ArticlePDF AvailableLiterature Review

Exercise Interventions for Cancer Patients: Systematic Review of Controlled Trials

January 2005
Cancer Causes & Control 15(10):1035-56

January 2005
15(10):1035-56

DOI:10.1007/s10552-004-1325-4

Source
PubMed

Authors:

Kenneth R Fox

University of Bristol

To systematically review controlled trials investigating the effects of exercise interventions in cancer patients. Studies were located through searching seven electronic databases (Medline, Embase, Cochrane Library, CancerLit, PsycInfo, Cinahl, SportDiscus), scanning reference lists of relevant articles, contacting experts (n = 20), and checking the contents lists of journals available through ZETOC (Electronic Table of Contents). To be included, trials had to be prospective, controlled, involve participants diagnosed with cancer and test an exercise intervention. Types of outcome were not restricted. Two reviewers independently applied the selection criteria. Thirty-three controlled trials (including 25 randomized trials) were included in the review. There was some evidence that physical function was increased among those who exercised. Furthermore, symptoms of fatigue did not appear to be increased and there were few adverse effects reported. There was insufficient evidence to determine effects on other outcomes, such as quality of life, with results hampered by the heterogeneity between studies as well as poor methodological quality. Data were also lacking on the long term effects of exercise relating to cancer recurrence or survival. There is preliminary evidence that exercise interventions for cancer patients can lead to moderate increases in physical function and are not associated with increased symptoms of fatigue. However, it is impossible from current evidence to determine whether exercise has long term beneficial effects on survival or quality of life.

Process of study selection.

…

(a) Effects of exercise on physical function in controlled trials recruiting patients with breast cancer [n ¼ 10]; (b) Effects of exercise on physical function in controlled trials recruiting patients with any cancer [n ¼ 9].

…

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Content uploaded by Kenneth R Fox

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Exercise interventions for cancer patients: systematic review of controlled trials

Clare Stevinson

*, Debbie A Lawlor

& Kenneth R Fox

Department of Exercise and Health Sciences, University of Bristol, Centre for Sport, Exercise and Health, Tyndall

Avenue, Bristol BS8 1TP, UK;

Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies

Road, Bristol BS8 2PR, UK

Received 16 April 2004; accepted in revised form 13 July 2004

Key words: cancer, rehabilitation, exercise, walking, fatigue.

Abstract

Objective: To systematically review controlled trials investigating the eﬀects of exercise interventions in cancer

patients.

Methods: Studies were located through searching seven electronic databases (Medline, Embase, Cochrane Library,

CancerLit, PsycInfo, Cinahl, SportDiscus), scanning reference lists of relevant articles, contacting experts (n ¼ 20),

and checking the contents lists of journals available through ZETOC (Electronic Table of Contents). To be

included, trials had to be prospective, controlled, involve participants diagnosed with cancer and test an exercise

intervention. Types of outcome were not restricted. Two reviewers independently applied the selection criteria.

Results: Thirty-three controlled trials (including 25 randomized trials) were included in the review. There was some

evidence that physical function was increased among those who exercised. Furthermore, symptoms of fatigue did

not appear to be increased and there were few adverse eﬀects reported. There was insuﬃcient evidence to determine

eﬀects on other outcomes, such as quality of life, with results hampered by the heterogeneity between studies as well

as poor methodological quality. Data were also lacking on the long term eﬀects of exercise relating to cancer

recurrence or survival.

Conclusions: There is preliminary evidence that exercise interventions for cancer patients can lead to moderate

increases in physical function and are not associated with increased symptoms of fatigue. However, it is impossible

from current evidence to determine whether exercise has long term beneﬁcial eﬀects on survival or quality of life.

Introduction

Exercise has a role in the management or rehabilitation

of an increasing number of chronic diseases including

coronary heart disease [1], hypertension [2], stroke [3],

obesity [4], non-insulin dependent diabetes [5] and

musculoskeletal disorders [6]. Although it has also been

recommended for helping cancer patients recover from

treatment [7], exercise rehabilitation is not generally

incorporated into cancer care or discussed with patients

[8, 9]. Potential beneﬁts of exercise include helping to

preserve or restore cardiopulmonary function, muscle

and bone strength, and mobility, all of which can be

adversely affected by cancer therapy. Furthermore,

exercise may help promote psychological well-being

following cancer diagnosis and treatment. Conversely,

there may be risks associated with exercise for cancer

patients, particularly possible exacerbation of fatigue –

an important symptom that affects more than half of all

patients to a signiﬁcant degree [10].

Several reviews of the literature have suggested that

exercise is likely to be beneﬁcial for cancer patients [11–

17]. However, in addition to not employing fully explicit

and systematic methods, these reviews have incorpo-

rated studies of various types including retrospective

surveys and uncontrolled trials. Clearer indications of

the effect of exercise interventions are provided by

prospective clinical trials with appropriate control

groups [18]. A recent systematic review in this area

identiﬁed 12 randomized trials and concluded that initial

* Address correspondence to: Clare Stevinson, Department of

Exercise and Health Sciences, University of Bristol, Centre for Sport

Exercise and Health, Tyndall Avenue, Bristol BS8 ITP, UK. Ph.: +44-

117-331-1108; Fax: +44-117-331-1148; E-mail: C.Stevinson@

bristol.ac.uk

Cancer Causes and Control 15: 1035–1056, 2004.

1035

2004 Kluwer Academic Publishers. Printed in the Netherlands.

evidence was promising for both physiological and

psychological beneﬁts of exercise [19]. In a more

extensive search of the literature we have identiﬁed 25

randomized trials and eight non- randomized studies and

have performed a statistical synthes is of the data in

order to determine the effects of exercise in cancer

patients.

Materials and methods

Search strategy

The following electronic databases were searched from

their respective inceptions to December 2003: Medli ne,

Embase, Cochrane Controlled Trials Register, Cancer-

Lit, Cinahl, PsycInfo, SportDiscus. Search terms in-

cluded subject headings and text words based on (i)

cancer (e.g., neoplasms; tumour; oncology); (ii) exercise

(e.g., exercise therapy; physical activity; sports); (iii)

clinical trials (e.g. , controlled clinical trials; random) and

were modiﬁed according to the speciﬁc vocabulary map

of each database. In addition, a simple search of ‘cancer

AND (exercise OR physical activity)’ was set-up via

ZETOC (Electronic Table of Contents) of all British

Library journals, with results received in a daily e-mail

notiﬁcation. Contact was made with 20 experts known

to be working in the ﬁeld to ask if they were aware of

any further published or unpublished trials [20]. Finally,

the reference lists of review articles on the subject and

studies already located were checked for potential trials.

Titles and available abstracts of all items identiﬁed by

the electronic searches were scrutinized by one author

(CS) and a random selection of 25% of the titles/

abstracts was independen tly assessed by a second au thor

(DAL) to check for consistency in selection. A kappa

score of 0.95 was achieved. Obtained reports were read

by two reviewers (100% by CS and 50% each by DAL

and KRF) who independently applied the selection

criteria. The three authors then met to discuss any

disagreements and reach consensus.

Selection criteria

Trials were included if they involved human participants

who had been diagnosed with cancer. Participants could

be of any age, either sex, have any type or stage of

cancer or be at any stage of treatment or recovery. Only

prospective trials with a control arm were included.

Control arms could comprise no intervention (e.g.,

normal care), an alternative intervention (e.g. , counsel-

ing, relaxation) or a diﬀerent exercise type (e.g., aerobic

versus ﬂexibility exercises). Trials with healthy or his-

torical control groups were excluded. Non-randomized

trials were included as well as randomized ones. This

was an a priori decision made on the basis that the

number of randomized trials might be small and that it

was important to appraise all available evidence. Trials

were included if they tested interventions involving

regular exercise of any type (e.g., aerobic, resistance,

ﬂexibility). Exercise could be the sole intervention or

combined with other interventions (e.g., diet, counsel-

ing). Trials of single exercise sessions that measured

acute eﬀects (e.g., [21]) were excluded, as were trials that

only investigated the eﬀects of physiotherapy (e.g., [22]).

