Home-based physical activity intervention for breast cancer patients

Maintaining physical activity among older adults: 24-month outcomes of the Keep Active Minnesota randomized controlled trial

OBJECTIVE

To evaluate the efficacy at 6-, 12-, and 24-month follow-up of Keep Active Minnesota (KAM), a telephone and mail-based intervention designed to promote physical activity (PA) maintenance among currently active adults age 50 to 70.

METHOD

Participants who reported having recently increased their MVPA to a minimum of 2d/wk, 30 min/bout, (N=1049) were recruited in 2004 and 2005 from one large managed care organization in Minnesota, and randomly assigned to either treatment (KAM; N=523), or Usual Care (UC; N=526) with PA assessed using the CHAMPS questionnaire, and expressed as kcal/wk energy expenditure.

RESULTS

We find a sustained, significant benefit of the intervention at 6, 12 and 24 months. kcal/wk expenditure in moderate or vigorous activities was higher at 6 (p<.03, Cohen's d(6m)=.16), 12 (p<.04, d(12 m)=.13) and 24 months (p<.01, d(24 m)=.16) for KAM participants, compared to UC participants.

CONCLUSIONS

The KAM telephone- and mail-based PA maintenance intervention was effective at maintaining PA in both the short-term (6 months) and longer-term (12 and 24 months) relative to usual care.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Objective monitoring of physical activity after a cancer diagnosis: challenges and opportunities for enhancing cancer control

BACKGROUND: Because physical activity (PA) provides multiple medical and psychosocial benefits after a cancer diagnosis, greater integration of objective activity monitoring into research and clinical practice is warranted. OBJECTIVES: To review randomized PA trials in cancer survivors after diagnosis using an accelerometer or pedometer and make recommendations for integrating objective monitoring into research and practice. MAJOR FINDINGS: Ten published PA and post-cancer diagnosis randomized trials have used pedometers (n=3), accelerometers (n=3), or both (n=4). Pedometers were primarily used to motivate PA adherence with several studies also using unblinded pedometers to assess the intervention effect on PA adherence. Accelerometers were primarily used to assess PA adherence after a PA intervention with one study using accelerometers to assess PA increase as a benefit of a non-PA intervention. One study used accelerometers to document sufficient ground forces for improving bone density in cancer survivors. Across studies, the reported objective monitoring outcome varied and was not always consistent with the stated intervention goal. CONCLUSIONS: PA and post-cancer diagnosis randomized trials have used objective monitoring primarily for motivation and/or adherence assessment. Investigators and practitioners are encouraged to expand the use of objective monitoring to also include understanding mechanisms of PA benefits and assess non-PA treatment modality effects. Future clinical and research protocols should consider the 1) outcome to be measured and reported, 2) need (or not) for blinding of the instrument outputs to participants, 3) appropriateness of activity intensity cutpoints for interpreting accelerometer data, and 4) logistical issues relevant to cancer survivors after diagnosis.

Psychological effects and mediators of a group multi-component program for breast cancer survivors

This study evaluated the short-term impact of YWCA Encore, a mixed-modality group exercise and information support program for breast cancer patients situated in the community setting. Australian post-surgical breast cancer patients (N = 162) were assigned to either the 8-week Encore intervention or a Waitlist control. Intervention impact was assessed in terms of quality of life, cancer-specific distress, and social support. Changes in familiarity with exercise, self-efficacy and social support were tested as mediators of the intervention impact on quality of life. Overall adherence and satisfaction with the program were high. Significant enhancements at follow-up for quality of life and social support were evident for intervention compared with control participants. Familiarity with exercise and self-efficacy satisfied the requirements for mediation of quality of life. These findings provide evidence for psychosocial benefits of YWCA Encore multi-component program and support the use of such community-based programs for breast cancer survivors. The role of exercise familiarity and self-efficacy as probable mediators of the multi-component intervention is a critical finding and highlights the need for future investigations into the underlying mediating processes of similar interventions for cancer patients.

Risks and benefits of physical activity among breast cancer survivors who have completed treatment

Worldwide, over 1 million cases of breast cancer are diagnosed each year. In the USA, approximately 185,000 women are newly diagnosed annually. Nearly 90% of newly diagnosed cancer patients in the USA will live for 5 years beyond diagnosis and there are estimated to be 2.4 million breast cancer survivors currently living in the USA. There are unique challenges in meeting the medical needs of these survivors. Persistent impairment and increased medical risks can occur as a result of treatment, including changes to the cardiovascular, pulmonary, endocrine, immune, musculoskeletal, neurological and lymphatic systems. Physical activity can cause positive changes in each of these body systems. However, physiologic impairments and altered risks for cardiopulmonary, bone health, neurosensory and other outcomes among breast cancer survivors can cause confusion regarding the safety of returning to exercise after treatment. In this article, we review the adverse effects of cancer treatments on the body systems affected by and used to perform exercise, the risks of exercise among breast cancer survivors, the effects of exercise on persistent treatment toxicities, whether exercise may prevent recurrence or mortality, as well as providing guidance for exercise testing and prescription among breast cancer survivors.

Motivational interviewing for adherence problems in cystic fibrosis

This review focuses on adherence in cystic fibrosis (CF), and the factors known to influence it. In particular, it discusses the importance of effective communication in clinical settings and considers the evidence for the effectiveness of motivational interviewing (MI), to increase adaptation and adherence in physical health and CF. The review also contains an overview of the key concepts of MI, its' practice in medical settings and recommendations on how to adopt MI techniques in the routine care of people with CF.

An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis

INTRODUCTION

Approximately 11.1 million cancer survivors are alive in the United States. Activity prescriptions for cancer survivors rely on evidence as to whether exercise during or after treatment results in improved health outcomes. This systematic review and meta-analysis evaluates the extent to which physical activity during and post treatment is appropriate and effective across the cancer control continuum.

METHODS

A systematic quantitative review of the English language scientific literature searched controlled trials of physical activity interventions in cancer survivors during and post treatment. Data from 82 studies were abstracted, weighted mean effect sizes (WMES) were calculated from 66 high quality studies, and a systematic level of evidence criteria was applied to evaluate 60 outcomes. Reports of adverse events were abstracted from all studies.

RESULTS

Quantitative evidence shows a large effect of physical activity interventions post treatment on upper and lower body strength (WMES = 0.99 & 0.90, p < 0.0001 & 0.024, respectively) and moderate effects on fatigue and breast cancer-specific concerns (WMES = -0.54 & 0.62, p = 0.003 & 0.003, respectively). A small to moderate positive effect of physical activity during treatment was seen for physical activity level, aerobic fitness, muscular strength, functional quality of life, anxiety, and self-esteem. With few exceptions, exercise was well tolerated during and post treatment without adverse events.

CONCLUSIONS

Current evidence suggests many health benefits from physical activity during and post cancer treatments. Additional studies are needed in cancer diagnoses other than breast and with a focus on survivors in greatest need of improvements for the health outcomes of interest.

