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Study: Physical activity may decrease fatigue associated with cancer treatment

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Contents

At a glance Questions for your doctor
Study findings Guidelines
Strengths and limitations Clinical trials
What does this mean for me? Related resources

 

STUDY AT A GLANCE

What is this study about?

This study is about the effects of at-home exercise routines on fatigue in cancer survivors.

 

Why is this study important?

Exercise is an essential part of a healthy lifestyle after cancer treatment. Survivors frequently report fatigue or extreme tiredness and an inability to function due to a lack of energy, depression and anxiety, all of which can be reduced by exercise. However, only about one-quarter of cancer survivors meet recommended guidelines for physical activity. The goal of this study was to understand whether exercising at home reduces fatigue for cancer survivors and whether exercise counseling helps patients form healthy, sustainable exercise habits.

 

Study findings

In this (a study that looks at data from several prior independent studies on the same subject) the authors reviewed the overall trends of 11 studies consisting of 1,066 cancer survivors.  In these studies, participants took part in low- to moderate-intensity exercise activities, including walking, biking, swimming and using at-home exercise equipment. In most studies, participants engaged in a minimum of 150 minutes of physical activity each week. They self-monitored their activity levels using pedometers (step counters), activity logs and in some cases, heart rate monitors. Nine of the 11 studies examined the effects of exercise on fatigue, while two looked at its effects on depression and anxiety.

Some studies included telephone counseling for the participants from a research staff member throughout the study period. The conversations focused on encouragement, goal-setting, building motivation and self-confidence and problem-solving about exercise barriers. Several studies also provided participants with workbooks containing strategies for beginning and maintaining an exercise routine and exercise tip sheets for cancer survivors.

Below is a table summarizing the exercise type, whether participants received counseling, how long and how often participants engaged in at-home exercise and the results of the nine fatigue-related studies.

Exercise type

Counseling

Duration

Frequency

Fatigue improved compared to control?

Brisk walking

Yes, frequent

12 weeks

From 3 days per week for 20 minutes daily to 5 days per week for 30 to 40 minutes

Yes

Walking, biking, or use of home exercise equipment

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes

Yes

Brisk walking, biking or swimming

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes

Yes

Brisk walking

No

12 weeks

5 days per week for 30 minutes daily

Yes

Brisk walking

Yes, frequent

6 months

150 minutes per week

Yes

Walking or other form if preferred

Yes, infrequent

6 months

30 minutes on most days of the week

Yes

Brisk walking, biking, swimming or use of home exercise equipment

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes daily

Yes

Walking

No

6 weeks

150 minutes per week

Yes

Walking

No

6 weeks

150 minutes per week

No

 

When the researchers analyzed the results of these studies, they found that physical activity interventions significantly reduced fatigue in participants. Participants who took part in frequent counseling (less than three weeks between phone calls/sessions) had greater reductions in fatigue than those who experienced infrequent or no counseling.

 

Strengths and limitations

Strengths

  • While the effect of exercise on fatigue in cancer survivors has been studied previously, this review of the literature provides a more comprehensive view of how physical activity interventions, especially those that are home-based, affect fatigue symptoms.
  • The effects of varying levels of counseling on survivors’ fatigue levels had not yet been studied; this review is the first to examine how frequent counseling influences fatigue in cancer survivors participating in a physical activity intervention.

 

Limitations

  • The participants were mostly white female breast cancer survivors with high socioeconomic status, so the results may not be generalizable to diverse populations with different cancer diagnoses. Importantly, not everyone may have equal access to safe places to exercise close to home.
  • Participants knew to which group they were assigned (with or without the physical activity). This could create behavioral changes or differences in self-reported fatigue that are not due to physical activity and could affect the results.
  • The studies included in the had relatively small sample sizes (number of participants), limiting the generalizability of the results.

 

What does this mean for me?

People who are diagnosed with cancer often experience effects from their cancer or treatment, including fatigue, depression and anxiety. An exercise routine that includes walking and other low- to moderate-intensity activities might reduce your fatigue and improve depression and anxiety.

Finding a space to exercise in or near your home might help you stick to a routine and form a habit of exercising. Pairing your physical activity with frequent counseling that targets behavioral change, goal setting and problem-solving could further help you manage your fatigue, depression and anxiety through exercise.