There were no restrictions on the outcomes assessed in

trials. Both published and unpublished trials written in

any language, in full or abstract form were considered

for inclusion.

Data extraction

Included trials were read in full and data were

extracted by two reviewers (100% by CS and 50%

each by DAL and KRF) using a pre-piloted struc-

tured form. Any disagreements or discrepancies were

resolved throu gh discussion and checking the original

papers. Details on the study design, participants,

interventions, outcome measures, results and conclu-

sions were recorded. Where key information was not

reported, efforts were made to contact the authors in

order to obtain further de tails.

Quality assessment

In the absence of validated methods of assessing

methodological rigor suitable for trials of exercise

interventions, trial quality was assessed by recording

whether the following features were incorporated in the

study design: randomization; allocation concealment;

blinding of the main outcome assessment and inten-

tion-to-treat analysis. These have been identiﬁed as the

most important components in minimizing bias in

clinical trials [23]. Trials were deﬁned as randomized if

the method of allocating participants to intervention

and control groups was described using terms such as

random, randomly or randomization. Allocation con-

cealment was considered adequate if randomization

took place at a remote site or involved drawing sealed

sequentially numbered envelopes. Trials were deﬁned

as blind if the main outcomes were measured by an

assessor who was blind to group allocation. If the main

outcomes were measured by a non-blinded assessor or

by the participants themselves as with self-report

questionnaires, the trial was deﬁned as not blind.

Trials were deﬁned as using intention-to-treat analysis

1036 C. Stevinson et al.

if all patients were analysed in the groups to which

they were allocated, regardless of completion or

adherence. Studies described as using intention-to-treat

analysis that excluded participants not completing the

intervention, were recorded as not using intention-to-

treat analysis.

Data analysis

Included trials were summarized in tables and de-

scribed in the text. After completion of this descriptive

synthesis we examined the data to determine whether

there were areas where statistical pooling would be

possible. This was determined on the basis of having at

least four studies in a similar population group with a

similar outcome. On this basis we were able to examine

the effect of exercise on physical functioning in patients

with breast cancer and also examine the same outcome

in a separate pooling of studies that had included

patients with any cancer diagnosis. In addition we

performed a third meta-analysis of trials (irrespective

of cancer type) with fatigue as an outcome. Cancer-

related fatigue has been identiﬁed as an important

outcome and has the potential to be either reduced or

increased through exercise. It was considered appro-

priate therefore to try to quantify this possibility. For

each outcome (physical function and fatigue) effect

sizes were calculated for each trial using Cohen’s

method [24] to produce a standardized mean difference

for the effect of exercise. It was anticipated that there

would be systematic differences (heterogeneity) be-

tween the results of studies and a random effects model

using DerSimonian and Laird’s [25] method was used

to calculate the pooled effect size. Hete rogeneity

between studies was further explored using meta-

regression analysis to determine the role of trial type

(randomized or not), allocation concealment, blinding

of outcome assessment , intention-to-treat analysis and

cancer type (for the fatigue meta-analysis only) on

difference between studies [26]. Funnel plots were

examined and statistical evidence of small study bias

(indicative of publication bias) was assessed with Egger

and Begg tests [26]. All analyses were undertaken using

Stata version 8 [26].

Results

Figure 1 shows the outcome of the search process. From

the 80 reports of potential trials that were located, 40 did

not meet the eligibility criteria [27–66], and a total of 33

studies reported in 40 different papers were included in

the review [67–106]. Data were pooled for 19 trials that

assessed physical functioning and 12 trials that assessed

fatigue.

Trial characteristics

Table 1 shows the characteristics of included trials.

Thirteen trials included breast cancer patients during

[67, 70, 72, 74, 76, 77, 79–81], or after [68, 71, 73, 75]

adjuvant therapy. Eleven trials involved adult patients

with any cancer [85, 87, 90–93, 95–97, 99, 100] and

one involved paediatric cancer survivors [94]. The

remaining trials included patients undergoing treat-

ment for prostate [82–84], lung [104], colorectal [101],

or stomach [105] cancer, multiple myeloma [102] or

leukemia [106]. Nineteen studies tested aerobic exercise

interventions, of which eight used cycle ergometers

[68, 77, 79-81, 93, 96, 105], and eight used walking

programs [70, 71, 73, 74, 76, 85, 91, 95]. Three trials

tested resistive exercise [82, 83, 106], 10 had combined

aerobic and resistive programs [67, 75, 84, 86, 92, 97,

99, 100, 103, 104] and one study was based on team

sport activities [94]. Most trials compared an exercise

intervention with no intervention; six that did not,

used information training [84], psychological therapies

[85, 92], stretching [70, 88], or tai chi [71] as

comparison arms. Exercise interventions lasted for

10 weeks or longer in 17 trials [67, 68, 72, 73, 76, 77,

79–83, 85, 87, 90, 94, 101, 102], between 4 and

8 weeks in 12 trials [70, 71, 74, 75, 84, 91, 92, 95, 97,

99, 100, 106], and 2 weeks or less in four studies [93,

96, 104, 105]. The longest intervention period of any

trial was 26 weeks [72].

Methodological quality

Table 2 shows the methodological features of included

trials. In general, studies were of poor quality. There

were eight trials not using randomized allocation [73,

80, 81, 86, 93–95, 99], and of the 25 that did, only ﬁve

indicated that concealment of allocation may have been

adequate [68, 82, 92, 102, 104]. Two studies appeared to

include participants in the control group who had

declined to undertake the intervention [94, 99], and for a

further ﬁve studies it was unclear whet her eligibility

(including willingness to participat e) was determined

prior to group allocation or whether the control gro up

may have solely or partly consisted of those who

declined to be allocated to exercise [73, 80, 81, 88, 95].

Assessor blinding for a main outcome measure took

place in two trials [68, 100]. In 13 studies, the main

outcome measure was completed by the participant, so

blinding was not possible [72, 73, 79, 83–85, 92, 93, 97,

99, 101, 102, 104]. The other 18 trials for which assessor

Exercise for cancer patients 1037

blinding was possible, either did not use blinding [67,

96], or did not state if the assessor was blind to the

allocation group [70, 71, 74–77, 80–82, 87, 90, 91, 94,

95, 105, 106]. Four studies analysed data on an

intention-to-treat basis [69, 72, 83, 99]. In six other

papers intention-to-treat analysis was described [68, 85,

92, 93, 96, 101], but not all the allocated participants

were included in the analysis. Other methodol ogical

limitations that were common among included trials

were small sample sizes and multiple statistical testing.

Only eight trials had more than 30 participants per

group, [72, 83–85, 92, 97, 101, 104], and 14 trials had 10

or fewer subjects [67, 71, 73, 75, 76, 80–82, 87, 90, 91,

94, 100, 106]. Sample sizes were based on power

calculations in only nine trials [67, 68, 72, 74, 83, 85,

89, 94, 104], with two failing to recruit the required

number [67, 89], and a further trial reported an

insufﬁcient sample size from a post hoc power calcula-

tion [106]. Seventeen trials did not speciﬁcally state the

primary outcome measures [70, 73, 74, 76, 84, 87, 90–94,

97, 99, 100, 102, 104, 106], and even among those that

did, there were several with numerous secondary out-

come measures and sub-group analyses. With many

questionnaire measures having additional subscales and

with measurements taken at multiple time-points, some

studies involved considerable numbers of statistical

comparisons [68–70, 72, 76, 82–89, 91, 94, 97, 99, 101,

106]. Conclusions were commonly based on isolated

positive ﬁndings (those with a p-value below the

conventional 0.05 level), while the role of chance as an

explanation for these and results with higher p-values,

was disregarded.