Physical activity and breast cancer survivorship

A diagnosis of breast cancer is associated with treatments that have physiologic effects beyond the intended curative therapy. The first section of this chapter provides and integrative physiology review of the effects of breast cancer treatment on the body systems used by and affected by physical activity, including effects of chemotherapy, radiation, and surgery. In later sections, we review the literature on physical activity and breast cancer from the point of diagnosis and for the balance of life. The efficacy of physical activity for supportive cancer care outcomes is reviewed separately from the purported usefulness of physical activity for disease-free and overall survival from breast cancer. The current evidence supports the safety of physical activity during and after breast cancer therapy. The supportive cancer care outcomes for which there is sufficient evidence of efficacy during and after breast cancer treatment include fitness, fatigue, body size, and quality of life. Further, there is growing evidence that upper body exercise does not pose additional risk for negative lymphedema outcomes among survivors with and at risk for lymphedema. For overall survival, the evidence is largely observational, with sufficient evidence that physical activity does confer benefit. Finally, we outline future directions for research on physical activity among breast cancer survivors, including expanding to focus on subsets of the population not included in most prior studies (minority women and older women), tailoring of interventions to stages of cancer most likely to benefit, expanding to study women with metastatic cancer, and new modes of exercise, such as team sports, martial arts, and Pilates.

Integrative review: behavioral interventions for physical activity practice

This study aimed to carry out an integrative literature review on the effectiveness of interventions in physical activity (PA) practice in the general population. The search was carried out in articles indexed in online databases: Scopus, CINAHL and Medline. Studies in English or Brazilian Portuguese were included, with evidence levels 2 or 3, published between 2004 and 2008. The final sample consisted of 14 studies. In 57.1% of the studies, interventions were effective for behavior change to practice PA. The diversity of target populations, assessment instruments and intervention designs makes it difficult to compare results and build evidence on the effectiveness of interventions for PA promotion.

Causal relationships among factors associated with cancer-related fatigue

PURPOSE

This study was conducted to develop and verify a comprehensive model, which illustrates the dynamic causal relationships between fatigue and its associated factors in cancer patients.

METHOD

The subjects were 110 in- or out-patients with various types of cancer being treated at a University Hospital, Incheon, South Korea. The comprehensive model consists of physical distress, sleep-related, physiologic, psychological distress, physical performance, and exercise factors.

RESULTS

Psychological distress had a significant direct effect on physical distress, and 81% of the variance in physical distress was explained by psychological distress. While psychological distress showed to have a significant total effect (the sum of direct effects of psychological distress and indirect effects through its relationship with physical distress) on fatigue, it was not found to have a significant direct effect on fatigue. Only exercise had a significant direct effect on fatigue and 70% of fatigue variance was explained by exercise alone. All remaining factors were not found to have significant direct effects on fatigue.

CONCLUSIONS

The hypothetical model was well suited to explain cancer-related fatigue. Our result indicates that psychological distress should be relieved in combination with a strategy to reduce physical distress in order to obtain better outcomes with respect to cancer-related fatigue. Only exercise had a significant direct effect on fatigue. In terms of the nursing implications, the proposed model can help oncology nurses better understand cancer-related fatigue and assess presence of correctable correlates. This model can be a future framework when developing intervention strategies for cancer-related fatigue.

Tumorbedingte Fatigue

Zusammenfassung. Die tumorbedingte Fatigue ist ein verbreitetes und den Patienten sehr belastendes Syndrom im Rahmen der Krebserkrankung und -therapie. Tumorbedingte Fatigue (im angloamerikanischen Sprachraum als cancer-related fatigue, CRF, bezeichnet) geht einher mit dem subjektiven Gefühl von physischer und mentaler Müdigkeit, Erschöpfung, Energieverlust und wenig Möglichkeiten der Erholung. Es geht weit über das „normale” Maß an Erschöpfung hinaus, was gesunde Personen erleben. Tumorbedingte Fatigue kommt als Folge der Krebserkrankung selbst und als Nebeneffekt der Krebstherapie vor. Das genaue Ursachengefüge ist jedoch bislang nicht genau geklärt. Zum Diagnosezeitpunkt leiden bis zu 40%, im weiteren Verlauf der Krebsbehandlung mehr als 90% der Patienten unter tumorbedingter Fatigue. Unter der Strahlentherapie tritt die tumorbedingte Fatigue bei über 90%, während der Chemotherapie bei bis zu 80% der Betroffenen auf. Tumorbedingte Fatigue neigt zur Chronifizierung auch nach Abschluss der Therapie und ist dann umso belastender für die Patienten, da eine Ursachenzuschreibung erschwert ist. Die Beeinträchtigungen durch die tumorbedingte Fatigue sind beträchtlich, die Lebensqualität, das psychische Wohlbefinden so wie die Teilhabe am Alltagsleben und die berufliche Leistungsfähigkeit sind in aller Regel massiv eingeschränkt. Trotz dieser hohen Relevanz für Patienten und Behandler hat sich die Forschung über tumorbedingte Fatigue, im Vergleich zu anderen Begleitsymptomen der Krebserkrankung und -therapie, erst in den letzten Jahren intensiviert. Die vorliegende Arbeit gibt einen systematischen Überblick über epidemiologische Grundlagen, krankheitsbegleitende Aspekte sowie evaluierte nicht-medikamentöse Interventionen und ihren Stellenwert innerhalb der Behandlung tumorbedingter Fatigue.

Effects of Exercise Interventions on Body Image

Our meta-analysis examined the impact of exercise interventions on body image; and participant, intervention, and design features associated with larger effects. We identified 57 interventions (with pre-and post-data for the exercise and control groups) examining the effects of exercise on body image. A small random effect indicated that exercise intervention conditions had improved body image compared to control conditions; and that participant (age), design (year of publication), and intervention (exercise frequency and specificity) features moderated the effect size. Research examining the mechanisms and the exercise dose-response required for body image change is needed.

Quality of life after breast cancer: survivorship and sexuality

Breast cancer survivors make up a largest proportion of cancer survivors in the United States. This has prompted a concerted effort to address and meet the needs of this ever-growing population, far beyond the emphasis on improvements on therapy. Breast cancer survivors face multiple concerns that span the medical, psychosocial, sexual, and physical realms. Among these issues, concerns related to fatigue and distress, fertility considerations, and sexual dysfunction are perhaps ones that treating oncologists are not as comfortable in discussion and counseling their patients on. This report will focus on these four issues highlighting information for the treating oncologist which can assist in the evaluation, counseling, and treatment for their patients.

Exercise and relaxation intervention for breast cancer survivors: feasibility, acceptability and effects

OBJECTIVE

Although evidence mounts regarding the beneficial effects of physical activity (PA) interventions for breast cancer survivors, not all interventions have produced significant improvement in mood. Relaxation training may be a promising strategy for enhancing mood effects from these interventions. The goals of Be Calm and Move On were to assess the feasibility, acceptability and preliminary effects of a 12-week combined PA and relaxation intervention for breast cancer survivors.

