Effect of exercise on cancer-related fatigue: A systematic review
Keywords:Aerobic, Resistance, Endurance, Combined exercise, Physical activity, Cancer
Cancer is the second leading cause of death in the world and cancer-related fatigue (CRF) is the most common disease in cancer patients that received radiotherapy, chemotherapy, hormone therapy and biotherapy. Many studies recommended physical activity and exercise to improve fatigue. This systematic review aims to provide a qualitative synthesis of Randomized Clinical Trials (RCTs) evaluating the effects of Aerobic, Resistance, Endurance and combined exercises on CRF versus control or different exercise group in cancer adult patients and survivors that did not receive palliative care. This systematic review is written and presented according to PRISMA protocols. Articles in the English language were collected using the PubMed and WoS databases from 2001 January 1st to 2019 September 1st. Only RCTs lasted 5 weeks or more were analysed of which CRF outcomes were examined. A total of 15 RCTs met our inclusion criteria. Different outcomes in CRF self-reports were found between Aerobic, Resistance, Endurance and Combined exercises. Findings suggest that exercise improves CRF, especially with aerobic or combined programs. The outcomes of trials could help exercise professionals to properly plan the sessions by dosing the volume and intensity. Nevertheless, more studies are needed to better understand the beneﬁts of physical exercise on cancer patients.
ACSM (2018). ACSM's Guidelines for Exercise Testing and Prescription (10th ed.). Baltimore: Lippincott Williams & Wilkins.
Adams, S. C., DeLorey, D. S., Davenport, M. H., Fairey, A. S., North, S., & Courneya, K. S. (2018). Effects of high-intensity interval training on fatigue and quality of life in testicular cancer survivors. British Journal of Cancer, 118(10), 1313-1321. https://doi.org/10.1038/s41416-018-0044-7
Ahlberg, K., Ekman, T., Gaston-Johansson, F., & Mock, V. (2003). Assessment and management of cancer-related fatigue in adult. Lancet, 362, 640-650. https://doi.org/10.1016/s0140-6736(03)14186-4
AIOM, AIRTUM, PASSI. (2018). I numeri del cancro in Italia (9^ ed.). Brescia: Intermedia Editore. https://www.aiom.it/wp-content/uploads/2018/10/2018_NumeriCancro-operatori.pdf
Akechi, T., Kugaya, A., Okamura, H., Yamawaki, S., & Uchitomi, Y. (1999). Fatigue and its associated factors in ambulatory cancer patients: a prelilinary study. Journal of Pain and Symptom Management, 17(1), 42-48. https://doi.org/10.1016/s0885-3924(98)00105-5
American Cancer Society (2019). Cancer Facts & Figure. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2019/cancer-facts-and-figures-2019.pdf
Bernsten, S., Aaronson, N. K., Buffart, L., Börjeson, S., Demmelmaier, I., Hellbom, M., Hojman, P., Igelström, H., Johansson, B., Pingel, R., Raastad, T., Velikova, G., Åsenlöf, P., & Nordin, K. (2017). Design of randomized controlled trial of physical training and cancer (Phys-Can)- the impact of exercise on cancer related fatigue, quality of life and disease outcome. BMC Cancer, 17(1), 218. https://doi.org/10.1186/s12885-017-3197-5
Borg, G. (1970). Perceived exertion and pain scales. Scandinavian Journal of Rehabilitation Medicine, 23, 92-96.
Bower, J., Ganz, P., & Desmond, K. (2000). Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. Journal of Clinical Oncology, 18(4), 743-753. https://doi.org/10.1200/jco.2000.18.4.743
Broeckel, J., Jacobsen, P., Horton, Balducci, L., & Lyman, G. H. (1998). Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 16(5), 1689-1696. https://doi.org/10.1200/jco.19220.127.116.119
Brown, D. J., McMillan, D. C., & Milroy, R. (2005). The correlation between fatigue, physical function, the systemic inflammatory response, and psychological distress in patients with advanced lung cancer. Cancer, 103(2), 377-382. https://doi.org/10.1002/cncr.20777
Cataldi, S., Latino, F., Greco, G., & Fischetti, F. (2019). Multilateral training improves physical fitness and fatigue perception in cancer patients. Journal of Human Sport and Exercise, 14(4proc), S910-S920. https://doi.org/10.14198/jhse.2019.14.proc4.54
Cella, D., Davis, K., Breitbart, W., & Curt, G. (2001). Cancer-related fatigue: Prevalence of proposed diagnostic criteria in a United States sample of cancer survivors. Journal of Clinical Oncology, 19(14), 3385-3389. https://doi.org/10.1200/jco.2001.19.14.3385
Cheng, Y. J., Macera, C. A., Church, T. S., & Blair, S. N. (2002). Heart rate reserve as a predictor of cardiovascular and all-cause mortality in men. Medicine & Science in Sports & Exercice, 34(12), 1873-1878. https://doi.org/10.1097/00005768-200212000-00003
Cink, R. E., & Thomas, T. R. (1981, September). Validity of the Astrand-Ryhming nomogram for predicting maximal oxygen intake. British Journal of Sports Medicine, 15(3), 182-185. https://doi.org/10.1136/bjsm.15.3.182
Cleeland, C. S., Wang, X. S., & Proceedings NCCN. (1999). Measuring and understanding fatigue. Oncology, 13, 91-97.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. New York: Routledge.