Trial outcomes

Physical function

Thirteen trials reported small but statistically signiﬁ-

cant improvements in tests of aerobic capacity [68, 70,

77, 80, 81, 88, 90, 95, 100] or timed walk distances

[67, 74–76] following aerobic exercise programmes

lasting from 6 to 25 weeks. In one study, loss of

physical performance was attenuated among inpatients

80 papers reporting trials considered for inclusion

37 excluded

- 26 had no control group [29-54]

- 5 were abstracts duplicating data from full papers [55-59]

- 2 were not of prospective design [60, 61]

- 2 included non-cancer patients [62, 63]

- 1 had inadequate control group [64]

- 1 provided no data from control group [65]

2 unable to be traced [27, 28]

41 papers reporting trials meeting inclusion criteria

1 excluded during data extraction

- 1 data not analyzed according to group allocation [66]

40 papers included reporting a total of 33 trials [67-106]

10 trials assessing physical

function in breast cancer

patients included in statistical

analysis [67, 68, 70, 72, 74-

77, 80, 81]

9 trials assessing physical

function in patients with any

cancer included in statistical

analysis [85, 88, 90, 91, 94-

97, 99]

12 trials assessing fatigue in

cancer patients included in

statistical analysis [67, 68,

70, 74, 80, 82, 83, 85, 93, 97,

99, 101]

Fig. 1. Process of study selection.

1038 C. Stevinson et al.

Table 1. Characteristics of controlled clinical trials of exercise interventions for cancer patients

Author

Location

Participants

[Number

allocated/analysed]

Intervention and

control arms

Frequency and

duration

of exercise

Main endpoints Reported results Authors conclusion Reviewers

comments

Breast cancer

Campbell et al. [67]

United Kingdom

Breast cancer patients

receiving adjuvant

therapy [22/19]

(1) Supervised group

aerobic and

resistive exercise

(2) Usual care

2 days per week

for 12 weeks

QoL (FACT-B);

physical function

(12-min walk test);

fatigue (PFS)

Group 1 increased

distance walked

by 333 m more

than group

2(p = 0.001)

‘exercise may

be a safe and

eﬀective way of

improving the

QoL for patients

with early stage

breast cancer’

All outcomes

favoured

intervention

group but study

lacked power

Courneya et al. [68]

Fairey et al. [69]

Canada

Post-menopausal breast

cancer survivors

(average 14 months

post-treatment) [53/52]

(1) Supervised

aerobic cycle

ergometer training

(2) Usual care

3 days per week

for 15 weeks

Physical ﬁtness

(VO

max); QoL

(FACT-B);

fasting insulin;

other outcomes

included fatigue,

body composition,

insulin resistance,

IGFs

Group 1 improved

by 0.29 l/min

more than group 2

(p < 0.001) and

also improved

more on physical

strength and increased

physical training and

social activities more’

No eﬀect

reported for

most of the

outcomes

measured;

(> 60) poor

(p < 0.05), but for

most outcomes had

poorer scores before

and throughout 1 year

of follow up

compliance and

exercise only

one component

Beuttner and

Gavon [100]

United States

Cancer survivors within

5 years of diagnosis

[18/17]

(1) Supervised group

aerobic/strength training

(2) No intervention

3 days per week

for 8 weeks

Fitness (estimated

, heart rate,

strength, ﬂexibility);

personality (C16PFQ)

Group 1 improved all

aspects of ﬁtness

and some of

personality, but group

diﬀerences not

analysed

‘program was suﬃcient

for improvements in

physical ﬁtness’

Suggests ﬁtness

improvements

are possible in

cancer survivors

Other cancers

Courneya et al. [101]

Canada

Colorectal cancer

patients following

surgery [102/93]

(1) Unsupervised

aerobic exercise

2) Usual care

3–5 days per week

for 16 weeks

Quality of life

(FACT-C); other

outcomes included

life satisfaction,

depression, anxiety

fatigue, ﬁtness,

body composition

No diﬀerences between

groups on any outcomes;

reported levels of

exercise similar

between groups

‘increased

cardiovascular

ﬁtness is associated with

improvements in QoL’

High levels of

exercise in con-

trol group may

have masked

eﬀects of inter-

vention

1044 C. Stevinson et al.

Table 1. Continued.

Author

Location

Participants

[Number

allocated/analysed]

Intervention and

control arms

Frequency and

duration

of exercise

Main endpoints Reported results Authors conclusion Reviewers

comments

Coleman et al.

[102, 103]

United States

Multiple myeloma

patients receiving

high-dose chemotherapy

and autologous

peripheral stem-cell

transplantation [24/17]

(1) Unsupervised

home-based aerobic

and resistive training

(2) Usual care (including

advice to walk for

20 minutes 3 days per

week)

5 days per week for

12 weeks pre and

post transplant

Fatigue, sleep; other

outcomes included

aerobic capacity,

strength, body

composition, mood

Group 1 gained lean

body tissue compared

with group 2; no

diﬀerences in

other outcomes

‘patients can

maintain or

improve ﬁtness

levels’ ...

‘exercise

program is

feasible and

may be eﬀective for

decreasing fatigue and

mood disturbance

and improving sleep’

Most outcomes

favoured group

1, but substan-

tial amounts of

missing data

from analysis

preclude inter-

pretation

Wall [104]

United States

Lung cancer patients

about to undergo

surgery [104/97]

(1) Unsupervised

pre-operative aerobic,

resistive and breathing

home-based exercises

once daily

(2) No intervention

Once daily for

1 week pre-surgery

Hope (HHI);

power (PKPCT-VII)

Group 1 increased

power more than group

2; no diﬀerent on hope

‘exercise is a form of

knowing participation

in change’

Importance of

outcomes for pa-

tients unclear

Na et al. [105]

South Korea

Stomach cancer patients

undergoing surgery

[35/32]

(1) Supervised aerobic

exercise on arm and

cycle ergometers in bed

twice daily (2) Usual care

5 days per week

for 2 weeks

Change in NK cell

cytotoxic activity

Group 1 increased

NK cell cytotoxic

activity more

than group 2

‘early moderate exercise

has beneﬁcial eﬀect

on function of in vitro

NK cells after

curative surgery’

Implies exercise-

induced immu-

nologic change

following sur-

gery

Cunningham et al.

[106] United States

Acute leukaemia

patients receiving bone

marrow transplant

[40/30]

(1) Supervised resistive

exercises

(2) Supervised resistive

exercises 5 days per week

(3) Usual care

3 days per week

for 5 weeks

Body composition

(skinfolds); muscle

protein (nitrogen

balance; creatinine

excretion)

Group 1 maintained

creatinine status

while group 3

decreased, but group

diﬀerences not analysed;

no diﬀerences in

other outcomes

‘lack of physical

activity appears

to have a negative

inﬂuence on

maintenance of muscle

protein, but results are

not conclusive’

Implies possible

sparing of

muscle protein

through exercise

but not

clearly

demonstrated

Notes. QoL: quality of life; FACT-B: Functional Assessment of Cancer Therapy – Breast; PFS: Piper Fatigue Scale; IGF: (insulin-like growth factor); SF-36: Medical Outcomes Survey –

Short Form-36; BDI: Beck Depression Inventory; SSTAI: Spielberger State Trait Anxiety Inventory; RSEI: Rosenthal Self-Esteem Inventory; SAS: Symptom Assessment Scale; NK:

natural killer; KPS: Karnofsky Performance Scale; PAIS: Psychosocial Adjustment to Illness Scale; BSI: Brief Symptom Inventory; VAS: visual analogue scale; TSCS: Tennessee Self-

Concept Scale; SCL-9-R: Derogatis Symptom Check List – 90-Revised; POMS: Proﬁle of Mood States; METs: metabolic equivalents; LLC; Levenson Locus of Control; DEXA: dual

energy X-ray absorptiometry; BIS: bioelectrical impedance spectroscopy; FACT-F: Functional Assessment of Cancer Therapy – Fatigue; FACT-G: Functional Assessment of Cancer

Therapy – General; QLICP: Quality of Life Index for Cancer Patients; CARES: Cancer Rehabilitation Evaluation System; HAD: Hospital Anxiety and Depression scale; IES: Impact of

Event Scale; FVC: forced vital capacity; SPPC: Self-Perception Proﬁle for Children; C16PFQ: Cattell’s Sixteen Personality Factor Questionnaire; HHI: Herth Hope Index; PKPCT-VII:

Power as Knowing Participation in Change Test, version II.