METHODS

Twenty-three early-stage breast cancer survivors were enrolled and 19 were retained for the intervention and 12- and 24-week follow-ups. Participants received a theoretically grounded intervention delivered via telephone.

RESULTS

Participant evaluations of the intervention indicated that it was feasible and acceptable (e.g. 100% would recommend it to others); objective data further supported its feasibility (e.g. 83% completed the trial, 91% of intervention calls were received). In addition, when comparing 12- and 24-week follow-up data to baseline data, participants demonstrated significantly increased PA, improved mood and sleep quality, and reduced fatigue (p's<0.05).

CONCLUSION

Thus, this pilot study suggests that the intervention is feasible and acceptable and produces promising effects on mood, sleep, and fatigue.

A randomized trial to increase physical activity in breast cancer survivors

PURPOSE

Interventions to increase physical activity among breast cancer survivors are needed to improve health and quality of life and possibly to reduce the risk of disease recurrence and early mortality. Therefore, we report the feasibility and preliminary outcomes of a pilot randomized trial designed to increase physical activity in sedentary breast cancer survivors receiving hormone therapy.

METHODS

Forty-one sedentary women on estrogen receptor modulators or aromatase inhibitors for stage I, II, or IIIA breast cancer were randomly assigned to receive a 12-wk multidisciplinary physical activity behavior change intervention or usual care.

RESULTS

Recruitment was 34%, intervention adherence was 99%, and complete follow-up data were obtained on 93%. Most participants (93%) were white with mean age of 53 +/- 9 yr. Differences favoring the intervention group were noted for accelerometer physical activity counts (mean difference = 72,103; 95% confidence interval (CI) = 25,383-119,000; effect size (d) = 1.02; P = 0.004), aerobic fitness (mean difference = 2.9; 95% CI = -0.1 to 5.8; d = 0.64; P = 0.058), back/leg muscle strength (mean difference = 12.3; 95% CI = 0.4-15.9; d = 0.81; P = 0.017), waist-to-hip ratio (mean difference = -0.05; 95% CI = -0.01 to -0.08; d = -0.77; P = 0.018), and social well-being (mean difference = 2.0; 95% CI = 0.3-3.8; d = 0.76; P = 0.03). However, the intervention group also reported a greater increase in joint stiffness (mean difference = 1.1; 95% CI = 0.1-2.2; d = 0.70; P = 0.04).

CONCLUSIONS

A behavior change intervention for breast cancer survivors based on the social cognitive theory is feasible and results in potentially meaningful improvements in physical activity and selected health outcomes. Confirmation in a larger study is warranted.

Promoting Lifestyle Change Among Cancer Survivors: When Is the Teachable Moment?

There is mounting evidence that cancer survivors who adopt a healthy lifestyle—for example, by exercising, consuming a healthy diet, and not smoking—reap physical and emotional benefits. Depending on the behavior targeted, these benefits may include reduced fatigue, improved physical functioning, improved quality of life, and greater likelihood of disease-free survival. Given the advantages, cancer survivors should be urged to address any unhealthy behaviors. It remains unclear, however, when cancer survivors will be most receptive to advice from health care providers and others about their lifestyle behaviors. In other words, it is unclear if a “teachable moment” occurs shortly after the cancer diagnosis, during cancer treatment, or sometime after treatment has been completed. This review describes the reasons it has been difficult to identify the optimal time within the cancer trajectory to promote healthy lifestyle behaviors. Some strategies for clarifying the optimal timing are discussed. The review concludes by summarizing health behavior recommendations for cancer survivors outlined by an American Cancer Society expert panel.

Group vs. individual exercise interventions for women with breast cancer: a meta-analysis

BACKGROUND: Both during and after treatment, cancer survivors experience declines in physical and psychosocial quality of life (QoL). Prior research indicates that exercise interventions alleviate problems in physical functioning and some aspects of psychological functioning. For survivors seeking social support, exercise programs that are conducted in group settings may foster optimal QoL improvement (by addressing additional issues related to isolation, social support) over individually-based exercise programs. METHODS: We reviewed literature on group cohesion in exercise studies, and conducted a meta-analysis to test the hypothesis that group as compared to individual exercise interventions for breast cancer survivors would show greater improvement in QoL. RESULTS: As currently implemented, group exercise interventions showed no advantage. However, they typically did not provide any evidence that they capitalized upon potentially beneficial group processes. CONCLUSIONS: Future exercise intervention studies could investigate the effect on QoL of deliberately using group dynamics processes, such as team building experiences and group goal setting to foster group cohesion.

A structured exercise program for patients with advanced non-small cell lung cancer

INTRODUCTION

Exercise improves functional outcome and symptoms for certain cancer populations, but the feasibility, efficacy, and safety of structured exercise in patients with lung cancer is unknown. In this study, we examined the feasibility of a hospital-based exercise program for patients with advanced non-small cell lung cancer.

METHODS

This study included patients with newly diagnosed advanced stage non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0-1. A physical therapist facilitated twice-weekly sessions of aerobic exercise and weight training over an 8-week period. The primary end point was feasibility of the intervention, defined as adherence to the exercise program. Secondary endpoints included functional capacity, measured by the 6-minute walk test and muscle strength, as well as quality of life, lung cancer symptoms and fatigue, measured by the Functional Assessment of Cancer Therapy-lung and Functional Assessment of Cancer Therapy-fatigue scales.

RESULTS

Between October 2004 and August 2007, 25 patients enrolled in the study. All participants received anticancer therapy during the study period. Twenty patients (80%) underwent the baseline physical therapy evaluation. Eleven patients (44%) completed all 16 sessions. An additional 6 patients attended at least 6 sessions (range, 6-15), and 2 patients only attended one session. Study completers experienced a significant reduction in lung cancer symptoms and no deterioration in their 6-minute walk test or muscle strength.

CONCLUSIONS

Although the majority of participants attempted the exercise program, less than half were able to complete the intervention. Those who completed the program experienced an improvement in their lung cancer symptoms. Community-based or briefer exercise interventions may be more feasible in this population.

Physical activity and health outcomes three months after completing a physical activity behavior change intervention: persistent and delayed effects

PURPOSE

We previously reported the effectiveness of a 12-week physical activity behavior change intervention for breast cancer survivors postintervention with this report, aiming to determine delayed and/or persistent effects 3 months after intervention completion.

METHODS

Forty-one sedentary women with stage I, II, or IIIA breast cancer currently receiving hormonal therapy were randomly assigned to receive the 12-week Better Exercise Adherence after Treatment for Cancer intervention or usual care. Assessments occurred at baseline, postintervention, and 3 months postintervention.

