0.17-0.72) (P = .002), the FACT-An score by 5.40 (P = .015), the FACT-An Toi score by 5.22 (P = .009) and the Anaemia-ANS by 3.76 (P = .002). There was no statistically significant effect on the General Quality of Life score (FACT-G) or on any of the individual wellbeing scores; Physical (P = .13), Emotional (P = .87), Social (P = .83) and Functional (P = .26).

CONCLUSION

In summary, this six-week supervised multimodal exercise intervention can lead to significant reduction in self-reported CRF in cancer patients undergoing chemotherapy.

Exercise interventions on health-related quality of life for cancer survivors

BACKGROUND

Cancer survivors experience numerous disease and treatment-related adverse outcomes and poorer health-related quality of life (HRQoL). Exercise interventions are hypothesized to alleviate these adverse outcomes. HRQoL and its domains are important measures for cancer survivorship.

OBJECTIVES

To evaluate the effectiveness of exercise on overall HRQoL and HRQoL domains among adult post-treatment cancer survivors.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, PEDRO, LILACS, SIGLE, SportDiscus, OTSeeker, and Sociological Abstracts from inception to October 2011 with no language or date restrictions. We also searched citations through Web of Science and Scopus, PubMed's related article feature, and several websites. We reviewed reference lists of included trials and other reviews in the field.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing exercise interventions with usual care or other nonexercise intervention to assess overall HRQoL or at least one HRQoL domain in adults. Included trials tested exercise interventions that were initiated after completion of active cancer treatment. We excluded trials including people who were terminally ill, or receiving hospice care, or both, and where the majority of trial participants were undergoing active treatment for either the primary or recurrent cancer.

DATA COLLECTION AND ANALYSIS

Five paired review authors independently extracted information on characteristics of included trials, data on effects of the intervention, and assessed risk of bias based on predefined criteria. Where possible, meta-analyses results were performed for HRQoL and HRQoL domains for the reported difference between baseline values and follow-up values using standardized mean differences (SMD) and a random-effects model by length of follow-up. We also reported the SMDs between mean follow-up values of exercise and control group. Because investigators used many different HRQoL and HRQoL domain instruments and often more than one for the same domain, we selected the more commonly used instrument to include in the SMD meta-analyses. We also report the mean difference for each type of instrument separately.

MAIN RESULTS

We included 40 trials with 3694 participants randomized to an exercise (n = 1927) or comparison (n = 1764) group. Cancer diagnoses in study participants included breast, colorectal, head and neck, lymphoma, and other. Thirty trials were conducted among participants who had completed active treatment for their primary or recurrent cancer and 10 trials included participants both during and post cancer treatment. Mode of the exercise intervention included strength training, resistance training, walking, cycling, yoga, Qigong, or Tai Chi. HRQoL and its domains were measured using a wide range of measures.The results suggested that exercise compared with control has a positive impact on HRQoL and certain HRQoL domains. Exercise resulted in improvement in: global HRQoL at 12 weeks' (SMD 0.48; 95% confidence interval (CI) 0.16 to 0.81) and 6 months' (0.46; 95% CI 0.09 to 0.84) follow-up, breast cancer concerns between 12 weeks' and 6 months' follow-up (SMD 0.99; 95% CI 0.41 to 1.57), body image/self-esteem when assessed using the Rosenberg Self-Esteem scale at 12 weeks (MD 4.50; 95% CI 3.40 to 5.60) and between 12 weeks' and 6 months' (mean difference (MD) 2.70; 95% CI 0.73 to 4.67) follow-up, emotional well-being at 12 weeks' follow-up (SMD 0.33; 95% CI 0.05 to 0.61), sexuality at 6 months' follow-up (SMD 0.40; 95% CI 0.11 to 0.68), sleep disturbance when comparing follow-up values by comparison group at 12 weeks' follow-up (SMD -0.46; 95% CI -0.72 to -0.20), and social functioning at 12 weeks' (SMD 0.45; 95% CI 0.02 to 0.87) and 6 months' (SMD 0.49; 95% CI 0.11 to 0.87) follow-up. Further, exercise interventions resulted in decreased anxiety at 12 weeks' follow-up (SMD -0.26; 95% CI -0.07 to -0.44), fatigue at 12 weeks' (SMD -0.82; 95% CI -1.50 to -0.14) and between 12 weeks' and 6 months' (SMD -0.42; 95% CI -0.02 to -0.83) follow-up, and pain at 12 weeks' follow-up (SMD -0.29; 95% CI -0.55 to -0.04) when comparing follow-up values by comparison group.Positive trends and impact of exercise intervention existed for depression and body image (when analyzing combined instruments); however, because few studies measured these outcomes the robustness of findings is uncertain.No conclusions can be drawn regarding the effects of exercise interventions on HRQoL domains of cognitive function, physical functioning, general health perspective, role function, and spirituality.Results of the review need to be interpreted cautiously owing to the risk of bias. All the trials reviewed were at high risk for performance bias. In addition, the majority of trials were at high risk for detection, attrition, and selection bias.