Exercise for cancer patients 1045

Table 2. Methodological features of included trials

Author Randomized allocation Concealment of allocation Assessor blinding for

main outcomes

Intention-to-treat analysis

for main outcomes

Other aspects

Breast cancer

Campbell et al. [67] Yes – computer

generated number

Not stated No No – 3 not included Sample size calculation indicated

insuﬃcient power for main QoL

outcome

Courneya et al. [68]

Fairey et al. [69]

Yes – random number table Yes – sealed envelopes

prepared by person not

involved with allocation

Yes for ﬁtness &

blood tests; No for

self-report QoL

No for ﬁtness &

QoL – 3 not included; Yes

for insulin – last value

carried forward

Sample size calculation reported but

lacking details; multiple outcomes

assessed

Drouin et al. [70] Yes – random number table Not stated Not stated No – 2 not included Baseline diﬀerences existed

Galantino et al. [71] Yes – random number table Not stated Not stated No – 3 not included

Segal et al. [72] Yes – random numbers table No No – self-report measure Yes Multiple outcomes assessed; baseline

diﬀerences existed

Segar et al. [73] No – rotated sequentially No No – self report measures No – 6 not included Only half of sample included in

results

Mock et al. [74] Yes – random for 1st patient

then alternate

No Not stated No – 4 not included Lack of outcome data

provided; baseline diﬀerences existed

Nieman et al. [75] Yes – no detail Not stated Not stated No – 4 not included Sample size may have lacked power;

baseline diﬀerences

existed

Mock et al. [76] Yes – cluster randomized

– no further detail

Not stated Not stated No – 4 not included Baseline diﬀerences existed

MacVicar et al. [77]

Winningham et al. [78]

Yes – stratiﬁed on

aerobic capacity – no

further detail

Not stated Not stated No – 17 not included Lack of outcome data

provided

Winningham and

MacVicar [79]

Yes – no detail Not stated No – self report measure Not stated – no

dropouts reported

Lack of outcome data

provided

MacVicar and

Winningham [80]

Not stated Not stated Not stated Not stated – no

dropouts reported

Baseline diﬀerences existed

Winningham et al. [81] No – based on ability

to attend exercise sessions

No Not stated Not stated – no

drop-outs reported

Baseline diﬀerences existed

Prostate cancer

Oliver et al. [82] Yes – computerized

random number table

Yes – sealed envelopes

prepared by individual

not connected with study

Not stated No – 1 not included Sample size may have lacked power;

multiple outcomes assessed

Segal et al. [83] Yes – random number table Not stated No – self-report measures Yes Sample size calculation indicated

adequate power for main outcome

measures

Berglund et al. [84] Yes – no detail Not stated No – self report measure No – 96 not included

1046 C. Stevinson et al.

Table 2. Continued.

Author Randomized allocation Concealment of allocation Assessor blinding for

main outcomes

Intention-to-treat analysis

for main outcomes

Other aspects

Mixed cancers

Courneya et al. [85] Yes – random numbers

table – cluster randomized

No No – self report measure No – 12 not included Multiple outcomes assessed

Hayes et al. [86, 87]

Hayes et al. [88, 89]

No – matched groups Not stated Not stated No – 2 not included

for some variables

Sample size calculation

reported for some variables but

lacking details; baseline diﬀerences

existed; multiple outcomes assessed

Mello et al. [91] Yes – no details Not stated Not stated Not stated – no drop

outs reported

Lack of outcome data provided

Burnham et al. [90] Yes – stratiﬁed on

aerobic capacity &

QoL – no further details

Not stated Not stated No – 3 not included Three groups collapsed into 2 for

analysis; baseline diﬀerences existed

on some variables

Petersson et al. [92] Yes – no detail Yes – performed by

statistics unit

No – self report No – 117 not included Four groups collapsed into 2 for

analysis

Dimeo et al. [93] No – based on date of

hospitalisation

No No – self report measures No – 3 not included No inter-group analysis

Niesen-Vertommen

et al. [94]

No – based on ability

to attend exercise sessions

No Not stated No Power calculation reported but lack-

ing details; baseline diﬀerences

existed

Dimeo et al. [95] No – based on living

close to facility

No Not stated No – 4 not included

Dimeo et al. [96] Yes – no detail Not stated No – but yes for some

secondary outcomes

No – 10 not included Multiple outcomes assessed

Berglund et al. [97, 98] Yes – Efron biased coin

method for small samples

Not stated No – self-report measures No Baseline diﬀerences existed on some

variables; multiple outcomes

assessed

Berglund et al. [99] No – matched control

group selected from those

declining intervention

No No – self-report measures Yes Baseline diﬀerences existed on some

variables; multiple outcomes

assessed

Beuttner and

Gavon [100]

Yes – drawing names

without replacement

No Yes No – one not included Lack of outcome data available

Other cancers

Courneya et al. [101] Yes – random number table Not stated No – self-report measure No – 9 not included

Coleman et al.

[102, 103]

Yes – computerized

randomization

Yes – sealed envelopes

prepared by research

assistant

No – self report measures

but yes for some other

outcomes

No – 14 not included Lack of outcome data provided;

much missing data

Wall et al. [104] Yes – no detail Yes – sealed envelopes

prepared by statistics unit

No – self-report measures No – 7 not included Sample size calculation reported but

lacking details

Na et al. [105] Yes – no detail Not stated Not stated Not – 3 not included Lack of outcome data provided

Cunningham et al.

[106]

Yes – computer

generated number

Not stated Not stated No – 10 not included Post hoc calculation indicated insuf-

ﬁcient power; baseline diﬀerences

Exercise for cancer patients 1047

receiving high-dose chemotherapy who exercised dur-

ing hospitalization [96]. Increases in muscular strength

were recorded after resistive training schedules in three

trials [82, 83, 88]. Six other studies reported no

differences in ﬁtness parameters [71, 72, 94, 101, 102]

or muscle strength [70, 91] following aerobic exercise

programmes.

Figure 2 shows the effects of exercise on physical

function in 10 trials of breast cancer patients (Figure 2a)

and 9 trials of trials that recruited patients with any cancer

(Figure 2b). For both groups of patients there was some

evidence that exercise improved physical function. For

trials that recruited patients with breast cancer the pooled

standardized mean difference suggeste d that those who

Fig. 2. (a) Eﬀects of exercise on physical function in controlled trials recruiting patients with breast cancer [n ¼ 10]; (b) Eﬀects of exercise on

physical function in controlled trials recruiting patients with any cancer [n ¼ 9].

1048 C. Stevinson et al.

exercised had on average a 0.96 (95% CI: 0.49, 1.43)

standard deviation greater physical function than those

who did not. However, there was heterogeneity between

studies (p ¼ 0.001), which was not explained by whether

the trial was randomized (p ¼ 0.8), whether there was

allocation concealment (p ¼ 0.5), blinding of the outcome

assessment (p ¼ 0.5) or whether there was adequate

description of the control group such that it was clear

controls were eligible participants (p ¼ 0.2). Only one

study used intention-to-treat analysis and analysis type

was a source of heterogeneity (p ¼ 0.001). It should be

noted from Figure 2a that the largest study [72], which

was also the only study to use intent ion-to-treat analysis,

found no eﬀect of exerci se on physical function. There was

no evidence of small study bias in this meta-analysis (p-

values for Beggs and Egger test both > 0.5). For trials

that recruited patients with any type of cancer the pooled

standardized mean diﬀerence suggested that those who

exercised had on average a 0.55 (95% CI: 0.12, 0.97)

standard deviation greater physical function than those

who did not. However, there was considerable heteroge-

neity also between these studies (p < 0.001), which was

mainly due to one small trial that was not randomized, did

not blind the outcome assessment and did not undertake

intention-to-treat analysis. With this study removed, the

pooled standar dized mean diﬀerence suggested that those

who exercised had, on average, a 0.26 (95% CI: 0.03, 0.50)

standard deviation greater physical function than those

who did not, and there was no heterogeneity between the

remaining studies (p ¼ 0.19). It should also be noted that

two of the largest trials [85, 97], both of which were

randomized, showed no eﬀect of exercise on physical

function. There was evidence of small study bias in this

meta-analysis (both Beggs and Egger test p-value ¼ 0.01

with all studies included, and p ¼ 0.07 Beggs, and p ¼ 0.04

Egger, when the small heterogeneous study was re-

moved).