RESULTS

Weekly minutes of greater than or equal to moderate intensity physical activity measured by accelerometer showed a significant group by time interaction (F = 3.51; P = 0.035; between group difference in the mean change from baseline to 3 months postintervention, 100.1 minute, P = 0.012). Significant group by time interactions also showed sustained improvements from baseline to 3 months postintervention in strength (F = 3.82; P = 0.027; between group difference, 11.2 kg; P = 0.026), waist-to-hip ratio (F = 3.36; P = 0.041; between group difference, -0.04; P = 0.094), and social well-being (F = 4.22; P = 0.023; between group difference, 3.9; P = 0.039). A delayed reduction in lower extremity dysfunction 3 months postintervention was noted (F = 3.24; P = 0.045; between group difference in the mean change from postintervention to 3 months follow-up; P = -7.6; P = 0.015). No group by time effect was noted for fitness, body mass index, percent fat, bone density, total quality of life (Functional Assessment of Cancer Therapy-General), fatigue, endocrine symptoms, cognitive function, or sleep.

CONCLUSIONS

The intervention resulted in sustained improvements in physical activity, strength, central adiposity, and social well-being with lower extremity function benefits appearing 3 months after intervention completion. Testing translation in a multisite study is warranted.

Determinants of physical activity among women treated for breast cancer in a 5-year longitudinal follow-up investigation

OBJECTIVE

To estimate the 5-year trajectory of physical activity among women with breast cancer, and to evaluate biopsychosocial variables (health status, physical symptoms, health-related quality of life (HRQL), depressive symptoms, and social support), measured soon after breast cancer diagnosis, as predictors of the 5-year trajectory.

METHODS

Women diagnosed with Stage II or III regional breast cancer (n=227), surgically treated and awaiting the start of adjuvant therapy completed baseline assessments of medical, psychological, and behavioral functioning. Follow-up evaluations were conducted every 4 months during the first year and every 6 months during the subsequent 4 years (12 assessments total during the 5-year study). Mixed-effects modeling was utilized to estimate the baseline level of physical activity as well as rate of change over time. Measures of physical health status, HRQL, depressive symptoms, and social support were included as predictors of the physical activity trajectory.

RESULTS

A curvilinear pattern of change in physical activity was evident over the 5-year follow-up (p=0.002). Physical activity increased gradually during the first 18 months, then declined steadily over the subsequent 42 months. Poor physical health, depressive symptoms, and lower emotional HRQL were associated with less physical activity. Higher family support was associated with a slower decline in physical activity in the latter 42 months of the study.

CONCLUSIONS

Emotional HRQL following diagnosis with breast cancer appears to be important for sustaining physical activity in the first 1-2 years following diagnosis. Physical activity interventions among breast cancer survivors should address depressive symptoms early in the course of treatment.

Home-based exercise among cancer survivors: adherence and its predictors

OBJECTIVE

Evidence of the benefits of exercise for those treated for cancer has led to exercise interventions for this population. Some have questioned whether cancer patients offered a home-based intervention adhere to the exercise prescribed.

METHOD

We examined exercise adherence in a randomized controlled trial of a 12-week, home-based exercise trial for breast cancer patients. Three adherence outcomes were examined: minutes of exercise participation/week, number of steps taken during planned exercise/week, and whether the participant met her weekly exercise goal. Predictors of adherence (e.g. demographic and medical variables, Transtheoretical Model variables, history of exercise) were examined.

RESULTS

Findings indicate that participants significantly increased their minutes of exercise and steps taken during planned exercise from Week 1 to 12. The percentage of participants achieving exercise goals was highest in the first few weeks. Exercise self-efficacy significantly predicted each adherence outcome. Baseline PA predicted mean exercise session steps over the 12 weeks.

CONCLUSION

Adherence to a home-based exercise intervention for breast cancer patients changes over time and may be related to baseline levels of exercise self-efficacy.

Translating physical activity interventions for breast cancer survivors into practice: an evaluation of randomized controlled trials

BACKGROUND

Although physical activity (PA) interventions have been effective for improving health outcomes in breast cancer survivors, little is known relative to their potential for translation into practice.

PURPOSE

This review was designed to provide a quantitative estimate of the reporting of both internal and external validity in recent studies of PA in breast cancer survivors (BCS).

METHODS

The Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was utilized to assess the reporting of internal and external validity in 25 randomized controlled trials (RCTs) of PA and BCS published between 1998 and 2008. Each trial was evaluated relative to the degree it met criteria for each of the above dimensions.

RESULTS

The majority of studies in this review reported dimensions reflecting internal validity. The overall level of detail relative to external validity of PA interventions was rarely reported, limiting the generalizability of study findings.

CONCLUSIONS

As with many RCTs of health behavior change, detail relative to contextual elements of published PA interventions in BCS is limited. It is recommended that future physical activity interventions in BCS be designed to facilitate scalable and sustainable interventions for improving health outcomes in this population.

Psychological status in childhood cancer survivors: a report from the Childhood Cancer Survivor Study

Psychological quality of life (QOL), health-related QOL (HRQOL), and life satisfaction outcomes and their associated risk factors are reviewed for the large cohort of survivors and siblings in the Childhood Cancer Survivor Study (CCSS). This review includes previously published manuscripts that used CCSS data focused on psychological outcome measures, including the Brief Symptom Inventory (BSI-18), the Medical Outcomes Survey Short Form-36 (SF-36), the Cantril Ladder of Life, and other self-report questionnaires. Comparisons and contrasts are made between siblings and survivors, and to normative data when available, in light of demographic/health information and abstracted data from the medical record. These studies demonstrate that a significant proportion of survivors report more symptoms of global distress and poorer physical, but not emotional, domains of HRQOL. Other than brain tumor survivors, most survivors report both good present and expected future life satisfaction. Risk factors for psychological distress and poor HRQOL are female sex, lower educational attainment, unmarried status, annual household income less than $20,000, unemployment, lack of health insurance, presence of a major medical condition, and treatment with cranial radiation and/or surgery. Cranial irradiation impacted neurocognitive outcomes, especially in brain tumor survivors. Psychological distress also predicted poor health behaviors, including smoking, alcohol use, fatigue, and altered sleep. Psychological distress and pain predicted use of complementary and alternative medicine. Overall, most survivors are psychologically healthy and report satisfaction with their lives. However, certain groups of childhood cancer survivors are at high risk for psychological distress, neurocognitive dysfunction, and poor HRQOL, especially in physical domains. These findings suggest targeting interventions for groups at highest risk for adverse outcomes and examining the positive growth that remains despite the trauma of childhood cancer.

Physical activity and obesity in endometrial cancer survivors: associations with pain, fatigue, and physical functioning

OBJECTIVE

This study aims to determine the prevalence of physical activity and obesity and their relationship to physical functioning (PF), fatigue, and pain in endometrial cancer survivors.

STUDY DESIGN

Surveys were mailed to 200 survivors of endometrial cancer diagnosed within the last 5 years; 61% were returned. Surveys assessed physical activity, height and weight, comorbid health problems, PF, fatigue, and pain.

RESULTS

In all, 22% exercised in the past month at the level of current public health recommendations, 41% reported no physical activity, and 38% reported some activity. A total of 16% were overweight and 50% were obese. Both lower body mass index (BMI) and higher physical activity were related to better PF. Higher physical activity was related to less fatigue, primarily for patients of normal BMI.

