Running head: IMPROVING SYMPTOMS IN PATIENTS WITH CANCER

Improving Symptoms in Patients with Cancer

Patricia Korovich
University of South Florida

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Abstract
Clinical problem: Fatigue is a symptom frequently experienced by patients with cancer, and can
negatively affect their quality of life (Bower et al., 2014).
Objective: To consider whether exercise, versus no exercise, decreases cancer related fatigue
(CRF) and/or improves quality of life (QoL). Randomized controlled trials (RCTs) were sought
out via PubMed and CINAHL about exercise programs offered to cancer patients. The U.S.
Department of Health & Human Services Agency for Healthcare Research and Quality was
searched through the National Guideline Clearinghouse for guidelines concerning management
of fatigue in cancer patients. Key search terms used to find scholarly data included: RCT,
fatigue, cancer, quality of life and exercise.
Results: A guideline published by the Journal of Clinical Oncology endorses the use of exercise
to manage fatigue, such as walking programs (Bower et al., 2014). Three RCTs statistically
supported the implementation of exercise programs to better QoL and lessen CRF in comparison
with no exercise program.
Conclusion: Cancer patients experiencing CRF can potentially improve fatigue symptoms and
QoL through participation in exercise programs. Further trials must be conducted to include
larger numbers of participants and more succinct outcomes.

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Improving Symptoms in Patients with Cancer
The American Cancer Society (2016) published a summary explaining cancer-related
fatigue (CRF), defining fatigue as being physically, mentally and emotionally tired. This
summary helps distinguish every day fatigue, which is improved with rest, to CRF, which is
persistent and unaffected by rest. CRF can negatively impact a cancer patients capacity to
conduct activities of daily living like bathing or eating and this can make it an overwhelming and
distressing side effect (American Cancer Society, 2016). Unfortunately, fatigue is a commonly
experienced symptom in patients with cancer; it can be long-term and it can be detrimental to
quality of life (QoL) (Bower et al., 2014).
Regrettably, research on interventions that can decrease fatigue for cancer patients has not
been extensively addressed in research (Campbell, A., Mutrie, N., White, F., McGuire, F., &
Kearney, N., 2005). However, several randomized control trials (RCTs) support implementation
of different exercise programs as a method to improve fatigue symptoms for cancer patients, as
well as QoL. A guideline published by Bower et al. (2014) suggests 150 minutes of moderate
aerobic exercise plus two or three strength training sessions per week for those who are capable.
For those patients who are not physically well enough, a walking program would be sufficient.
It is important to assess the validity of literature showing the correlation between exercise
programs and CRF and/or QoL in cancer patients. In doing so, one can take an EBP approach in
determining if an increase in exercise compared with no increase in exercise can reduce CRF and
improve QoL for cancer patients over the course of six months.
Literature Search
The U.S. Department of Health and Human Services Agency for Healthcare Research
and Quality website was accessed, and using the National Guideline Clearinghouse search,
guidelines concerning management of fatigue in cancer patients were found. The search terms
used were cancer and fatigue. RCTs were obtained through the PubMed and CINAHL databases
by conducting searches concerning exercise programs offered to cancer patients. Key search

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terms used to find data included RCT, fatigue, cancer, quality of life and exercise. The search
was first restricted to full-access, scholarly journal, peer-reviewed research in the English
language; however, later searches also included a publishing year range from 2011 to 2016. The
initial search provided 15 results, of which four were ultimately selected for literature review.
Literature Review
In order to assess the efficacy of exercise in countering CRF and improving QoL in
cancer patients, four RCTs and their results were evaluated. In addition, one set of guidelines
was reviewed to understand recommendations currently in place.
Campbell, Mutrie, White, McGuire, and Kearney (2005) conducted a pilot RCT assessing
if exercise as an adjunctive therapy could improve physical functioning, fatigue and QoL in
women who have early stage breast cancer and are receiving radiotherapy and/or chemotherapy.
These patients had undergone surgery for breast cancer and had no concurrent major health
issues. Of the 22 participants, 12 women were placed in the intervention group, which involved
a 12-week exercise program, and 10 in the control group, who did not participate in the exercise
program. All participants were randomly placed into their groups, assessed with a 12-minute
walking test and questionnaires, both before and after the exercise program. Questionnaires
utilized included the Functional Assessment of Cancer Therapy Breast (FACT-B) and
Functional Assessment of Cancer Therapy General (FACT-G) scales, which evaluated cancerspecific QoL, the Satisfaction With Life Scale (SWLS), which was a general QoL assessment
and the Revised Piper Fatigue Scale (PFS), which measured overall fatigue. The intervention
group achieved a significant increase in quality of life (p=.046) and reports of fatigue decreased
(p=.115), however it did not reach the appropriate significance value. The strengths related to
this trial included random and initially concealed assignments, reasons were given for
incompletion of the study and participants in both groups were similar in regards to baseline
variables and demographics. Weaknesses in this study included self-reporting questionnaires,