Fatigue

Reductions in cancer-related fatigue were reported in 10

studies [67, 68, 74, 76, 80, 82, 83, 85, 93, 95], although in

three of them, statistical signiﬁcance was not reached

[67, 82] or not tested for [93]. No differences between

groups were reported for fatigue in six trials immediately

after the intervention or several months later [70, 71, 97–

99, 101, 102]. Pooling the data from 12 trials that

assessed fatigue suggested that there was no overall

effect of exercise on symptoms of fatigue: mean stan-

dardized difference ) 0.15 ()0.38, 0.09) standard devia-

tion (Figure 3). Heterogeneity between studies

Fig. 3. Eﬀects of exercise on symptoms of fatigue in any cancer trials [n ¼ 12]

Exercise for cancer patients 1049

(p < 0.001) was not related to randomization (p ¼ 0.16),

allocation concealment (p ¼ 0.65), intention-to-treat

analysis (p ¼ 0.42) or choice of control (p ¼ 0.16).

However, the eﬀect did appear to vary by population

type (p ¼ 0.04), with some evidence that in trials that

recruited patients with any type of cancer [85, 93, 97, 99]

ﬁnding no eﬀect of exercise on fatigue symptoms: 0.04

()0.26, 0.35) and those that recruited patients with

breast cancer [67, 68, 70, 74, 80] suggesting a modest

reduction in sympt oms of fatigue among those allocated

to exercise: )0.52 ()0.95, )0.09) standard deviation.

There was no strong evidence of small study bias in this

meta-analysis (Beggs and Egger test both

p-values >0.1).

Body composition

Decreases in skinfold measurements without simulta-

neous reductions in total body weight were reported in a

trial of non-obese breast cancer patients undergoing

chemotherapy [78], suggesting that fat mass had been

replaced by muscle tissue. Similar ﬁndings were reported

in two other studies involving breast cancer patients [85,

90]. Increased lean body weight was reported in a trial of

patients with multiple myeloma [102], and reductions in

body weight and fat mass were described in a sample of

breast cancer patients receiving radiation therapy [70].

Appendicular and total lean mass were increased in

prostate cancer patients receiving androgen deprivation

therapy [82]. Six other studies reported no changes in

body weight [72, 86], or skinfold measurements [68, 83,

101, 106]. Changes in muscle protein status of leukemia

patients receiving marrow transplants could not be

clearly demonstrated [106].

Other physiological parameters

Natural killer cell activity was increased among post-

operative stomach cancer inpatients exercising with bed

ergometers for 2 weeks [105], but was unchanged in

recovered breast cancer survivors following 8 weeks of

exercise [75]. T-cell numbers and function were not

changed by exercise after high-dose chemotherapy and

stem-cell transplantation [87]. No alterations to immune

parameters or oxidative stress were observed during

exercise in breast cancer patients receiving radiation

therapy [70]. In another study of inpatients exercising

with bed ergometers while undergoing high-dose che-

motherapy and stem-cell transplantation, no changes in

haemoglobin or haematocrit were reported [96], but

among patients having completed the same treatment,

haemoglobin increased by 1 g/dl following a six week

walking programme [95]. Fasting insulin, glucose and

insulin resistance were not changed by a 15 week

training programme in breast cancer survivors [69].

Testosterone and prostate-speciﬁc antig en levels of

prostate cancer patients did not differ between those

following a resistive exercise programme and the control

group [83].

Treatment-related symptoms

Sleep problem s were reduced in two studi es of breast

cancer patients [74, 76], while there was a trend

towards improved sleep in a trial of patients with

multiple myeloma [103]. Decreased nausea was de-

scribed in one trial of breast cancer patients [79], but

did not differ to the control group in another [76].

Lower severity of treatment-related pain and diar-

rhoea was reported for inpatients receiving high-dose

chemotherapy in one study [96]. In a further trial, no

differences in frequency and burden of sympt oms were

reported following exercise, information and coping

skills training [97].

Psychosocial outcomes

Increases in global quality of life measures were

reported in four trials [67, 68, 83, 89], while ﬁve

other studies did not demonstrate signiﬁcant differ-

ences between exercise and control groups [71, 72, 97,

99, 101]. Improvements in speciﬁc quality of life

dimensions of functional [85] and physical [68] well-

being were also reported.

Beneﬁcial effects on depression were reported in

three studies [72, 73, 76], but not in ﬁve others [74, 92,

97, 99, 101]. Anxiety was reduced in two trials [73,

74], but not in ﬁve others [76, 92, 97, 99, 101]. A

further trial did not ﬁnd additional effects of a

walking programme on depression, anxiety or other

psychological outcomes beyond those provided by

psychotherapy [85].

One study reported enhanced self-esteem [68], but

three others did not [72, 73, 76]. In two trials, body

image remained higher for exercisers during [76] and

after [74] treatment than for co ntrol participants, but no

differences in body image were reported in two other

studies [97, 99]. Reported reductions in global psycho-

logic distress [93] and changes in psychosocial adjust-

ment to illness and emotional distress [76] during

treatment favoured exercise groups.

Adherence

Adherence to exercise interventions was reported to be

over 70% in 19 studies [67, 68, 70, 72–76, 82–86, 90, 93,

94, 96, 102, 104]. One trial repo rted poor compliance

with 20% of the sample attending no more than one

exercise session [99]. In another study, 51% of the

control group reported exercising to the prescribed

1050 C. Stevinson et al.

intervention level, meaning that average level of activity

did not differ between groups [101]. Nine of the

remaining trials that did not report ad herence, involved

exercise interventions that were supervised by study

personnel [77, 79, 80, 92, 95, 97, 100, 105, 106].

Tolerability

Adverse events were reported in four trials. Lymp he-

dema (n ¼ 3), inﬂuenza and a gynecological complica-

tion were reported among participants from the exercise

group, while bronchitis and a foot fracture were

reported in participants from the control group in a

study with post-menopausal breast cancer survivors [68] .

A trial involving patients with multiple myeloma

reported no injuries but one patient broke a central

venous catheter stitch [102]. Shoulder tendonitis oc-

curred in one breast cancer patient who reportedly

exceeded the exercise prescription of the study [70].

Muscle and joint stiﬀness (n ¼ 5) were reported from the

control group in a trial of leukemia patients undergoing

bone marrow trans plant [106]. Nine studies reported

that no adverse events occurred [67, 72, 74–76, 89, 90,

95, 96], while no mention of adverse events was made in

the remaining 20 trials [65, 71, 73, 77, 79–83, 85, 91–94,

97, 99–101, 104, 105].

Discussion

A total of 33 controlled trials were identiﬁed, with

studies of breast cancer patients being most common.

There was some evidence of improved physical func-

tion due to exercise among patients with breast cancer

or those with any type of cancer, although the larger

and better quality trials tended to report null effects

with this outcome. For other outcomes, including

quality of life and psychological symptoms, there was

no clear or consistent evidence that exercise was

beneﬁcial with trials having conﬂicting results. We

found no evidence that exercise resul ted in increased

fatigue symptoms in patients with cancer. All of these

ﬁndings need to be treated with caution be cause of

heterogeneity between studies and methodological lim-

itations. Finally, there is no evidence from clinical trials

with which to determine the effect of exercise on long

term outcomes relating to cancer recurrence or sur-

vival.

Methodological issues

Comprehensive search procedures were adopted when

locating studies for this review in the attempt to limit the

impact of publication and reporting bias [107]. These

can result from the tendency for trials not showing

positive results to remain unpublished [108], take longer

to reach publication [109], or be published in non-

English language journals [110]. Furthermore, coverage

bias in the non-indexing of a number of European

journals in major literature databases has been reported

[111]. The comprehensive search procedures used in this

review contributed to the inclusion of 13 studies that

have not been reported in previous reviews of the

literature.