CONCLUSION

Results suggest endometrial cancer survivors' obesity and inactivity contributes to poorer quality of life. This population could benefit from quality-of-life interventions incorporating physical activity.

Physical activity and quality of life in adult survivors of non-Hodgkin's lymphoma

PURPOSE

To examine the prevalence and correlates of physical activity in adult survivors of aggressive non-Hodgkin's Lymphoma (NHL) and to explore the association between physical activity level and health-related quality of life (HRQOL).

PATIENTS AND METHODS

Physical activity and HRQOL data from 319 survivors of NHL (mean age, 59.8 years, standard deviation, +/-14.8) who were diagnosed in Los Angeles County approximately 2 to 5 years before the study was analyzed.

RESULTS

One quarter of survivors of NHL met public health guidelines of 150 minutes or more of moderate to vigorous exercise per week. More than half (53%) reported some activity but less than 150 minutes per week, whereas 20% reported no physical activity. Females, those with lower perceived health competence, and individuals with more comorbid limitations were at increased risk for inactivity. Individuals who met public health guidelines reported better HRQOL than those who were sedentary. Interestingly, our findings suggest a significant positive association between HRQOL and those who get at least some exercise.

CONCLUSION

The effort to promote physical activity among cancer survivors, who are at risk for poor quality of life as a result of treatment, is of great importance to the health of this growing population. As NHL, similar to other cancers, becomes a disease that people live with as opposed to one that people die as a result of, oncologists and primary care physicians will be increasingly challenged to provide evidence-based guidance for the long-term management of the patient's health. Consideration should be given to how clinicians frame exercise-promoting messages to cancer survivors, especially to those who are sedentary.

Exercise and quality of life: strengthening the connections

Exercise improves quality of life (QOL) in people with cancer. Most oncology healthcare providers recognize the statement to be true because the research literature provides strong support for the physical and psychological benefits of exercise. Because the terms exercise, QOL, and people with cancer have different meanings, the contextual connections in which they are used are important to understanding the relationship between exercise and QOL in people with cancer. This article explores the links between exercise and QOL in people with cancer and examines issues that impact the development, implementation, and evaluation of exercise programs for people with cancer. Issues related to exercise goal development, exercise prescription, exercise testing, exercise adherence, and methods to evaluate the efficacy of exercise in relation to QOL are discussed.

A meta-analysis of aerobic exercise interventions for women with breast cancer

The purpose of this meta-analysis was to examine the effectiveness of aerobic exercise interventions on cardiopulmonary function and body composition in women with breast cancer. Of 24 relevant studies reviewed, 10 studies (N = 588) met the inclusion criteria. The findings indicated that aerobic exercise significantly improved cardiopulmonary function as assessed by absolute VO2 peak (standardized mean difference [SMD] .916, p < .001), relative VO2 peak (SMD .424, p < .05), and 12-minute walk test ( SMD .502, p < .001). Similarly, aerobic exercise significantly improved body composition as assessed by percentage body fat (SMD -.890, p < .001), but body weight and lean body mass did not change significantly. Aerobic exercise during or after cancer adjuvant therapy seems to be an effective means of improving cardiopulmonary function and decreasing percentage body fat in women with breast cancer. Further studies are needed to examine the long-term benefits of aerobic exercise.

Evidence-based effect size estimation: an illustration using the case of acupuncture for cancer-related fatigue

Background

Estimating a realistic effect size is an important issue in the planning of clinical studies of complementary and alternative medicine therapies. When a minimally important difference is not available, researchers may estimate effect size using the published literature. This evidence-based effect size estimation may be used to produce a range of empirically-informed effect size and consequent sample size estimates. We provide an illustration of deriving plausible effect size ranges for a study of acupuncture in the relief of post-chemotherapy fatigue in breast cancer patients.

Methods

A PubMed search identified three uncontrolled studies reporting the effect of acupuncture in relieving fatigue. A separate search identified five randomized controlled trials (RCTs) with a wait-list control of breast cancer patients receiving standard care that reported data on fatigue. We use these published data to produce best, average, and worst-case effect size estimates and related sample size estimates for a trial of acupuncture in the relief of cancer-related fatigue relative to a wait-list control receiving standard care.

Results

Use of evidence-based effect size estimation to calculate sample size requirements for a study of acupuncture in relieving fatigue in breast cancer survivors relative to a wait-list control receiving standard care suggests that an adequately-powered phase III randomized controlled trial comprised of two arms would require at least 101 subjects (52 per arm) if a strong effect is assumed for acupuncture and 235 (118 per arm) if a moderate effect is assumed.

Conclusion

Evidence-based effect size estimation helps justify assumptions in light of empirical evidence and can lead to more realistic sample size calculations, an outcome that would be of great benefit for the field of complementary and alternative medicine.

Is exercise an acceptable and practical therapy for people with or cured of cancer? A systematic review

INTRODUCTION

Therapeutic exercise, although potentially beneficial, does not appear acceptable to many cancer patients. A greater understanding of the reasons for this is required. We have systematically reviewed the use of exercise in this group, identifying rates of uptake, adherence and completion along with factors influencing acceptability.

METHODS

Searches were completed using relevant key words. Data on study design, patient group, exercise intervention, patient flow data and reasons for declining or withdrawing from a programme were independently extracted by two researchers. Rates of study uptake, completion and adherence were compared according to dichotomised patient or programme characteristics using Mann Whitney U test (p=0.05). Reasons provided when declining or withdrawing from a study were categorised.

RESULTS

Sixty five studies were included. The majority contained groups made up entirely or predominantly of patients with breast cancer offered an aerobic or resistance exercise programme. The median [IQR] rates of uptake, adherence and completion were 63 [33-80]%, 84 [72-93]% and 87 [80-96]%, respectively. No characteristic influenced the proportion of patients taking up or completing a programme. The main reasons for refusal were disinterest or the impracticality of undertaking the programme and for withdrawal, medical complication or deterioration.

CONCLUSIONS

The invitation to undertake a programme of therapeutic exercise is accepted by about two-thirds of patients. Rates of adherence and completion are relatively high, but overall, only about half of patients offered a programme complete one. There is a need to modify exercise programmes if they are to be acceptable for the majority of patients.

A biobehavioral model for the study of exercise interventions in cancer-related fatigue

Cancer-related fatigue (CRF) is a multifactorial, biobehavioral phenomenon experienced by the majority of persons with cancer. It has negative consequences on the individual's physical functioning and quality of life. An array of biological, psychobehavioral, and functional mechanisms contributes to its occurrence. A relatively large number of studies have examined the effect of physical exercise on CRF over the past few decades. Most of these studies did not specifically examine the effect of physical exercise on the biobehavioral mechanisms underlying CRF. For the most part, these studies have not been guided by a consistent theoretical model. Consequently, the mechanisms by which exercise may ameliorate CRF are not fully elucidated. A theoretical model incorporating fatigue-related biobehavioral variables that could be affected by physical exercise will allow for effective knowledge development in this area and could lead to the development and refinement of exercise protocols that specifically target these mechanisms. Thus, the purpose of this paper is to present a comprehensive theoretical model to guide future research on the effectiveness of exercise interventions in CRF. The proposed model incorporates the biological, psychobehavioral, and functional variables implicated in the induction of CRF.