Cormie, P., Galvão, D. A., Spry, N., Joseph, D., Chee, R., & Taaffe, D. R. (2015). Can supervised exercise prevent treatment toxicity in patients with prostate cancer initiating androgen-deprivation therapy: a randomised controlled trial. British Journal of Urology International, 115(2), pp. 256-266. https://doi.org/10.1111/bju.12646
Cramp, F., & Byron-Daniel, J. (2012). Exercise for the management of cancer-related fatigue in adults. Cochrane Database Systematic Review, CD006145. https://doi.org/10.1002/14651858.cd006145.pub3
Curt, G. A., Breitbart, W., Cella, D., Groopman, J. E., Horning, S. J., Itri, L. M., Johnson, D. H., Miaskowski, C., Scherr, S. L., Portenoy, R. K., & Vogelzang, N. J. (2000). Impact of cancer-related fatigue on the lives of patients: New findings from the Fatigue Coalition. Oncologist, 5(5), 353-360. https://doi.org/10.1634/theoncologist.5-5-353
Delorme, T. L., & Watkins, A. L. (1948, May). Technics of progressive resistance exercise. Archives of Physical Medicine and Rehabilitation, 29(5), 263-273.
Dieli-Conwright, C. M., Courneya, K. S., Demark-Wahnefried, W., Sami, N., Lee, K., & Sweeney F. C. (2018, October 19). Aerobic and resistance exercise improves physical fitness, bone health, and quality of life in overweight and obese breast cancer survivors: a randomized controlled trial. Breast Cancer Research, 20(1), 124. https://doi.org/10.1186/s13058-018-1051-6
Fischetti, F., Greco, G., Cataldi, S., Minoia, C., Loseto, G., & Guarini, A. (2019). Effects of Physical Exercise Intervention on Psychological and Physical Fitness in Lymphoma Patients. Medicina, 55(7), 379. https://doi.org/10.3390/medicina55070379
Fiuza-Luces, C., Garatachea, N., Berger, N. A., & Lucia, A. (2013, September). Exercise is the real polypill. Physiology (Bethesda), 28(5), 330-358. https://doi.org/10.1152/physiol.00019.2013
Forsyth, L. M., Preuss, H. G., MacDowell, A. L., Chiazze, L., Birkmayer, G. D., & Bellanti, J. A. (1999). Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome. Annual of Allergy, Asthma & Immunology, 82(2), 185-191. https://doi.org/10.1016/s1081-1206(10)62595-1
Galiano-Castillo, N., Cantarero-Villanueva, I., Fernàndez-Lao, C., Ariza-García, A., Díaz-Rodríguez L., & Del-Moral-Ávila, R. (2016). Telehealth system: A randomized controlled trial evaluating the impact of an internet-based exercise intervention on quality of life, pain, muscle strength, and fatigue in breast cancer survivors. Cancer, 122(20), 3166-3174. https://doi.org/10.1002/cncr.30172
Hofman, M., Ryan, J. L., Figueroa-Moseley, C. D., & Jean-Pierre, P. (2007). Cancer-related fatigue: the scale of the problem. Oncologist, 12(Suppl 1), 4-10. https://doi.org/10.1634/theoncologist.12-s1-4
Hojan, K., Kwiatkowska-Borowczyk, E., Leporowska, E., Górecki, M., Ozga-Majchrzak, O., Milecki, T., & Milecki, P. (2016). Physical exercise for functional capacity, blood immune function, fatigue, and quality of life in high-risk prostate cancer patients during radiotherapy: a prospective, randomized clinical study. European Journal of Physical and Rehabilitation Medicine, 52(4), 489-501. https://doi.org/10.1016/j.rehab.2014.03.1350
Humpel, N., & Iverson, D. C. (2007). Depression and quality of life in cancer survivors: is there a relationship with physical activity? International Journal of Behavioral Nutrition and Physical Activity, 4, 65. https://doi.org/10.1186/1479-5868-4-65