Conclusions of any review are dependent on the

quality of the included studies. Although there are signs

in this review that this is improving, with some of the

more recent trials demonstrating the greatest rigor [69,

72, 82, 83, 104], most trial ﬁndings must be interpreted

with caution because of methodological limitations.

Although the majority of trials were randomized, very

few described using an adequate method of allocation

concealment. Both inadequate methods of generating,

and concealing, allocation sequences are prone to

selection bias and associated with overestimations of

the value of interventions [112, 113]. Double blinding is

not possible with behavioural interventions such as

exercise. However, few of the trials that measured

objective endpo ints reported blinded assessment, which

increases the risk of biased assessment and exaggerated

treatment effects [112]. Few studies analysed data on an

intention-to-treat basis meaning that the advantages of

randomization are lost and estimates of efﬁcacy may be

inﬂated [114]. Many of the studies in the review had only

small samples, few of which were based on sample size

calculations. Differential outcomes between groups in

trials with small samples are more likely to be due to

chance [115] leading to a false-positive result (type-I

error). Conversely, small samples may lack sufﬁcient

power to detect signiﬁcant differences between interven-

tion groups even if they exist, creating a false-negative

ﬁnding (type-II error). Multiple outcomes measurement

and sub-group analyses were undertaken in many trials.

This raises the possibility that signiﬁcant results

reported for one outcome among many others in a

single study, are due to chance [116, 117].

Effects of exercise

There was some evidence of improvements in physical

function. Minimizi ng loss of physical function during

treatment and regaining it afterwards, are important for

patients in terms of facilitating activities of daily living.

Prolonged inactivity following surgery and adjuvant

therapy exacerbates physical debilitation leading to

increased fatigue with even minor exertion. Graded

Exercise for cancer patients 1051

exercise interventions have therefore been recommended

for breaking the vicious cycle that can develop between

inactivity, physical deconditioning, and fatigue [118].

There is evidence that patients undergoing adjuvant

therapy, as well as those who have completed treatment,

were able to maintain a regular exercise programme

without experiencing major adverse effects or increased

fatigue. As is always the case with clinical trials, results

may only apply to carefully screened patients who are

sufﬁciently motivated to consent to participate. Within

wider clinical practice, uptake and adherence to exercise

programmes and physical limitations of patients may be

more problematic than for participants in the studies

reviewed.

For other outcomes it was not possible to elucidate

any clear or consistent effects of exercise. There was

considerable heterogeneity between studies in terms of

participant, intervention and outcome variables and

many methodological weaknesses, all of which may

contribute to the inconsistencies among results.

Future directions

One of the purposes of conducting systematic reviews in

newly developing research ﬁelds is to identify and

acknowledge the deﬁciencies in the literature in order

to stimulate further and better research in the future

[119]. There are currently several important gaps in the

evidence base.

Patient groups

Although a number of trials have focused on patients

with breast cancer, there are few studies on the other

three most common cancers – colorectal, lung and

prostate. It is not always appropriate to generalize

ﬁndings from one cancer population to another due to

the major differences in disease-related factors, treat-

ment regimes and patient demographics.

Outcome measures

A large number of outcomes were assessed in some trials

with primary endpoints rarely deﬁ ned. The most impor-

tant outcomes for cancer patients relate to recurrence of

disease, survival, quality of life and ability to perform

activities of daily living. Since studies to date have

tended to assess outcomes at the end of the exercise

intervention only (rather than longer term follow-up),

there is current ly no evidence from clinical trials of the

effect of exercise on disease recurrence or survival. For

quality of life and functional abilities, studies should aim

to use the same standardized measures so that ﬁndings

are comparable. Furthermore, it is essential to

pre-deﬁne main outcome and the magnitude of a

clinically important effect for all measures, rather than

simply report statistically signiﬁcant differences based

on arbitrary p-values.

Intervention components

There is so far little evidence to help identify the

optimum mode, frequency, intensity and duration of

activity required for beneﬁcial effects in cancer popula-

tions. Existing attempts to compare low versus moderate

intensity activity [90], or gym versus home-based exercise

[72] have not produced clear ﬁndings. A staged

approach may be helpful in addressing these issues such

as the framework proposed by the Medical Research

Council Health Services and Public Health Research

Board in the UK for the development and evaluation of

complex health interventions [120].

Methodological design

There are multiple methodological weaknesses among

existing studies. Randomization, allocation conceal-

ment, blinded assessment, intention-to-treat analysis

and sample size calculations are all essential for clinical

trials of effectiveness. Other design considerations

include the choice of comparison arms in order to

control for spontaneous improvements over time and

the contextual aspects of an interventi on (i.e. , additional

contact with researchers and other participants). Fur-

thermore, studies combining and comparing exercise

with other interventions (e.g., support groups; psycho-

therapy) will help determine how best to integrate

rehabilitation strategies to address the full range of

needs of patients. Finally, continuing to monitor

patients beyond the end of the structured intervention

is essential for establishing the long term eﬀects of

interventions in promoting sustained physical activity,

increasing survival, preventing recurrence and enhanc-

ing quality of life.

Conclusion

From a critical evaluation of data currently available

from controlled trials, it appears that cancer patients

can beneﬁt from improved physical function without

increases in fatigue associated with exercise. It is

impossible to determine from current evidence whether

exercise has direct effects on survival, recurrence or

quality of life.

Nonetheless, on the basis of the rationale for exercise

during cancer rehabilitation and prelimina ry ﬁndings

from existing studies, further research of this subject is

encouraged.

1052 C. Stevinson et al.

Acknowledgements

We thank the following investigators for providing

information on study sources and/or additional infor-

mation about their work: L Buettner (Florida Gulf

Coast University), G Berglund (Uppsala University), A

Campbell (University of Glasgow), E Coleman (Uni-

versity of Arkansas for Medical Sciences), K Courne ya

(University of Alberta), A Daley (Shefﬁeld Hallam

University), F Dimeo (Freiburg University Medical

Centre), J Drouin (University of Michigan-Flint),

E Durak (Medical Health & Fitness), S Hayes (Queens-

land University of Technology), S Macora (University

of Wales – Bangor), A Morgan (Fred Hutchinson

Cancer Research Centre), N Mutrie (University of

Glasgow), S Oliver (University of Wales – Bangor),

L-M Petersson (Uppsala University), D Porock (Uni-

versity of Missouri-Columbia), A Schwartz (Oregen

Health Services University), R Segal (Ottawa Regional

Cancer Centre), M Segar (University of Michigan), B

Stoll (St Thomas’ Hospital), P Swan (Arizona State

University).

Funding: Clare Stevinson is funded by Cancer

Research UK [CUK] grant number C3875/A3887.

Debbie A Lawlor is funded by a UK Department of

Health Career Scientist Award. The views expressed in

this paper are those of the authors and not necessarily

those of any funding body.

Conﬂicts of interest: None

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The effects of exercise on sleep disturbances and cancer‐related fatigue for female breast cancer survivors receiving adjuvant hormone therapy: A systematic review

Article

Full-text available

Sep 2023

Background Breast cancer is the most common type of cancer, accounting for 15% of all new cases. Hormone therapy (HT) is extremely effective in reducing breast cancer recurrence. However, adherence to HT medication is often poor due to negative side effects such as fatigue and sleep disturbances. Physical activity has been identified as a possible intervention to improve quality of life and reduce side effects of HT. Objective The objective of this systematic review was to summarise evidence of exercise interventions for women being treated with HT for breast cancer. Method Electronic searches were conducted from inception to March 2022 using Medline, SPORTdiscus, Embase, Scopus, PsycINFO and Web of Science databases. Searches included a combination of terms related to breast cancer, exercise, sleep disturbances, fatigue and HT. Results Ten eligible papers were identified, and their quality was assessed. Type, frequency, duration and intensity of exercise interventions varied. Exercise types included aerobics, strength/resistance training, walking and yoga. Heterogeneity of data made it difficult to draw conclusions. However, aerobic exercise interventions provide clear improvements in fatigue and sleep disturbances. Conclusions This review identified a lack of consistency in exercise recommendations for women being treated for breast cancer. It identifies that aerobic exercise can successfully improve fatigue and sleep disturbances, consistent with existing literature. Exercise has a range of benefits for this population, including improving psychological well‐being and quality of life. Clinicians should strongly advocate for engagement in exercise to promote overall physical and psychological well‐being in women being treated for breast cancer.