Dimensions of physical activity and their relationship to physical and emotional symptoms in breast cancer survivors

BACKGROUND

Many breast cancer survivors experience long term sequelae, including fatigue, decreased physical functioning, pain, and psychological distress. Physical activity can ameliorate these problems, but there is little research on how activity should be performed to be most beneficial. This study explores how dimensions of physical activity (total energy expenditure, frequency, and duration) are associated with symptoms among breast cancer survivors.

METHODS

We conducted a secondary analysis of data on physical activity behavior and symptoms in a cross-sectional study (n = 148) of breast cancer survivors who were off treatment and had been diagnosed within the past 5 years.

RESULTS

Multivariate analyses showed that total energy expenditure was associated with better general health (p = 0.006) and fewer depressive symptoms (p = 0.014), while frequency of activity was linearly related to physical functioning (p = 0.047), pain (0.057), general health (p < 0.001), and depressive symptoms (p < 0.001). Duration was related to physical functioning, pain, and general health, but the worst outcomes were reported by the participants with the shortest and longest duration of activity (quadratic trend p values = 0.002, 0.003, 0.008, respectively).

DISCUSSION/CONCLUSIONS

Greater total energy expenditure, higher physical activity frequency, and moderate duration were associated with better outcomes for most symptoms, although there was no relationship between any of the dimensions of physical activity and fatigue.

IMPLICATIONS FOR CANCER SURVIVORS

The association of better outcomes with higher energy expenditure, higher frequency of activity, and moderate duration indicates that increasing activity through multiple short bouts may be the most beneficial for breast cancer survivors. However, randomized studies are needed to confirm this finding.

Social and physical environments of sports and exercise reported among adults in the American Time Use Survey

OBJECTIVE

Demographic and temporal patterns in the social and physical environments of sports and exercise in the American Time Use Survey (years 2003-2006) are described.

METHOD

The sample consisted of adult respondents (ages 21+) reporting at least one bout of sports or exercise (N=8844). During the interview, participants reported where (e.g., outdoors, home, work) and with whom (e.g., alone, family, coworkers) each bout occurred. Sample-weighted multinomial logistic regression analyses estimated the adjusted proportion of bouts occurring in each environment by gender, age, education, race/ethnicity, season, weekend/weekday, and time of day.

RESULTS

Among members of the oldest age group (ages 60+), more exercise bouts occurred alone and outdoors compared to younger age groups. Among college graduates, more exercise bouts occurred at a gym/health club compared to groups with lower levels of education. Exercise bouts occurring alone were most likely to happen in the winter, on weekdays, and in the morning. Exercise bouts occurring outdoors were most likely to happen in the summer, on weekend days, and in the morning.

CONCLUSION

Future research and intervention efforts exploring where, when and with whom exercise bouts occur may prove beneficial to addressing public health concerns about physical inactivity.

Maintenance of effects of a home-based physical activity program among breast cancer survivors

PURPOSE

Although physical activity (PA) adoption improves fitness and psychological well-being among cancer survivors, PA maintenance has not been examined. This paper presents follow-up of a home-based PA program for women treated for early-stage breast cancer.

MATERIALS AND METHODS

Eighty-six sedentary women (mean age = 53.14 years, SD = 9.70) were randomly assigned to a PA or contact control group. The PA group received a 12-week telephone counseling program to adopt PA. Assessments were conducted at baseline, end-of-intervention (12 weeks), 6, and 9 months post-baseline.

RESULTS

When comparing change from end-of-intervention (12 weeks) between groups, a significant reduction was observed in minutes of PA at 6 months (t = -2.10, p < 0.05), but there was no decrease in intervention effect at 9 months (t = -0.19, p = 0.84). Similarly, post-intervention reductions in fatigue were lost at 6 months (t = 3.27, p < 0.01), but remained present at 9 months (t = 1.65, p = 0.10). PA group's fitness improvements were maintained at both follow-ups (t = 1.04, p = 0.30 and t = 0.05, p = 0.96). The previously significant intervention effect on vigor was maintained at 6 months (t = 1.32, p = 0.19) but was significantly reduced at 9 months (t = -2.15, p < 0.05). PA participants were more likely to progress in motivational readiness at 6 (OR = 5.95, 95% CI = 2.30, 15.36) and 9 months (OR = 4.09, 95% CI = 1.69, 9.87); however, group differences in meeting PA guidelines were not maintained.

CONCLUSION

Some positive effects of a home-based PA intervention for breast cancer patients were maintained at 6 and 9 months.

Theories underlying health promotion interventions among cancer survivors

OBJECTIVES

To review the theories that have been the basis for randomized controlled trials (RCTs) promoting health behavior change among adults diagnosed and treated for cancer.

DATA SOURCES

Electronic databases and recent review papers.

CONCLUSION

Several theories have been used in intervention development: Transtheoretical Model, Motivational Interviewing, Social Learning and Social Cognitive Theory, Theory of Planned Behavior, and Cognitive Behavioral Theory. There is support for the efficacy of some of these interventions. However, there has been limited assessment of theory-based constructs and examination of the mediational role of theoretical constructs in intervention efficacy.

IMPLICATIONS FOR NURSING PRACTICE

There is a need to apply theory in the development of interventions to assess the effects of the intervention on the constructs and to conduct mediational tests of these constructs.

A pilot study on disseminating physical activity promotion among cancer survivors: a brief report

There is growing evidence that physical activity (PA) can improve quality of life (QOL) and reduce fatigue in cancer survivors. Research staff or healthcare providers have delivered PA interventions to cancer populations. As a first step to dissemination of a previously tested PA intervention, seven American Cancer Society Reach to Recovery volunteers (mean age = 57.4 years) were trained to deliver the telephone-based intervention to 25 breast cancer survivors (mean age = 52.9 years, 56% Stage 2 cancer, mean of 3.3 years since diagnosis). A single group design was used. The theory-based intervention consisted of 12 weekly calls to encourage participants to adopt moderate-intensity PA. Participants' PA, QOL, mood, and fatigue were assessed at baseline, 12, and 24 weeks. Data on intervention feasibility and preliminary effects were collected. The intervention was feasible (mean of 10.7 out of 12 calls were delivered) and acceptable to the volunteers. At 12 weeks, there were significant increases in participants' PA and improvements in fatigue, QOL, and vigor. Effects were maintained at 24 weeks. This pilot study demonstrated that it was feasible for trained volunteers to deliver a telephone-based PA intervention to breast cancer survivors, and there were positive effects on survivors' PA behavior and psychological outcomes.

