<LEAP> highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on an older patient with fatigue and dypsnea following treatment for lung cancer. Could an exercise regimen help reduce her cancer-related fatigue?
Cancer-related fatigue reportedly affects 70% to 100% of people with cancer.2 The fatigue can occur during treatment or after treatment is completed. It has been reported to result in restrictions in activity and participation in life events.3 The cause of cancer-related fatigue is largely unknown,4 although factors contributing to it have been suggested.5–7 Guidelines for managing cancer-related fatigue, published by the National Comprehensive Cancer Network, suggest first treating any identifiable conditions—for example, anemia or insomnia.8 If these treatments do not work, or if no potentially causative factor can be identified, the guidelines suggest a variety of possible approaches. One of the recommended nonpharmacological approaches is increased activity. Activity and exercise may reduce both the physical effects and the psychological stress connected with cancer treatments, improve mood, and reduce anxiety and fear in patients.9 Recently, the American College of Sports Medicine (ACSM) published consensus-derived guidelines for exercise for people surviving cancer, which stated that exercise is safe and results in improved physical functioning and quality of life and in reduced fatigue.9
To determine the effect of exercise on cancer-related fatigue, Cramp and Daniel conducted a systematic review, which was published in The Cochrane Database of Systematic Reviews in 2009.10 The review sought to determine the effect of exercise in patients with various types and stages of cancer and with various treatment regimens, during and after treatment. The review included randomized controlled trials with participants of any age who had any type of cancer and any type of cancer treatment. To be included, studies had to examine the effect of any type of exercise provided in any setting compared to no exercise, usual care, or an alternative treatment. Studies could report outcomes in several forms, including standardized tools for assessment of fatigue, aerobic capacity, quality of life, anxiety, and depression. The Table outlines the findings of the review.
Key Resultsa
Take-Home Message
The review by Cramp and Daniel10 supports the benefits of various types of exercise in reducing cancer-related fatigue and improving aerobic capacity in patients with various types of cancer immediately following the exercise intervention. The benefits were seen for both unsupervised and supervised exercise programs, whether provided during or after the cancer treatment. Diverse modes, intensities, frequencies, and durations of exercise appear to be effective; however, there was insufficient evidence to guide the specific choice of exercise regimen.
<LEAP> Case #5 Exercise and Cancer-Related Fatigue
Can an exercise program help this patient?
Ms. Hunter is a 65-year-old retired physical education teacher who came to her physician with a chronic cough and a weight loss of 15 pounds over a 1-year period. Computed tomography of the chest revealed a 3.3-cm left upper-lobe mass, and a biopsy confirmed non-small-cell lung cancer. Over a 7-month period, she was treated with a lobectomy, followed by adjuvant chemotherapy and radiation therapy. One year after completion of her cancer treatments, Ms. Hunter complained to her physician about dyspnea on exertion and fatigue. Her rating of fatigue was 60 out of 100 on a 100-mm visual analog scale (VAS).
How did the clinicians apply the results of the Cochrane systematic review to Ms. Hunter?
Both Ms. Hunter's physician and her physical therapist questioned whether she would be a good candidate for an exercise program for survivors of cancer. Follow-up medical tests were completed to examine possible causes of her dyspnea and fatigue. Based on the results, no physiological explanation was discovered for the fatigue, and it was determined that the dyspnea on exertion was likely due to deconditioning.
Using a PICO format (Patient, Intervention, Comparison, Outcome), they asked the question: In a 65-year-old woman following lobectomy, chemotherapy, and radiation for lung cancer, will an exercise regimen (as compared to no exercise regimen) be beneficial for reducing fatigue? They determined that the systematic review by Cramp and Daniel10 provided relevant information that allowed them to answer their question. The systematic review reported on studies in which the participants included those who were 65 years of age. Most of the studies in the systematic review included only people with breast cancer, and none of the studies included only people with lung cancer; however, several studies included participants with various types of cancer who had various types of cancer-related medical interventions. The studies included in the systematic review examined the effect of a wide variety of exercise regimens, most of which were multimodal. The outcomes of participants receiving exercise were most often compared to no intervention or “usual care.” Studies included in the systematic review measured fatigue as an outcome using self-report instruments with reported reliability and validity.
Based on their assessment of the systematic review, Ms. Hunter's health care team recommended that she begin an exercise program. She agreed with the recommendation and began an individualized, supervised program of 60-minute sessions, twice weekly, for 10 weeks. Each session included a 5- to 10-minute warm-up period on either a stationary bike or a treadmill with an intensity of 10 to 12 on the 6-to-20 Borg Rating of Perceived Exertion scale, while maintaining oxygen saturation greater than 90%. Warm-up was followed by circuit weight training for all major muscles of the upper and lower extremities. Exercises were initiated with 1 set of 8 to 15 repetitions and progressed to a maximum of 3 sets of 15 repetitions for each, based on Ms. Hunter's exercise tolerance. Resistance also was increased progressively. Sessions concluded with stretching exercises of all the major muscle groups. The total weight lifted across all muscle groups during the entire program was recorded.
How well do the outcomes of the intervention provided to Ms. Hunter match those suggested by the systematic review?
Ms. Hunter completed 19 of 20 exercise sessions. She lifted a total of 87,397 pounds during her program, with an average of 4,600 pounds per session. Her fatigue was reduced at the end of the program, with a score of 22 out of 100 on the VAS. Given that a clinically important difference (CID) of 10 points on the fatigue scale has been reported in patients with rheumatoid arthritis,11 the magnitude of Ms. Hunter's reduction in fatigue (38 points) may be considered clinically important. In addition, she reported no adverse effects from the exercise program.
Can you apply the results of the systematic review to your patients?
The findings of this review apply to adult patients with various types of cancer receiving exercise intervention during or following cancer treatments. The results apply to patients in both home-based and supervised exercise programs.
What can be advised based on the results of this systematic review?
Patients fitting the description above are likely to benefit from an exercise program that is approximately 12 weeks long. Although the studies cited in the review used a wide variety of frequency, duration, and intensity of exercise, most used multiple modes of exercise. Like Ms. Hunter's regimen, the recent guidelines from the ACSM suggest that exercise prescriptions be individualized and based on the precautions associated with the individual's specific cancer, fitness level, comorbidities, and response to treatment. Although Ms. Hunter engaged in an exercise program after all her cancer treatments were completed, the review demonstrated that patients completing exercise programs during or following their cancer treatments are likely to have reduced fatigue and may have improved quality of life.
- © 2011 American Physical Therapy Association
Issue highlights