 

Reference

Huizinga F, Westerink N, Berendsen A, et al. Home-based physical activity to alleviate fatigue in cancer survivors: a systematic review and . Medicine & Science in Sports & Exercise 2021; 53(12): 2661-74. Published online December 2021.

Disclosure: FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

 

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This article is relevant for:

Cancer patients who are experiencing fatigue related to cancer or its treatment.

This article is also relevant for:

People with breast cancer

People with colorectal cancer

People with endometrial cancer

People with ovarian cancer

People with pancreatic cancer

People with prostate cancer

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IN-DEPTH REVIEW OF RESEARCH

Study background

Exercise can improve quality of life and physical health for cancer survivors. However, only about one-quarter of cancer survivors meet recommended guidelines for physical activity. Several studies on physical activity and fatigue noted that many cancer patients abandoned prescribed exercise routines or refused to participate due to lack of time, motivation or confidence, feeling unwell or tired or not enjoying the type of exercise. Travel time to the exercise facility also decreased participation.

Physical activity that takes place in or near one’s home might boost participation in and adherence to exercise routines. This of 11 smaller studies looked at how home-based physical activity affects the possible side effects of cancer diagnosis and treatment—fatigue, depression and anxiety. While the effect of exercise on fatigue in cancer survivors has been studied before, this is the first review to compare the effectiveness of home-based to clinic-based approaches and to assess the effects of frequent counseling versus infrequent or no counseling.

Researchers of this study wanted to know

Researchers wanted to know how home-based physical activity interventions affect fatigue, depression and anxiety in adult cancer survivors.

Populations looked at in this study

In this , researchers reviewed 11 studies that included 1,066 participants:

  • 94% were female
  • 82% identified as Caucasian
  • 56% had completed post-secondary education or higher
  • 77% had a history of breast cancer
  • 14% had a history of ovarian cancer
  • 4% had a history of colorectal cancer
  • 4% had a history of cancer
  • 1% had a history of an unspecified cancer type
  • Mean age ranged from 53 to 69 years
  • On average, participants had completed treatment 1.7 to 5.9 years before participating in the study.

Study design

The studies examined in this were controlled trials that included cancer survivors who were age 18 or older and had completed cancer treatment. Also included were breast cancer survivors receiving hormonal therapy. Nine studies looked specifically at fatigue, and two studies focused on depression and anxiety. Each study consisted of an intervention group that participated in the physical activity and a control group that did not change their exercise habits.

Participants in each study engaged in moderate- to low-intensity physical activity (such as brisk walking, biking, swimming or using exercise equipment) that was home-based and self-monitored. The interventions lasted from 6 weeks to 6 months, with most continuing for 12 weeks. In the nine studies looking at fatigue, participants reported their levels of fatigue immediately after the intervention. Some studies followed up with participants, asking them to again rate their fatigue at 3 months and 6 to 9 months after they had completed the intervention. Researchers compared the responses of individuals who performed the physical activity to those who did not receive any intervention. Some interventions included frequent counseling focused on exercise motivation, encouragement and problem-solving.

The researchers performed a random-effects on the nine fatigue-based studies to understand the effect of exercise on fatigue. Because some studies measured fatigue levels in different ways, the researchers needed to standardize the results of each study so they could compare the outcomes. To do this, they calculated the standardized mean difference (SMD) for each of the nine studies. The researchers calculated SMD by first finding the difference between fatigue scores for people in the intervention and control groups. Then, they divided that number by the standard deviation of all outcomes in the study. The resulting SMD is a standardized figure the researchers used to compare how well each study’s intervention worked to reduce fatigue.

Additional details about the study design can be found by searching the PROSPERO database using registration ID# CRD42020195618.

Study findings

Here is a summary of the methods and outcomes of the nine studies that looked at fatigue:

Study

Number of participants

Exercise type

Counseling

Duration

Frequency

Fatigue improved compared to control?