AUTHORS' CONCLUSIONS

This systematic review indicates that exercise may have beneficial effects on HRQoL and certain HRQoL domains including cancer-specific concerns (e.g. breast cancer), body image/self-esteem, emotional well-being, sexuality, sleep disturbance, social functioning, anxiety, fatigue, and pain at varying follow-up periods. The positive results must be interpreted cautiously due to the heterogeneity of exercise programs tested and measures used to assess HRQoL and HRQoL domains, and the risk of bias in many trials. Further research is required to investigate how to sustain positive effects of exercise over time and to determine essential attributes of exercise (mode, intensity, frequency, duration, timing) by cancer type and cancer treatment for optimal effects on HRQoL and its domains.

Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis

CONTEXT

Exercise-induced improvements in cancer-related fatigue may be moderated differentially in patients during and following treatment. These effects have not been reviewed systematically. In accordance with PRISMA guidelines, the population effect size for exercise training on cancer-related fatigue during and following treatment was estimated and the extent to which the effect is differentiated across the time course of treatment and recovery was determined.

EVIDENCE ACQUISITION

Articles published before August 2011 were retrieved using Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science databases. Seventy studies involving 4881 cancer patients during or following treatment were selected. Articles included a cancer-related fatigue outcome measured at baseline and post-intervention and randomized allocation to exercise or non-exercise comparison. From August to October 2011, Hedges' d effect sizes were computed, study quality was evaluated, and random effects models were used to estimate sampling error and population variance.

EVIDENCE SYNTHESIS

Exercise significantly reduced cancer-related fatigue by a mean effect Δ (95% CI) of 0.32 (0.21, 0.43) and 0.38 (0.21, 0.54) during and following cancer treatment, respectively. During treatment, patients with lower baseline fatigue scores and higher exercise adherence realized the largest improvements. Following treatment, improvements were largest for trials with longer durations between treatment completion and exercise initiation, trials with shorter exercise program lengths, and trials using wait-list comparisons.

CONCLUSIONS

Exercise reduces cancer-related fatigue among patients during and following cancer treatment. These effects are moderated differentially over the time course of treatment and recovery. Exercise has a palliative effect in patients during treatment and a recuperative effect post-treatment.

Timing and sustainability of an exercise intervention in women with breast cancer during and after cancer treatment

PURPOSE/OBJECTIVES

To compare changes in frequency, duration, and intensity of exercise behaviors over time in women with breast cancer between those who started their exercise intervention at the beginning of chemotherapy (EE) and those who started at the completion of chemotherapy (CE).

DESIGN

A secondary data analysis of a randomized, controlled trial for exercise intervention.

SETTING

Five cancer centers in the San Francisco Bay Area in California.

SAMPLE

66 outpatient women with breast cancer who were receiving chemotherapy.