Hwang, J. H., Chang, H. J., Shim, Y. H., Park, W. H., Park, W., Huh, S. J., & Yang, J. H. (2008). Effects of supervised exercise therapy in patients receiving radiotherapy for breast cancer. Yonsei Medical Journal, 49(3), 443-450. https://doi.org/10.3349/ymj.2008.49.3.443
Isaksson, B., Rippe, C., Simonoska, R., Holm, J. E., Glaumann, H., Segersvärd, R., Larsson, J., Erlanson-Albertsson, C., & Permert, J. (2002). Obstructive jaundice results in increased liver expression of uncoupling protein 2 and intact skeletal muscle glucose metabolism in the rat. Scandinavia Journal of Gastroenterology, 37(1), 104-111. https://doi.org/10.1080/003655202753387446
Jacobsen, P. B., Hann, D. M., Azzarello, L. M., Horton, J., Balducci, L., & Lyman, G. H. (1999). Fatigue in woman receiving adjuvant chemotherapy for breast cancer: characteristics, course and correlates. Journal of Pain and Symptom Management, 18(4), 233-242. https://doi.org/10.1016/s0885-3924(99)00082-2
Kampshoff, C. S., Chinapaw, M. J., Brug, J., Twisk, J. W., Schep, G., Nijziel, M. R., van Mechelen, W., & Buffart, L. M. (2015). Randomized controlled trial of the effects of high intensity and low-to-moderate intensity exercise on physical fitness and fatigue in cancer survivors: results of the Resistance and Endurance exercise After ChemoTherapy (REACT) study. BMC Medicine, 13, 275. https://doi.org/10.1186/s12916-015-0513-2
Kessels, E., Husson O., & Van der Feltz-Cornelis, C. M. (2018). The effect of exercise on cancer-related fatigue in cancer survivors: a systematic review and meta-analysis. Neuropsychiatric Diseas and Treatment, 14, 479-494. https://doi.org/10.2147/ndt.s150464
Lane, R. J., Barrett, M. C., Taylor, D. J., Kemp, G. J., & Lodi, R. (1998). Heterogeneity in chronic fatigue syndrome: Evidence from magnetic resonance spectroscopy of muscle. Neuromuscular Disorders, 8(3-4), 204-209. https://doi.org/10.1016/s0960-8966(98)00021-2
Lee, J. Q., Simmonds, M. J., Wang, S., & Novy, D. M. (2003). Differences in physical performance between men and women with and without lymphoma. Archive of Physical Medicine Rehabilitation, 84(12), 1747-1752.
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009). The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration. PLOS MED, 6(7), e1000100. https://doi.org/10.1371/journal.pmed.1000100
McCully, K. K., Natelson, B. H., Lotti, S., Sisto, S., & Leigh, J. S. (1996). Reduced oxidative muscle metabolism in chronic fatigue syndrome. Muscle & Nerve, 19(5), 621-625. https://doi.org/10.1002/(sici)1097-4598(199605)19:5<621::aid-mus10>3.0.co;2-q
Mendes, M. A., da Silva, I., Ramires, V., Reichert, F., Martins, R., Ferreira, R., & Tomasi, E. (2018). Metabolic equivalent of task (METs) thresholds as an indicator of physical activity intensity. PLOS ONE, 13(7), e0200701. https://doi.org/10.1371/journal.pone.0200701
Mendoza, T. R., Wang, X. S., Cleeland, C. S., Morrissey, M., Johnson, B. A., Wendt, J. K., & Huber, S. L. (1999). The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer, 85(5), 1186-1196. https://doi.org/10.1002/(sici)1097-0142(19990301)85:5<1186::aid-cncr24>3.0.co;2-n
Midtgaard, J., Baadsgaard, M. T., Rasmussen, B., Quist, M., Andersen, C., Rørth, M., & Adamsen, L. (2009). Self-reported physical activity behaviour; exercise motivation and information among Danish adult cancer patients undergoing chemotherapy. European Journal of Oncology Nursing, 13(2), 116-121. https://doi.org/10.1016/j.ejon.2009.01.006
Miller, S. A. (2001). Four Elements of the Clinical Question: PICO worksheet and search strategy.