Physical Activity Behavior Change Interventions Based on the Transtheoretical Model: A Systematic Review

This review critically examines Transtheoretical Model (TTM)—based interventions for physical activity (PA) behavior change. It has been suggested that the TTM may not be the most appropriate theoretical model for applications to PA behavior change. However, previous reviews have paid little or no attention to how accurately each intervention represents the TTM. Findings comprise two sections: sample characteristics of each intervention reviewed and a summary outlining the use of the TTM to develop the interventions. Results reveal numerous inconsistencies regarding the development and implementation/application of TTM-based interventions. Specifically, the majority of interventions reported to be based on the TTM fail to accurately represent all dimensions of the model. Therefore, until interventions are developed to accurately represent the TTM, the efficacy of these approaches and the appropriateness of the underpinning theoretical model cannot be determined.

Results of a diet/exercise feasibility trial to prevent adverse body composition change in breast cancer patients on adjuvant chemotherapy

PURPOSE

Patients with breast cancer on adjuvant chemotherapy can experience weight gain and concurrent losses in muscle mass. Exercise interventions can prevent these changes, but time and travel pose barriers to participation. The Survivor Training for Enhancing Total Health (STRENGTH) trial assessed the feasibility and impact of 2 home-based interventions.

PATIENTS AND METHODS

Ninety premenopausal patients with breast cancer on adjuvant chemotherapy were randomized to a calcium-rich diet (CA) intervention (attention control) or to 2 experimental arms: a CA + exercise (EX) arm or a CA + EX and high fruit and vegetable, low-fat diet (FVLF) arm. Exercise arms included aerobic and strength-training exercises. Body composition, weight status, waist circumference, dietary intake, physical activity, quality of life, anxiety, depression, serum lipids, sex hormone binding globulin, insulin, proinsulin, C-reactive protein, interleukin-1B, and tumor-necrosis factor receptor-II were measured at baseline and at 6-month follow-up.

RESULTS

Accrual targets were achieved and modest attrition was observed (8.8%). Self-reports suggest increased calcium intakes in all arms, and higher fruit and vegetable and lower fat intake in the CA + EX + FVLF arm; no differences in physical activity were observed. While measures of adiposity were generally lower in the CA + EX + FVLF arm, the only significant difference was in percentage of body fat (arms and legs); change in scores (mean +/- standard deviation) were +0.7% +/- 2.3% (CA); +1.2% +/- 2.7% (CA + EX); and +0.1% +/- 2% (CA + EX + FVLF; P = .047). Lean body mass was largely preserved, even in the control arm (net gain of 452 g +/- 2395 g). No differences were observed in other endpoints.

CONCLUSION

Diet and exercise interventions can prevent weight gain and adverse body composition changes, but more research is needed to determine optimally effective interventions that can be implemented during active treatment and that promote adherence.

The development of an evidence-based physical self-management rehabilitation programme for cancer survivors

OBJECTIVE

This paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems are described: decreased aerobic capacity, decreased muscle strength, fatigue and impaired role physical functioning. The study aimed to identify the optimal content for an exercise programme that addresses these four physical problems, based on the highest level of evidence available. The study further aimed to review the evidence available on the delivery of the programmes. The final goal was to develop a programme in which content and delivery are based on the best available evidence.

METHODS

Literature searches (PUBMED and MEDLINE, to July 2006) on content looked for evidence about the efficacy of exercise on aerobic capacity, muscle strength, fatigue and impaired role physical functioning. Literature searches on delivery looked for self-management and/or self-efficacy enhancing techniques in relation to outcome, adherence to and/or adoption of a physically active lifestyle.

RESULTS

Evidence on the effectiveness of exercise in cancer patients varies and increases when moving from muscle strength (RCT level), fatigue and physical role functioning to aerobic capacity (all at the meta-analysis level). Effect sizes for aerobic capacity were moderate, while effect sizes for fatigue and physical role functioning were zero and/or small. Many of the studies have significant methodological shortcomings. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

CONCLUSION

Limited data are available on the effectiveness of exercise for cancer patients. Although evidence supports the positive effects of exercise on exercise capacity during and after completion of cancer treatment, the effects for fatigue and role functioning are ambiguous. Evidence on the effectiveness of progressive exercise training on muscle strength is promising. In addition, some evidence supports the positive effects of self-management programmes and self-efficacy enhancing programmes on health outcomes, exercise adherence and later exercise behaviour.

PRACTICE IMPLICATIONS

The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. The content is based on information obtained from the present review, and on the recommendations of the American College of Sports Medicine. Potential advantages of the programme include: (a) tailored physical training towards focusing on the patient's established problems and (b) delivery of the training as a self-management programme that might have beneficial effects on health outcome, exercise adherence and a long-term physically active lifestyle.

High-intensity strength training improves quality of life in cancer survivors

INTRODUCTION

Cancer rehabilitation programs mainly involve endurance training, and little attention is paid to strength training. Cancer survivors are generally advised to train at much lower workloads than the standard guidelines for strength training suggest. The purpose of this study is to evaluate the effectiveness of an 18-week high-intensity strength training program in cancer survivors.

METHODS

Fifty-seven patients (age 24 to 73 years) who had received chemotherapy for lymphomas, breast, gynecologic, testicular, or colorectal cancer completed the program. Outcome measures were changes in muscular strength (one-repetition maximum), cardiopulmonary function (VO2 max), maximal short exercise capacity (MSEC), body composition and health-related quality of life (HRQOL) between baseline and follow-up.

DISCUSSION

The high-intensity strength training was well tolerated by all patients. Significant improvements in muscle strength were found, with effect sizes varying from 1.32 to 2.68. VO2 max increased significantly by 10% in men and by 13% in women. Different functional scales of HRQOL improved (p < 0.01), with effect sizes varying from 0.47 to 0.82. Muscle strength correlated significantly with physical functioning before and after the training program.

CONCLUSION

We conclude that a supervised, high-intensity strength training program seems to be an effective means to improve muscle strength, cardiopulmonary function, and HRQOL and should be incorporated in cancer rehabilitation programs. Further randomized trials are needed to confirm the results.

Exercise for the management of cancer-related fatigue in adults

BACKGROUND

Cancer-related fatigue is now 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 with no definitive conclusions regarding its effectiveness.

OBJECTIVES

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

SEARCH STRATEGY

The Cochrane Controlled Trials Register (CENTRAL/CCTR), MEDLINE (1966 to July 2007), EMBASE (1980 to July 2007), CINAHL (1982 to July 2007), British Nursing Index (January 1984 to July 2007), AMED (1985 to July 2007), SIGLE (1980 to July 2007), and Dissertation Abstracts International (1861 to July 2007) were all searched using key words. Reference lists off all studies identified for inclusion and relevant reviews were also searched. In addition, relevant journals were hand searched and experts in the field of cancer-related fatigue were contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that investigated the effect of exercise on cancer-related fatigue in adults were included.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Twenty-eight studies were identified for inclusion (n = 2083 participants), with the majority carried out on participants with breast cancer (n = 16 studies; n = 1172 participants). A meta-analysis of all fatigue data, incorporating 22 comparisons provided data for 920 participants who received an exercise intervention and 742 control participants. At the end of the intervention period exercise was statistically more effective than the control intervention (SMD -0.23, 95% Confidence Interval (CIs) -0.33 to -0.13).