METHODS

Piecewise linear mixed models analysis was used to study changes in exercise behaviors over time in the EE group during and after treatment. In addition, linear mixed models analysis was used to examine changes between the EE and CE groups after treatment. Participants were in the trial for various length of time (EE group: 19-86 weeks; CE group: 6-43 weeks).

MAIN RESEARCH VARIABLES

Exercise frequency, intensity, and duration.

FINDINGS

In the EE group, weekly exercise duration increased significantly during treatment (p = 0.02). In addition, weekly exercise intensity increased significantly during treatment (p = 0.02) and decreased significantly after treatment (p = 0.003). After treatment, initial weekly exercise duration was significantly lower in the CE group than in the EE group (p = 0.01). No significant differences existed in frequency and intensity over time between the EE and CE groups.

CONCLUSIONS

Women with breast cancer can sustain exercise behaviors when they start an exercise intervention in the beginning of chemotherapy treatment.

IMPLICATIONS FOR NURSING

Strategies to support patients in maintaining their exercise habit may be needed during the post-treatment period.

Comparisons of exercise dose and symptom severity between exercisers and nonexercisers in women during and after cancer treatment

CONTEXT

Although numerous studies of the efficacy of exercise are reported, few studies have evaluated changes in characteristics of exercise dose in women with cancer both during and after cancer treatment.

OBJECTIVES

To describe the characteristics of exercise dose (i.e., frequency, duration, and intensity) and evaluate for differences in symptom severity (i.e., fatigue, sleep disturbance, depression, and pain) between women who did and did not exercise during and after cancer treatment.

METHODS

In a sample of 119 women, two groups were classified: exercisers and nonexercisers. Exercisers were defined as women who met specific criteria for frequency (three times per week), duration (20 minutes/session), intensity (moderate), and mode (aerobic). Nonexercisers were defined as women who did not meet all these criteria. Evaluation of exercise dose was completed at baseline (T1: the week before chemotherapy cycle 2), at the end of cancer treatment (T2), and at the end of the study (T3: approximately one year after the T1 assessment) using self-report exercise questionnaires.

RESULTS

Approximately 50% of the participants exercised during treatment and 70% exercised after treatment. At T1, exercisers had lower total fatigue, lower behavioral and sensory subscale fatigue scores, and lower depression scores (P = 0.038) than nonexercisers. No significant differences in sleep disturbance or pain were found between groups. At T2, exercisers had lower cognitive/mood subscale fatigue and depression scores than nonexercisers (P = 0.047). At T3, no significant differences were found between groups in any symptom severity scores.

CONCLUSION

Both during and after cancer treatment, achieving or maintaining exercise guideline levels were met by most patients. Further study is needed to examine the link between exercise dose and symptom severity.

A randomized trial of aerobic exercise and sleep quality in lymphoma patients receiving chemotherapy or no treatments

BACKGROUND

Patients with lymphoma experience sleep problems that may be managed with aerobic exercise but no previous study has examined this issue.

METHODS

We randomized 122 patients with lymphoma to usual care (n = 62) or 12 weeks of supervised aerobic exercise training (AET; n = 60). Our primary sleep endpoint was global sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI). Secondary endpoints were the PSQI component scores. Planned subgroup analyses were also conducted.

RESULTS

Intention-to-treat analyses indicated that AET resulted in a nonsignificant (P = 0.16) improvement in global sleep quality compared with usual care [mean group difference = -0.64; 95% confidence interval (CI), -1.56 to +0.27]. In planned subgroup analyses, statistically significant or borderline significant interactions were identified for type of lymphoma (P(interaction) = 0.006), current treatment status (P(interaction) = 0.036), time since diagnosis (P(interaction) = 0.010), body mass index (P(interaction) = 0.075), and baseline sleep quality (P(interaction) = 0.041). Specifically, AET improved global sleep quality in patients with lymphoma who had indolent non-Hodgkin lymphoma (P = 0.001), were receiving chemotherapy (P = 0.013), were <2 years post-diagnosis (P = 0.005), were obese (P = 0.025), and were poor sleepers at baseline (P = 0.007).