Moher, D., Liberati, A., Tezlaff, J., & Altman, D. G. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLOS MED, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Monga, U., Garber, S. L., Thornby, J., Vallbona, C., Kerrigan, A. J., Monga, T. N., & Zimmermann, K. P. (2007). Exercise prevents fatigue and improves quality of life in prostate cancer patients undergoing radiotherapy. Archives of Physical Medicine and Rehabilitation, 88(11), 1416-1422. https://doi.org/10.1016/j.apmr.2007.08.110
Mustian, K. M., Alfano, C. M., Heckler, C., Kleckner, A. S., Kleckner, I. R., Leach, C. R., Mohr, D., Palesh, O. G., Peppone, L. J., Piper, B. F., Scarpato, J., Smith, T., Sprod, L. K., Miller, & S. M. (2017). Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue: A Meta-analysis. JAMA Oncology, 3(7), 961-968. https://doi.org/10.1001/jamaoncol.2016.6914
National Comprehensive Cancer Network. (2000). NCCN Practice Guidelines for Cancer-Related Fatigue. Oncology, 14(11A), 151-161.
National Comprehensive Cancer Network (2003). National Comprehensive Cancer Network practice guidelines cancer-related fatigue panel 2003 guidelines. Journal of National Comprehensive Cancer Network, 1(3), 308. https://doi.org/10.6004/jnccn.2003.0029
National comprehensive cancer network (2015). Cancer-Related Fatigue, Version 2.2015: Clinical Practice Guidelines in Oncology. Journal of the National Comprehensive Cancer Network, 13(8), 1012-1039. https://doi.org/10.6004/jnccn.2015.0122
Noonan, V., & Dean, E. (2000). Submaximal exercise testing: clinical application and interpretation. Physical Therapy, 80(8), 782-807. https://doi.org/10.1093/ptj/80.8.782
Parkin, D. M., Boyd, L., & Walker, L. C. (2011). The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. British Journal of Cancer, 105(suppl2), 77-81.
Paulo, T. R., Rossi, F. E., Viezel, J., Tosello, G. T., Seidinger, S. C., Simões, R. R., de Freitas, R., & Freitas, I. F. (2019). The impact of an exercise program on quality of life in older breast cancer survivors undergoing aromatase inhibitor therapy: a randomized controlled trial. Health and Quality of Life Outcomes, 17(1), 17. https://doi.org/10.1186/s12955-019-1090-4
Penttinen, H., Utriainen, M., Kellokumpu-Lehtinen, P. L., Raitanen, J., Sievänen, H., Nikander, R., Blomqvist, C., Huovinen, R., Vehmanen, L., & Saarto, T. (2019). Effectiveness of a 12-month Exercise Intervention on Physical Activity and Quality of Life of Breast Cancer Survivors; Five-year Results of the BREX-study. In Vivo, 33(3), 881-888. https://doi.org/10.21873/invivo.11554
Pinto, B. M., Frierson, G. M., Rabin, C., Trunzo, J. J., & Marcus, B. H. (2005). Home-based physical activity intervention for breast cancer patients. Journal of Clinical Oncology, 23(15), 3577-3587. https://doi.org/10.1200/jco.2005.03.080
Piper, B. (1997). Measuring fatigue. In M. Frank-Stromborg, S. J. Olsen, & J. &. Barlett (Ed.), Instruments for clinical health-care research (pp. 482-496). Sudbury: Jones & Barlett publishers.
Piper, B. F., Dibble, S. L., Dodd, M. J., Weiss, M. C, Slaughter, R. E., & Paul, S. M. (1998). The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncology Nursing Forum, 25(4), 677-684. https://doi.org/10.1037/t18854-000
Piper, B., Lindsey A, Dodd, M., Ferketich, S., Paul, S. M., & Weller, S. (1989). The development of an instrument to measure the subjective dimension of fatigue. In S. G. Funk, & S. G. Funk (Ed.), Key aspects of comfort (pp. 199–216). New York: Springer Pubblishing Company.
Robinson, K. D., & Posner, J. D. (1992). Patterns of self-care need, and interventions related to biologic response modifier therapy: fatigue as a model. Seminars in Oncology Nursing Journal, 8(4 suppl 1), 17-22. https://doi.org/10.1016/0749-2081(92)90050-d
Ryan, J. L., Carroll, J. K., Ryan, E. P., Mustian, K. M., Fiscella, K., & Morrow, G. R. (2007). Mechanisms of cancer-related fatigue. Oncologist, 12(Suppl 1), 22-34. https://doi.org/10.1634/theoncologist.12-s1-22
Schmidt, M. E., Wiskemann, J., Armabrust, P., Glassley, P., Stigge, R., Northfelt, D., Mikhael, J., Aguirre, A., Bennett, R. M., & Mesa, R. A. (2015). Effects of resistance exercise on fatigue and quality of life in breast cancer patients undergoing adjuvant chemotherapy: A randomized controlled trial. International Journal of Cancer, 137(2), 471-480. https://doi.org/10.1002/ijc.29383
Schwart, A., & Meek, P. (1999). Additional contruct of validity of the Schwartz cancer fatigue scale. Journal of Nursing Measurement, 7(1), 35-45.