Comparison of the effects of high-intensity interval and moderate-intensity continuous training on inflammatory markers, cardiorespiratory fitness, and quality of life in breast cancer patients

Article

Full-text available

Jul 2023

Background: As the effectiveness of breast cancer treatment has improved, a growing number of long-term breast cancer survivors are seeking help for unique health problems. These patients may be at increased risk of cardiovascular disease due to the side effects of treatment. The positive impact of most types of exercise has been repeatedly reported in people with cancer, but the most effective exercise approaches for maximum beneficial adaptations remain controversial. Thus, this study aimed to compare the effects of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) on inflammatory indices, adipokines, metabolic markers, body composition, cardiorespiratory fitness, and quality of life in breast cancer patients during adjuvant endocrine therapy. Methods: Thirty non-metastatic breast cancer patients during adjuvant endocrine therapy who had been treated with chemotherapy and/or radiotherapy were recruited from Iran and randomized to HIIT, MICT, or control groups for a supervised exercise intervention that took place 3 times a week for 12 weeks. The training intensity was determined based on the peak oxygen uptake (VO2peak), and the volume of training was matched in HIIT and MICT based on the VO2peak. Body composition, functional capacity, cardio-respiratory fitness, metabolic indices, sex hormones, adipokines, and inflammatory markers were assessed before and after the intervention. Results: The VO2peak increased by 16.8% in the HIIT group in comparison to baseline values (mean difference = 3.61 mL/kg/min). HIIT significantly improved the VO2peak compared to control (mean difference = 3.609 mL/kg/min) and MICT (mean differences = 2.974 mL/kg/min) groups. Both HIIT (mean difference = 9.172 mg/dL) and MICT (mean difference = 7.879 mg/dL) interventions significantly increased high-density lipoprotein cholesterol levels compared to the control group. The analysis of covariance showed that physical well-being sginificantly improved in MICT compared to control group (mean difference = 3.268). HIIT significantly improved the social well-being compared to the control group (mean difference = 4.412). Emotional well-being subscale was significantly improved in both MICT (mean difference = 4.248) and HIIT (mean difference = 4.412) compared to the control group. Functional well-being scores significantly increased in HIIT group compared with control group (mean difference = 3.35) . Significant increase were also observed in total functional assessment of cancer therapy-General scores in both HIIT (mean difference = 14.204) and MICT groups (mean difference = 10.036) compared with control group. The serum level of supressor of cytokine signaling 3 increased significantly (mean difference = 0.09 pg/mL) in the HIIT group compared to the baseline. There were no significant differences between groups for body weight, body mass index, fasting blood glucose, insulin resistance, sex hormone binding globulin, total cholesterol, low-density lipoprotein cholesterol, adipokines, interleukin-6, tumor necrosis factor-α, and interleukin-10. Conclusion: HIIT can be used as a safe, feasible, and time-efficient intervention to improve cardiovascular fitness in breast cancer patients. Both HIIT and MICT modalities enhanced quality of life. Further large-scale studies will help determine whether these promising results translate into improved clinical and oncological outcomes.

Outcomes and experiences of an online Balance-Space music therapy intervention for cancer patients: A mixed methods study

Article

Feb 2023
ART PSYCHOTHER

Coping with cancer requires both physical and emotional fortitude, and various intervention programs attempt to address these needs. Since the outbreak of the COVID-19 pandemic, many interventions have transitioned from live to online settings. Balance-Space is a music therapy intervention, which includes listening to original composed music, followed by an open discussion. Participants with a cancer diagnosis were randomized to either an online group music listening intervention or an online group meditation intervention. Both activities were followed by a group discussion led by two music therapists. A mixed methods study was employed and included both quantitative measurements of distress, anxiety, and pain and a qualitative analysis of the group discussion in the music intervention group. We found a significant reduction in participants' perceived pain levels following the music intervention when compared to the meditation intervention. This result was supported by qualitative content analysis, which revealed how music evoked physical reactions and affected the participants' experience of pain. There were no significant differences in participants' perceived distress levels and perceived anxiety levels between the two groups. These preliminary results are encouraging and support the need for further exploration of online music therapy interventions as a non-pharmacological treatment for cancer patients.

An Integrated Approach of Yoga and Ayurveda in Cancer Rehabilitation: A Systematic Review

Article

Dec 2022

Aims: In this comprehensive evaluation of literature, body-mind practices of Yoga and Ayurveda during cancer rehabilitation are summarized. Methodology: Through a methodical searching of PubMed, Embase, Scopus, Web of Science, and Allied Health Plus with a timescale of January 2007 to April 2021, appropriate research papers were identified. Data about study design, method of recruiting, subjects, interventions, and findings were taken out. Retrospective data analysis, pilot or feasibility studies were eliminated, whereas preliminary, controlled studies involving one- and multiple equipped samples, examining rehabilitating therapies for cancer patients at any phase with in-care spectrum had been included. Results: The study included fifteen papers as outcome of PRISM model, wherein, breast carcinoma cases are predominant. Majority of therapies involved herbal and yoga-based regimens that enhanced psycho-physiological indicators and quality of life. Conclusion: Preliminary research suggests that integrating Yoga and Ayurveda remedies with lifestyle-relied intervention is possible to improve self-healing capacity and sustainability in cancer patients, however methodical constraints of investigations in this growing field should be addressed. To progress the discipline, new research with robust research approaches seems to be necessary.

Determinants of physical activity behaviour change in (online) interventions, and gender-specific differences: a Bayesian network model

Article

Full-text available

Dec 2022
INT J BEHAV NUTR PHY

Background Physical activity (PA) is known to be beneficial for health, but adherence to international PA guidelines is low across different subpopulations. Interventions have been designed to stimulate PA of different target groups by influencing relevant psycho-social determinants, essentially based on a combination of the Integrated Model for Change, the Theory of Planned Behaviour, its successor the Reasoned Action Approach and the self-determination theory. The current study investigates the pathways through which interventions influence PA. Further, gender differences in pathways of change are studied. Methods An integrated dataset of five different randomised controlled trial intervention studies is analysed by estimating a Bayesian network. The data include measurements, at baseline and at 3, 6 (short-term), and 12 (long-term) months after the baseline, of important socio-cognitive determinants of PA, demographic factors, and PA outcomes. A fragment is extracted from the Bayesian network consisting of paths between the intervention variable, determinants, and short- and long-term PA outcomes. For each relationship between variables, a stability indicator and its mutual information are computed. Such a model is estimated for the full dataset, and in addition such a model is estimated based only on male and female participants’ data to investigate gender differences. Results The general model (for the full dataset) shows complex paths, indicating that the intervention affects short-term PA via the direct determinants of intention and habit and that self-efficacy, attitude, intrinsic motivation, social influence concepts, planning and commitment have an indirect influence. The model also shows how effects are maintained in the long-term and that previous PA behaviour, intention and attitude pros are direct determinants of long-term PA. The gender-specific models show similarities as well as important differences between the structures of paths for the male- and female subpopulations. For both subpopulations, intention and habit play an important role for short-term effects and maintenance of effects in the long-term. Differences are found in the role of self-efficacy in paths of behaviour change and in the fact that attitude is relevant for males, whereas planning plays a crucial role for females. The average of these differences in subpopulation mechanisms appears to be presented in the general model. Conclusions While previous research provided limited insight into how interventions influence PA through relevant determinants, the Bayesian network analyses show the relevance of determinants mentioned by the theoretical framework. The model clarifies the role that different determinants play, especially in interaction with each other. The Bayesian network provides new knowledge about the complex working mechanism of interventions to change PA by giving an insightful overview of influencing paths. Furthermore, by presenting subpopulation-specific networks, the difference between the influence structure of males and females is illustrated. These new insights can be used to improve interventions in order to enhance their effects. To accomplish this, we have developed a new methodology based on a Bayesian network analysis which may be applicable in various other studies.