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which are subjective information, a small study sample and the study was not double-blind. In
addition, there was concern that the intervention group had added psychosocial benefits through
group support.
Culos-Reed, Carlson, Daroux, and Hately-Aldous (2006) conducted a pilot RCT with 38
participants examining the physical and psychological benefits as a result of a seven-week yoga
program for cancer survivors not undergoing treatment. Participants in both the control group
(n=18) and intervention group (n=20) were primarily women with breast cancer, 18 years and
older, at least three months-post treatment and had no additional health concerns. Measures
included the Profile of Mood States (PoMS), which had a fatigue element, the EORTC QLQ-C30
questionnaire, which included fatigue and QoL scales and physical activity assessments. The
two groups completed these assessments both pre-intervention and post-intervention. Significant
results were seen in QoL (p=.01); however, the numeric results for measures that were not
statistically relevant were not provided, including fatigue. Strengths of this RCT included
participant similarity in regards to baseline variables between groups, random assignment, and
reasons for incompletion of the program were given. Potential weaknesses involved the
inclusion of former control group participants in a second wave; once the first seven-week
program was completed, a second intervention group was created to participate. This could have
potentially caused contamination of results. Additionally, the numeric results for measures that
were not statistically relevant were excluded from the results, including fatigue.
Mock et al. (2001) lead a multi-institutional pilot study to investigate how a home-based
moderate walking exercise program affected emotional distress, fatigue, physical functioning,
and QOL during breast cancer treatment. Measures included questionnaires assessing fatigue
(Piper fatigue scale [PFS]), fatigue-inertia (Profile of Mood States [PoMS]) and QoL (MOS SF36). Additionally, a 12-minute walk test was conducted to test physical functioning at the start,

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middle, and at conclusion of treatment. The program lasted through the length of the patients
individual chemotherapy and/or radiotherapy. Fifty women between the ages of 28 and 75, with
no concurrent health issues, undergoing chemotherapy and/or radiotherapy after having had
surgical intervention were included in the trial. Initially, participants were randomly assigned to
control and intervention groups; however, as the trial progressed, it came to the attention of
researchers that a portion of those in the control group had decided to independently begin
walking programs on their own, while those in the intervention group did not sustain the
prescribed activities. This began to affect results, so the activity levels of all participants were
assessed, leading to the division of low walkers (n=22) and high walkers (n=28). The high
walker group achieved a significant increase in quality of life, although the p value was not
clearly expressed. Reports of fatigue decreased (p=.00) in both the PFS and PoMs scale for the
high walker group. Reasons why participants did not complete the study were given,
participants demonstrated group equivalence in cancer treatments and the study acknowledges
some potential weaknesses. There are several issues with this trial including the reassignment of
groups, noncompliance with the walking program, and statistical data that was difficult to
decipher from the text.
Andersen et al. (2013) evaluated with an RCT whether a six-week supervised exercise
program, adjunct to standard care and chemotherapy, could reduce a patient's CRF level. A total
of 213 cancer patients participated. There were N=106 participants in the intervention group and
n=107 participants in the control group. Participants were eligible if they were undergoing
chemotherapy during the six-week study period at least once. The mean age was 47.5, and
participants were mostly female. Individuals who were placed in the control group were placed
on a wait list to participate in the program; however, this participation occurred post-study and
results of this group were not included in the provided statistics. The intervention included

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massage, relaxation and body awareness training, as well supervised exercise. Exercise training
comprised of heavy resistance and high-intensity cardiovascular training. These interventions
took place nine hours weekly for six weeks. Relevant study measures included fatigue scoring
with the Functional Assessment of Cancer Therapy-Anaemia Questionnaire (FACT-An). Results
were self-reported before randomization and after the study period. It was found that CRF was
reduced in the intervention group (p=.002). The patients were randomized into groups and the
study included an extensive breakdown of demographic details on participants (including those
who received blood transfusions, every type of cancer reported, etc.) Participants demonstrated
group equivalence in chemotherapy treatments and this trial, unlike several of the other RCTs,
included a variety of cancer types and a large number of participants. Weaknesses were
addressed including self-referral leading to highly motivated individuals being more likely to
participate. However, the initial assessment having been conducted before randomization was an
astute technique in avoiding bias.
Bower et al. (2014) composed a set of guidelines for the screening, assessment, and
management of fatigue in adults with cancer. These guidelines were created based on
information found in meta-analyses, systematic reviews and RCTs. Recommended in these
guidelines is that patients be evaluated for fatigue symptoms after primary treatment and
subsequently be educated on strategies for relief of fatigue, including exercise. According to the
guidelines, sustaining physical activity could potentially lower CRF for patients in the posttreatment period, which can lead to an improvement in QoL. It is also mentioned that exercise
strategies should be tailored to each individual depending upon his or her level of fatigue and
level of physical ability. The guidelines recommend 150 minutes of moderate exercise plus two
to three sessions of strength training per week, walking programs for those who do not have the