Schwartz, A. (1998). The Schwartz Cancer Fatigue Scale: testing reliability and validity. Oncology Nursing Forum, 25(4), 711-717.
Segal, R. J., Reid, R. D., Courneya, K. S., Sigal, R. J., Kenny, G. P., Prud'Homme, D. G., Malone, S. C., Wells, G. A., Scott, C. G., & Slovinec D'Angelo, M. E. (2009). Randomized controlled trial of resistance or aerobic exercise in men receiving radiation therapy for prostate cancer. Journal of Clinical Oncology, 27(3), 344-351. https://doi.org/10.1200/jco.2007.15.4963
Shobeiri, F., Masoumi, S. Z., Nikravesh, A., Heidari Moghadam, & R., Karami, M. (2016). The Impact of Aerobic Exercise on Quality of Life in Women with Breast Cancer: A Randomized Controlled Trial. Journal of Research in Health Sciences, 16(3), 127-132.
Sitzia, J., & Huggins, L. (1998, January- February). Side effects of cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy for breast cancer. Cancer Practice, 6(1), 13-21. https://doi.org/10.1046/j.1523-5394.1998.1998006013.x
Smets, E. M., Garssen, B., Bonke, B., & De Haes, J. C. (1995). The multidimensional fatigue inventory (MFI). Psychometric qualities of an instrument to assess fatigue. Journal of Psychosomatic Research, 39(3), 315-325. https://doi.org/10.1016/0022-3999(94)00125-o
Stefani, L., Pedrizzetti, G., & Galanti, G. (2016). Clinical application of 2D speckle tracking strain for assessing cardiotoxicity in oncology. Journal of Functional Morphology and Kinesiology, 1(4), 343-354. https://doi.org/10.3390/jfmk1040343
Steindorf, K., Schmidt, M. E., Klassen, O., Ulrich, C. M., Oelmann, J., Habermann, N., Beckhove, P., Owen, R., Debus, J., Wiskemann, J., & Potthoff, K. (2014). Randomized, controlled trial of resistance training in breast cancer patients receiving adjuvant radiotherapy: results on cancer-related fatigue and quality of life. Annals of Oncology, 25(11), 2237-2243. https://doi.org/10.1093/annonc/mdu374
Stone, P., Hardy, J., Huddart, R., A'Hern, R., & Richards, M. (2000). Fatigue in patients with prostate cancer receiving hormone therapy. European Journal of Cancer, 36(9), 1134-1141. https://doi.org/10.1016/s0959-8049(00)00084-8
Stout, N. L., Baima, J., Swisher, A. K., Winters-Stone, K. M., & Welsh, J. (2017). A Systematic Review of Exercise Systematic Reviews in the Cancer Literature (2005-2017). PM&R, 28(5), S347-S384. https://doi.org/10.1016/j.pmrj.2017.07.074
Sutherland, H. J., Walker, P., & Till, J. E. (1999). The development of a method for determining oncology patients’ emotional distress using linear analogue scales. Cancer Nursing, 11(5), 303-308. https://doi.org/10.1097/00002820-198810000-00006
Torre, L., Siegel, R., & Jemal, A. (2015). Global Cancer Facts & Figs. American Cancer Society, 65(2), 87-108.
Van Waart, H., Stuiverm, M. M., van Harten, W. H., Geleijn, E., Kieffer, J. M., Buffart, L. M., de Maaker-Berkhof, M., Boven, E., Schrama, J., Geenen, M. M., Meerum Terwogt, J. M., van Bochove, A., Lustig, V., van den Heiligenberg, S. M., Smorenburg, C. H., Hellendoorn-van Vreeswijk, J. A., Sonke, G. S., & Aaronson, N. K. (2015). Effect of low-intensity physical activity and moderate—To high-intensity physical exercise during adjuvant chemotherapy on physical ﬁtness, fatigue, and chemotherapy completion rates: Results of the PACES randomized clinical trial. Journal of Clinical Oncology, 33(17), 1918-1927. https://doi.org/10.1200/jco.2014.59.1081
Wasserstein, R. L., & Lazar, N. A. (2016). The ASA's Statement on p-Values: Context, Process, and Purpose. The American Statistician, 70(2), 129-133. https://doi.org/10.1080/00031305.2016.1154108
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