CONCLUSIONS

AET did not significantly improve sleep quality in this heterogeneous sample of patients with lymphoma; however, clinically identifiable subgroups appeared to benefit. Future exercise trials targeting these responsive subgroups are needed to confirm these findings.

IMPACT

If replicated in larger and more focused trials, aerobic exercise may be an attractive option to manage sleep dysfunction in patients with cancer because of its favorable safety profile and other documented health benefits.

The efficacy of exercise in reducing depressive symptoms among cancer survivors: a meta-analysis

INTRODUCTION

The purpose of this meta-analysis was to examine the efficacy of exercise to reduce depressive symptoms among cancer survivors. In addition, we examined the extent to which exercise dose and clinical characteristics of cancer survivors influence the relationship between exercise and reductions in depressive symptoms.

METHODS

We conducted a systematic search identifying randomized controlled trials of exercise interventions among adult cancer survivors, examining depressive symptoms as an outcome. We calculated effect sizes for each study and performed weighted multiple regression moderator analysis.

RESULTS

We identified 40 exercise interventions including 2,929 cancer survivors. Diverse groups of cancer survivors were examined in seven exercise interventions; breast cancer survivors were examined in 26; prostate cancer, leukemia, and lymphoma were examined in two; and colorectal cancer in one. Cancer survivors who completed an exercise intervention reduced depression more than controls, d(+) = -0.13 (95% CI: -0.26, -0.01). Increases in weekly volume of aerobic exercise reduced depressive symptoms in dose-response fashion (β = -0.24, p = 0.03), a pattern evident only in higher quality trials. Exercise reduced depressive symptoms most when exercise sessions were supervised (β = -0.26, p = 0.01) and when cancer survivors were between 47-62 yr (β = 0.27, p = 0.01).

CONCLUSION

Exercise training provides a small overall reduction in depressive symptoms among cancer survivors but one that increased in dose-response fashion with weekly volume of aerobic exercise in high quality trials. Depressive symptoms were reduced to the greatest degree among breast cancer survivors, among cancer survivors aged between 47-62 yr, or when exercise sessions were supervised.

Soy protein based supplementation supports metabolic effects of resistance training in previously untrained middle aged males

OBJECTIVE

To determine changes in body composition, physical performance, metabolic and hormonal parameters induced by lifestyle counselling, resistance training and resistance training with soy protein based supplemention in middle aged males.

DESIGN

Randomised controlled study consisting of resistance training without (RT-G) or with (RTS-G) a soy protein based supplement and a control group with lifestyle education only (LE-G).

SUBJECTS

Forty healthy middle aged men (50-65 years, BMI 25-29.9 kg/m2).

MEASUREMENTS

Changes in body weight (BW) and waist circumference (WC) were measured and body composition (BC), fat mass (FM), lean body mass (LBM) were measured by skin fold anthropometry at baseline and after 12 weeks of intervention. In addition, changes in physical fitness, metabolic and hormonal parameters (lipids, glucose, fructosamines, insulin, insulin-like growth factor-1, Leptin, human growth hormone, dehydroepiandrosterone, testosterone, hs-CRP, Il-6) were evaluated.

RESULTS

Thirty-five participants completed the 12 week study. No significant changes in BW were noted although RM and WC dropped and LBM increased after training, particularly in the RTS group (FM 22.6 ± 5.5 kg to 21.2 ± 4.7 kg; LBM 68.5 ± 7.2 kg to 70.1 ± 7.4; p < 0.01). Subjects in the RTS group experienced more pronounced improvements in the strength measurements than the RT group. After the training intervention there were significant changes in hormonal and metabolic parameters as well as in glycemic control, particularly in the RTS group.

CONCLUSIONS

Our data suggest that resistance training, particularly in combination with a soy protein based supplement improves body composition and metabolic function in middle aged untrained and moderately overweight males.