Rates of compliance and adherence to high-intensity interval training: a systematic review and Meta-analyses

Article

Full-text available

Nov 2023
INT J BEHAV NUTR PHY

Background To determine rates of compliance (i.e., supervised intervention attendance) and adherence (i.e., unsupervised physical activity completion) to high-intensity interval training (HIIT) among insufficiently active adults and adults with a medical condition, and determine whether compliance and adherence rates were different between HIIT and moderate-intensity continuous training (MICT). Methods Articles on adults in a HIIT intervention and who were either insufficiently active or had a medical condition were included. MEDLINE, EMBASE, PsychINFO, SPORTDiscus, CINAHL, and Web of Science were searched. Article screening and data extraction were completed by two independent reviewers. Risk of bias was assessed using RoB 2.0 or ROBINS-I. Meta-analyses were conducted to discern differences in compliance and adherence between HIIT vs. MICT. Sensitivity analyses, publication bias, sub-group analyses, and quality appraisal were conducted for each meta-analysis. Results One hundred eighty-eight unique studies were included (n = 8928 participants). Compliance to HIIT interventions averaged 89.4% (SD:11.8%), while adherence to HIIT averaged 63% (SD: 21.1%). Compliance and adherence to MICT averaged 92.5% (SD:10.6%) and 68.2% (SD:16.2%), respectively. Based on 65 studies included in the meta-analysis, compliance rates were not different between supervised HIIT and MICT interventions [Hedge’s g = 0.015 (95%CI: − 0.088–0.118), p = .78]. Results were robust and low risk of publication bias was detected. No differences were detected based on sub-group analyses comparing medical conditions or risk of bias of studies. Quality of the evidence was rated as moderate over concerns in the directness of the evidence. Based on 10 studies, adherence rates were not different between unsupervised HIIT and MICT interventions [Hedge’s g = − 0.313 (95%CI: − 0.681–0.056), p = .096]. Sub-group analysis points to differences in adherence rates dependent on the method of outcome measurement. Adherence results should be interpreted with caution due to very low quality of evidence. Conclusions Compliance to HIIT and MICT was high among insufficiently active adults and adults with a medical condition. Adherence to HIIT and MICT was relatively moderate, although there was high heterogeneity and very low quality of evidence. Further research should take into consideration exercise protocols employed, methods of outcome measurement, and measurement timepoints. Registration This review was registered in the PROSPERO database and given the identifier CRD42019103313.

Assessment and Management of Cancer-RelatedFatigue

Chapter

Jul 2010

IoT for Movement Recognation and Prehabilitation Support System

Conference Paper

Oct 2022

Physical Activity Status and Diabetic Retinopathy: A Review

Article

Full-text available

Aug 2022

Substantial evidence highlights the association between physical inactivity and diabetes onset and complications. Little is known regarding the link between physical inactivity and diabetic retinopathy in terms of onset, progression, and severity. This review aims to investigate these associations and understand the underlying mechanisms behind these associations. Decreased sedentary times and the inclusion of more physical activity have been linked to the delayed onset and progression of diabetic retinopathy and less severe forms of said condition. Physical activity provides both protective and anti-inflammatory effects on the retina. Further research is needed to understand and elucidate the exact mechanisms by which lack of physical activity affects retinal health and the onset, progression, and severity of diabetic retinopathy.

Onkoloji Hemşireliğinde Kanıta Dayalı Bakım Konsensus 2010

Book

Full-text available

Jan 2010

Gulbeyaz Can

Exercise in the rehabilitation of breast cancer survivors

Article

May 1999
PSYCHO-ONCOLOGY

With the increase in the number of women who have survived breast cancer, there is a growing need to attend to the physical and emotional effects of cancer and its treatment as experienced by these survivors. Psychological distress, fatigue, weight gain, premature menopause and changes in body image are some of the long‐term sequelae of breast cancer. Exercise as an adjunctive treatment may help to attenuate these effects and thereby contribute to rehabilitation of women with breast cancer. We present data from the exercise literature and from studies on breast cancer patients that support this role of exercise. Following a critique of the research efforts, we present a brief outline of questions that should be addressed in evaluating the role of exercise in cancer rehabilitation. Copyright © 1999 John Wiley & Sons, Ltd.

Exercise-based Rehabilitation for Coronary Heart Disease

Article

Dec 2001

Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation.

Article

Mar 1998

Exercise therapy effect on natural killer cell cytotoxic activity in stomach cancer patients after curative surgery.

Article

Jan 2001

Exercise Training in the Post-Treatment Remission Period of Patients with Limited Small Cell Lung Cancer (SCLC)

Article

Nov 1991

Differential Effects of Cancer Rehabilitation Depending on Diagnosis and Patients’ Cognitive Coping Style

Article

Nov 2002

Objective: The major aim was to explore the extent to which the Miller Behavioral Style Scale (MBSS) can be used to differentiate cancer patients who are likely to benefit from rehabilitation efforts with a strong information component from those who are not. Methods: Newly diagnosed patients with breast, gastrointestinal, or prostate cancer (N = 442) were included in a randomized, prospective study of the effects (on anxiety, depression, intrusion, avoidance) of rehabilitation approximately 4 months after diagnosis as compared with control patients. Patients were classified as “monitors” or “blunters” on the basis of the MBSS (368 patients, 83%, completed the MBSS). Results: The expected interaction at postintervention between coping style and experimental condition (ie, rehabilitation or control) was found only for avoidance among breast and prostate cancer patients. Assignment to the rehabilitation or control condition was of no importance for outcome among blunters. Among monitors, the response pattern differed between breast and prostate cancer patients. Prostate cancer monitors seemed to benefit from rehabilitation on all outcome measures, whereas intrusion and avoidance were reduced among breast cancer patients in the control condition. This interaction of diagnosis with condition (rehabilitation or control) among monitors is suggested to be due to demands for diagnosis-specific information during diagnostic work, in the period just after diagnosis, and before treatment decision. Conclusions: Only the monitor concept seems useful for predicting response to cancer rehabilitation with a strong information component. However, whether rehabilitation is of benefit depends also on other factors.

The Effects of Tai Chi and Walking on Fatigue and Body Mass Index in Women Living with Breast Cancer: A Pilot Study

Article

Jan 2003

ABSTRACT Purpose: The purpose of this study was to examine the effect of Tai Chi and walking on cancer related fatigue (CRF) and body mass index (BMI) in women living with breast cancer. Subjects: Eleven women between the ages of 40 to 59 were randomized to the Tai Chi or walking intervention. Methods: A specific program was designed and modified for this population by a Tai Chi instructor and was administered for 1 hour 3 times throughout the study. The walking program also had similar group meetings, which included postural assessment, stretching, and education. All participants were given videos to reinforce the 3 group sessions and received weekly phone calls to answer questions regarding the program. Primary outcome measures included the 6-minute walk test and the body mass index. Survey instruments included the Functional Assessment of Cancer Therapy-Breast (FACT-B) and the Brief Fatigue Inventory (BFI). All measures were taken at baseline and at 6 weeks. Subjects kept a diary of when they performed the program and how they felt throughout the 6-week intervention. Results: Due to the small number of subjects, no statistical significance was found. Trends in the functional measures showed decreased blood pressure and decreased fatigue for both groups. The walking group had an increase in body mass index (BMI) of +0.33, while the Tai Chi group had a decrease in BMI of −0.03. Analysis of the diaries revealed the following frequency of responses (1) walking and Tai Chi group intervention motivated the participants to participate in a regular exercise program and (2) both interventions fostered decreased fatigue and new awareness/learning. Discussion: Patients with CRF might benefit from Tai Chi and walking interventions. The impact on fatigue and BMI may be a primary outcome for further study. Additional functional outcome measures should be explored. This pilot study supports the need for further research in the effect of alternative forms of exercise to manage fatigue in this population.

Parametric measures of effect size

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