Baruth, et al. (2015)

32

Brisk walking

Yes, frequent

12 weeks

From 3 days per week for 20 minutes daily to 5 days per week for 30 to 40 minutes

Yes, statistically significant

Pinto, et al. (2013)

46

Walking, biking or using home exercise equipment

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes

Yes, not significant

Pinto, et al. (2013)

192

Brisk walking, biking or swimming

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes

Yes, not significant

Vallance, et al. (2007)

377

Brisk walking

No

12 weeks

5 days per week for 30 minutes daily

Yes, statistically significant

Zhou, et al. (2017)

144

Brisk walking

Yes, frequent

6 months

150 minutes per week

Yes, statistically significant

Bennett, et al. (2007)

56

Walking or other form if preferred

Yes, infrequent

6 months

30 minutes on most days of the week

Yes, unknown significance

Pinto, et al. (2005)

86

Brisk walking, biking, swimming or using home exercise equipment

Yes, frequent

12 weeks

From 2 days per week for 10 minutes daily to 5 days per week for 30 minutes daily

Yes, statistically significant

Pinto, et al. (2008)

86

Walking

No

6 weeks

150 minutes per week

Yes, statistically significant

Nyrop, et al. (2017)

62

Walking

No

6 weeks

150 minutes per week

No, not significant

 

Can home-based physical activity interventions reduce fatigue for cancer survivors?

Of the nine studies that looked at fatigue outcomes:

  • showed a statistically significant reduction in fatigue among cancer survivors who participated in home-based physical activity interventions compared to those who did not participate in any intervention (controls). An SMD between 0 and 1 means the physical activity intervention worked to reduce fatigue, with numbers closer to 1 signaling a stronger effect of the intervention and numbers closer to 0 indicating a weaker effect.
    • Reduction in fatigue was statistically significant immediately after intervention: SMD=0.22
    • Reduction in fatigue was statistically significant three months after intervention: SMD=0.27
    • Reduction in fatigue was statistically significant six to nine months after intervention: SMD=0.31
  • Frequent counseling led to better outcomes in fatigue reduction. Researchers think this might be because counseling promoted sustainable behavioral changes that led to increased exercise.
    • Frequent counseling: SMD=0.32
    • Infrequent or no counseling: SMD=0.05

Can home-based physical activity interventions reduce depression and anxiety in cancer survivors?

  • No conclusions about the effect of exercise on these mental health measures could be made because only two studies analyzed these issues.
  • The authors cite previous research that suggests exercise reduces depression and anxiety, and that both symptoms tend to occur with fatigue. One study showed that improving one symptom, such as fatigue, often improves the other two, so it’s possible that reducing fatigue through exercise also reduces depression and anxiety.

Are cancer survivors more likely to participate in and adhere to home-based interventions rather than clinic-based interventions?

  • When the authors compared the participation and adherence rates in the to previous studies that included mainly clinic-based interventions, they found that participation and adherence were higher for at-home interventions.
    • Participation:
      • At-home: 55%
      • Clinic-based: 37–43%
    • Adherence:
      • Exclusively at-home: 77.9%
      • At-home and clinic-based: 65%
         

Strengths and limitations

Strengths

  • While the effect of exercise on fatigue in cancer survivors has been studied previously, this analysis of the literature provides a more comprehensive view of how physical activity interventions, especially those that are home-based, affect fatigue symptoms.
  • The effects of varying levels of counseling on survivors’ fatigue levels had not been studied. This review is the first to examine how frequent counseling influences fatigue in cancer survivors participating in a physical activity intervention.
  • The researchers performed appropriate statistical analyses to properly support their conclusions.

Limitations

  • The participants were mostly white female breast cancer survivors with high socioeconomic status so the results might not be generalizable for diverse populations with different cancer diagnoses.
  • Participants knew to which group they were assigned (with or without physical activity). This could create behavioral changes or differences in self-reported fatigue symptoms that were not due to physical activity and would skew the results.
  • The studies that reported fatigue reduction at 3 months and 6 to 9 months after the intervention were conducted by the same researchers, creating the possibility of procedural or researcher bias in these findings.
     

Context

After cancer treatment, 30 to 40 percent of people report experiencing fatigue. Other common symptoms are depression and anxiety. Since the 1990s, “exercise oncology” research has shown that physical activity plays a vital role in improving quality of life for cancer survivors. Previous studies looking at physical activity interventions have shown that exercise helps reduce survivors’ fatigue, depression and anxiety. Observational studies also suggest that cancer survivors who exercise more have lower levels of fatigue, depression and anxiety.