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stamina for the former, or a referral to a physical therapist for those who are at high risk for
injury.
Synthesis
In 2013, Andersen et al. reported a statistically significant reduction in CRF through
participation in a six-week, high intensity exercise program (p=.002). Mock et al. (2001)
determined statistically that fatigue levels improved with a home-based walking program (p=.00)
and stated that QoL also improved. However, the statistical value for QoL improvement was not
provided. Culos-Reed et al. (2006) revealed an increased QoL for those involved in a sevenweek long yoga program (p=.01) but did not provide statistical values for CRF levels. Also,
Campbell et al. (2005) showed that patients in a 12-week exercise program experienced an
increase in QoL (p=.046) as well as a decrease in fatigue, albeit statistically insignificant
(p=.115). Lastly, guidelines provided by Bower et al. (2014) propose moderate exercise, walking
programs and/or physical therapy consults to counter CRF, depending on an individuals
capabilities.
The current research and guidelines discuss QoL and CRF jointly, with the exception of
the study conducted by Andersen et al. (2013), which solely assessed CRF. Andersen, et al.
(2013) and Mock, et al. (2001) showed statistically that CRF levels were improved with exercise.
Culos-Reed et al. (2006) and Campbell et al. (2005) showed statistically that QoL levels were
improved with exercise. It seems, after reviewing the literature, that some of these RCTs lacked
focus. The exercise interventions varied in intensity and several of the RCTs assessed such a
large number of outcomes (such as symptoms of stress, emotional distress, etc.) that the results
became muddled. In addition, several of these RCTs failed to report all necessary statistical data
including some p values. Two of the trials, Culos-Reed et al. (2006) and Campbell et al. (2005),
were pilot studies and, therefore, had a small number of participants. Due to the small
population, it is difficult to say whether the results can be reliably duplicated in larger

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populations or in the general public. In the future, several RCTs should be conducted with a
more narrow focus, with a larger trial group, and more stringent numerical reporting.
Current guidelines from Bower et al. (2014) recommend tailoring individual exercise
programs to each cancer patients abilities and fatigue level in order to combat CRF and increase
QoL. Although the RCTs mentioned earlier do have weaknesses, they do provide evidence that
QoL, CRF or both can be improved with exercise. This gives evidence in support of the current
guidelines.
Clinical Recommendations
The inclusion of an exercise program as an adjunctive therapy has potential to improve
CRF and/or QoL for patients with cancer. Current guidelines endorse assessing each patients
individual physical capabilities to determine the level of activity recommended to them.
Frequent moderate exercise is the preferred choice of exercise level, followed by a less intense
walking program, or at the very least a consultation with a physical therapist for those who are at
high risk for injury. More thorough research is necessary to further calculate the effects of
different exercise intensities on larger groups of participants. This would help medical
professionals better educate their patients with evidence-based practice. However, there is
sufficient evidence to endorse the application of policies and/or programs towards cancer
patients. Specifically, as directed by current guidelines, each patient should be assessed for level
of fatigue and subsequently level of function, then have an exercise program with parameters
recommended to them. It would be reasonable to anticipate an increase in QoL, CRF or both as
a result.

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References
American Cancer Society. (2016, May 24). What is cancer-related fatigue? Retrieved from
http://www.cancer.org/treatment/treatmentsandsideeffects/physicalsideeffects/fatigue/feel
ing-tired-vs-cancer-related-fatigue
Andersen, C., Rrth, M., Ejlertsen, B., Stage, M., Mller, T., Midtgaard, J., ... Adamsen, L.
(2013). The effects of a six-week supervised multimodal exercise intervention during
chemotherapy on cancer-related fatigue. European Journal Of Oncology Nursing, 17331339. doi:10.1016/j.ejon.2012.09.003
Bower, J. E., Bak, K., Berger, A., Breitbart, W., Escalante, C. P., Ganz, P. A., Jacobsen, P.B.
(2014). Screening, assessment, and management of fatigue in adult survivors of cancer:
an American Society of Clinical oncology clinical practice guideline adaptation. Journal
of Clinical Oncology, 32(17), 1840-1850. doi: 10.1200/JCO.2013.53.4495
Campbell, A., Mutrie, N., White, F., McGuire, F., & Kearney, N. (2005). A pilot study of a
supervised group exercise programme as a rehabilitation treatment for women with breast
cancer receiving adjuvant treatment. European Journal of Oncology Nursing, 9(1), 56-63.
doi:10.1016/j.ejon.2004.03.007

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Culos-Reed, S., Carlson, L., Daroux, L., & Hately-Aldous, S. (2006). A pilot study of yoga for
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891-897. doi:10.1002/pon.1021
Mock, V., Pickett, M., Ropka, M. E., Lin, E. M., Stewart, K. J., Rhodes, V. A., McCorkle, R.
(2001). Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer
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