Cancer-related fatigue: physical assessment is not enough

Cancer-related fatigue has been referred to as 'inevitable, unimportant and untreatable' (Stone et al, 2000), with patient experiences easily overlooked or even dismissed by health professionals. This article examines literature regarding the prevalence of cancer-related fatigue, its manifestation and assessment. It also aims to encourage fellow health professionals to reflect on their own practice when assessing and managing fatigue, and identifies the need to address the psychosocial dimensions of the experience, as well as the physical.

Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis

BACKGROUND

Depression is a distressing side effect of cancer and its treatment. In the general population, exercise is an effective antidepressant.

OBJECTIVE

We conducted a systematic review and meta-analysis to determine the antidepressant effect of exercise in cancer survivors.

DATA SOURCES

In May 2011, we searched MEDLINE, PsycInfo, EMBASE, CINAHL, CDSR, CENTRAL, AMED, Biosis Previews, and Sport Discus and citations from relevant articles and reviews.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials (RCT) comparing exercise interventions with usual care in cancer survivors, using a self-report inventory or clinician rating to assess depressive symptoms, and reporting symptoms pre- and postintervention.

STUDY APPRAISAL

Around 7,042 study titles were identified and screened, with 15 RCTs included.

SYNTHESIS METHODS

Effect sizes (ES) were reported as mean change scores. The Q test was conducted to evaluate heterogeneity of ES. Potential moderator variables were evaluated with examination of scatter plots and Wilcoxon rank-sum or Kruskal-Wallis tests.

RESULTS

The overall ES, under a random-effects model, was -0.22 (confidence interval, -0.43 to -0.09; P = 0.04). Significant moderating variables (ps < 0.05) were exercise location, exercise supervision, and exercise duration.

LIMITATIONS

Only one study identified depression as the primary endpoint.

CONCLUSIONS

Exercise has modest positive effects on depressive symptoms with larger effects for programs that were supervised or partially supervised, not conducted at home, and at least 30 minutes in duration.

IMPACT

Our results complement other studies showing that exercise is associated with reduced pain and fatigue and with improvements in quality of life among cancer survivors.

Sleep disturbance interventions in oncology patients and family caregivers: a comprehensive review and meta-analysis

Sleep disturbance is a significant problem for both oncology patients and family caregivers (FCs), and is associated with poorer functional status, quality of life, and potentially disease progression. This review describes a comprehensive literature search and meta-analysis of the efficacy of interventions for sleep disturbance in oncology patients and their FCs. This search revealed 47 studies that evaluated the effects of a number of interventions on sleep disturbance/sleep quality, as a primary or secondary outcome in oncology patients. The primary purposes of the review were to synthesize findings from intervention studies for sleep disturbance in oncology patients and their FCs; to evaluate the efficacy of these interventions; to identify gaps in the literature; and to provide directions for future research. In addition, all 47 intervention studies were evaluated in terms of key intervention and study characteristics. Both strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the efficacy of interventions, and may collectively guide future research. Finally, the importance of including the FC in sleep disturbance interventions is discussed. In light of the detrimental effects that sleep disturbance has on both the patient and the FC, this systematic review may better inform essential future intervention efforts.

Nutritional symptom and body composition outcomes of aerobic exercise in women with breast cancer

The purpose of this secondary analysis was to examine the nutritional symptoms and body composition outcomes of aerobic exercise in women with breast cancer. A single-blind clinical trial, randomized to tailored Pro-Self(©) exercise during and after chemotherapy, after chemotherapy only, or no Pro-Self (usual care). One hundred women, average age 49.9 years (SD = 9.6), participated. Mild taste changes, nausea, constipation, and anorexia were experienced by 47% to 55% at baseline and end of treatment but diminished post treatment. No group differences were found in total nutritional symptoms or symptom severity. Intervention group participants maintained lean body mass; control group participants had nonsignificant lean body mass loss. Issues related to self-report, protocol adherence, and generalizability limit findings. Aerobic exercise is useful in achieving healthy weight and body composition, but the intensity and duration achieved during cancer treatment and recovery did not produce significant changes.