The authors of this study recognized a need to examine factors that contribute to participation in and adherence to prescribed exercise routines. According to previous studies, less than half of eligible participants choose to enroll in a physical activity intervention after cancer treatment, despite the proven benefits of exercise on physical and mental well-being. Survivors in earlier studies have cited barriers to participation, such as travel time to the facility, lack of motivation or confidence, feeling unwell or tired or not enjoying the type of exercise. Exercising at home might eliminate some of these barriers, but differences in participation and adherence rates for home-based versus clinic-based interventions had not been examined previously.

To address this gap in the data, the authors of this compared the home-based participation data to participation rates in previous studies that included clinic-based interventions. This was also the first study to analyze how the presence or absence of counseling affects exercise participation and fatigue symptoms. Overall, this confirms previous findings that exercise helps reduce fatigue for cancer survivors.
 

Conclusions

Low- to moderate-intensity exercise such as brisk walking, biking, swimming or using home-exercise equipment is effective at reducing fatigue in cancer survivors. People are more likely to form a habit of exercising and adhere to physical activity interventions when the activity is home-based rather than in a clinic. In addition, interventions that include frequent counseling focused on behavioral change lead to a more drastic decrease in fatigue levels than those that are paired with infrequent or no counseling.

 

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posted 8/1/22

Expert Guidelines
Expert Guidelines

The National Comprehensive Cancer Network (NCCN) in their Survivorship Guidelines has specific recommendations related to fatigue in people diagnosed with cancer.

  • Patients should be told that fatigue management is an important part of their care and that fatigue can persist even after treatment ends. 
  • Patients should be screened for fatigue at their first visit and at regular intervals during and after treatment as indicated. 
  • Treating fatigue is best managed by a team of experts with specialties in different areas of supportive care, including:
    • survivorship
    • nutrition
    • integrative medicine
    • mental health
    • physical therapy
    • occupational therapy
    • sleep therapy
  • Patients should be screened and treated for symptoms that may be seen along with fatigue, including pain, emotional distress and sleep disruption. 
  • Interventions may include:
    • physical activity
    • rehabilitation, physical therapy
    • yoga
    • acupunture
    • massage therapy
    • behavioral therapy
    • nutrition consultation
    • consider stimulant drugs
    • treatment for sleep dysfunction

Updated: 08/06/2022

Questions To Ask Your Doctor
Questions To Ask Your Doctor

  • What physical activities are safe for me?
  • What are the physical activity guidelines for my age group?
  • What exercise counseling options are available to me?
  • How can I work physical activity into my daily life?
  • How frequently or vigorously should I exercise?
  • Are there any physical activities I should avoid and for how long?

Open Clinical Trials
Open Clinical Trials

The following studies are looking at management of side effects: 

Multiple cancers

Breast cancer

Colorectal cancer

Endometrial cancer

Ovarian cancer

  • NCT04533763: Living WELL: A Web-Based Program for Ovarian Cancer Survivors. This studies a group-based and web-delivered tool for ovarian cancer survivors in increasing quality of life and decreasing stress, depressive mood, anxiety, and fatigue across a 12-month period.
  • NCT05047926: Prehabilitation for Advanced Ovarian Cancer Patients. Prehabilitation may improve peri-operative outcomes in patients undergoing cancer surgery. This study will look at structured activity for women undergoing chemotherapy to improve their physical state prior to surgical intervention and thus improve outcomes.

cancer

Updated: 11/03/2022

Find Experts
Find Experts

Many cancer centers offer survivorship expertise and services, including fatigue clinics, sleep centers, experts, and pain management experts. Ask your doctor to refer you to experts who can address your symptoms and concerns. The following resources can help you find experts:

  • The American Academy of Sleep Medicine's website SleepEducation.org includes a section on finding a sleep center by location.
  • The American Physical Therapy Association's ChoosePT.com website allows you to search for a physical therapist in your area. 
  • Eatright.org, the website for the Academy of Nutrition and Dietetics, has an online tool to find a nutritionist in your area. You can search for nutritionists by specialty, including "cancer," "weight management" and "heart health." 
  • The National Certification Commission for Acupuncture and Oriental Medicine has a searchable directory of licensed acupuncturists.
  • The Lymphatic Education & Resource Network has tips and tools for finding experts.
  • The North American Menopause Society is an organization for menopause experts. Their website has a tool to help you find a qualified menopause expert in your area.

Updated: 08/06/2022

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