AUTHORS' CONCLUSIONS

Exercise can be regarded as beneficial for individuals with cancer-related fatigue during and post cancer therapy. Further research is required to determine the optimal type, intensity and timing of an exercise intervention.

A brief intervention for fatigue management in breast cancer survivors

The purpose of this randomized control trial was to verify the effectiveness of a brief group intervention that combines stress management psycho-education and physical activity (ie, independent variable) intervention in reducing fatigue and improving energy level, quality of life (mental and physical), fitness (VO 2submax), and emotional distress (ie, dependent variables) in breast cancer survivors. This study applied Lazarus and Folkman stress-coping theoretical framework, as well as Salmon's unifying theory of physical activity. Eighty-seven French-speaking women who had completed their treatments for nonmetastatic breast cancer at a university hospital in Quebec City, Canada, were randomly assigned to either the group intervention (experimental) or the usual-care (control) condition. Data were collected at baseline, postintervention, and at 3-month follow-up. The 4-week group intervention was cofacilitated by 2 nurses. Results showed that participants in the intervention group showed greater improvement in fatigue, energy level, and emotional distress at 3-month follow-up, and physical quality of life at postintervention, compared with the participants in the control group. These results suggest that a brief psycho-educational group intervention focusing on active coping strategies and physical activity is beneficial to cancer survivors after breast cancer treatments.

Impact of a mixed strength and endurance exercise intervention on insulin levels in breast cancer survivors

PURPOSE

Accumulating data suggest that exercise may affect breast cancer risk and outcomes. Studies have demonstrated that high levels of insulin, often seen in sedentary individuals, are associated with increased risk of breast cancer recurrence and death. We sought to analyze whether exercise lowered insulin concentrations in breast cancer survivors.

METHODS

One hundred one sedentary, overweight breast cancer survivors were randomly assigned either to a 16-week cardiovascular and strength training exercise intervention or to a usual care control group. Fasting insulin and glucose levels, weight, body composition, and circumference at the waist and hip were collected at baseline and 16 weeks.

RESULTS

Baseline and 16-week measurements were available for 82 patients. Fasting insulin concentrations decreased by an average of 2.86 microU/mL in the exercise group (P = .03), with no significant change in the control group (decrease of 0.27 microU/mL, P = .65). The change in insulin levels in the exercise group seemed greater than the change in controls, but the comparison did not reach statistical significance (P = .07). There was a trend toward improvement in insulin resistance in the exercise group (P = .09) but no change in fasting glucose levels. The exercise group also experienced a significant decrease in hip measurements, with no change in weight or body composition.

CONCLUSION

Participation in an exercise intervention was associated with a significant decrease in insulin levels and hip circumference in breast cancer survivors. The relationship between physical activity and breast cancer prognosis may be mediated, in part, through changes in insulin levels and/or changes in body fat or fat deposition.

Neuroendocrine-immune mechanisms of behavioral comorbidities in patients with cancer

Patients with cancer experience a host of behavioral alterations that include depression, fatigue, sleep disturbances, and cognitive dysfunction. These behavioral comorbidities are apparent throughout the process of diagnosis and treatment for cancer and can persist well into the survivorship period. There is a rich literature describing potential consequences of behavioral comorbidities in patients with cancer including impaired quality of life, reduced treatment adherence, and increased disease-related morbidity and mortality. Medical complications of cancer and its treatment such as anemia, thyroid dysfunction, and the neurotoxicity of cancer chemotherapeutic agents account in part for these behavioral changes. Nevertheless, recent advances in the neurosciences and immunology/oncology have revealed novel insights into additional pathophysiologic mechanisms that may significantly contribute to the development of cancer-related behavioral changes. Special attention has been focused on immunologic processes, specifically activation of innate immune inflammatory responses and their regulation by neuroendocrine pathways, which, in turn, influence CNS functions including neurotransmitter metabolism, neuropeptide function, sleep-wake cycles, regional brain activity, and, ultimately, behavior. Further understanding of these immunologic influences on the brain provides a novel conceptual framework for integrating the wide spectrum of behavioral alterations that occur in cancer patients and may reveal a more focused array of translational targets for therapeutic interventions and future research. Such developments warrant complementary advances in identification of cancer patients at risk as well as those currently suffering, including an increased emphasis on the status of behavior as a "sixth vital sign" to be assessed in all cancer patients throughout their disease encounter.

Behavioral symptoms in patients with breast cancer and survivors

Behavioral symptoms are a common adverse effect of breast cancer diagnosis and treatment and include disturbances in energy, sleep, mood, and cognition. These symptoms cause serious disruption in patients' quality of life and may persist for years after treatment. Patients need accurate information about the occurrence of these adverse effects as well as assistance with symptom management. This review considers four of the most common behavioral sequelae of breast cancer, namely fatigue, sleep disturbance, depression, and cognitive impairment. Research on the prevalence, mechanisms, and treatment of each symptom is described, concluding with recommendations for future studies.

Maintaining physical activity among older adults: six-month outcomes of the Keep Active Minnesota randomized controlled trial

OBJECTIVE

We evaluate the 6-month efficacy of Keep Active Minnesota, a phone- and mail-based physical activity maintenance intervention designed for use with adults age 50 to 70 years who have increased their physical activity within the past year.

METHOD

Participants (N=1049) recruited in 2004 and 2005 from one large managed-care organization in Minnesota were randomly assigned to either treatment (N=523) or usual care (N=526) with physical activity assessed using the Community Healthy Activities Model Program for Seniors questionnaire, and expressed as kcal/week expenditures.

RESULTS

Total physical activity at baseline was similar for treatment and usual care participants (p<0.44) as was moderate/vigorous physical activity (p<0.21). Maintenance of physical activity was higher among treatment participants whose mean 6-month change in total kcal/week energy expenditure was -91, compared to -683 for usual care participants (p<0.002). Mean 6-month change in kcal/week expenditure in moderate or vigorous activities was -49 for treatment participants, compared to -612 for usual care participants (p<0.001).

CONCLUSIONS

This phone- and mail-based physical activity maintenance intervention is efficacious at maintaining physical activity at 6 months.

Methodologic issues in exercise intervention research in oncology

OBJECTIVES

To review randomized controlled trials that offered exercise interventions for adults diagnosed and treated for cancer related to design, sample, type of intervention, and outcomes.

DATA SOURCES

Several electronic databases were searched and recent review papers were scanned to identify relevant publications.

CONCLUSION

Exercise adoption seems clearly feasible for early stage cancer patients, particularly breast cancer patients. Data support positive effects for physical functioning, quality of life, and psychological well-being. Effects for patients with later-stage disease and other cancers are less clear. The impact of exercise adoption on biomarkers of disease status, immune functioning, and hormone levels should also be examined.

IMPLICATIONS FOR NURSING PRACTICE

There are many opportunities for nurses to promote exercise in clinical care and in a research context.