From Medscape Medical News
News Author: Zosia Chustecka
CME Author: Désirée Lie, MD, MSEd
October 21, 2009 — A supervised exercise program significantly improved fatigue in cancer patients undergoing chemotherapy, according to a study published online October 13 in the British Medical Journal.
The study also found significant improvements in vitality, aerobic capacity, muscular strength, physical and functional activity, and emotional well-being. However, there was no improvement in quality of life.
"The effect size of the improvement in fatigue (0.33) suggests a small to medium clinically important change," say the researchers, headed by Lis Adamsen, PhD, professor of clinical nursing at the Copenhagen University Hospital in Denmark. This is in contrast to some previous studies that found only a small or no effect.
The researchers suggest that the larger effect on fatigue seen in their study was due to several elements of their exercise program, including the high-intensity training.
"Doctors may encourage patients to exercise, but the exercise must be supervised," Dr. Adamsen told Medscape Oncology. In addition, for patients who are undergoing chemotherapy, there must be "specific inclusion criteria and screening procedures" in place to prevent adverse reactions, she added.
For example, 1 participant in this study who had a brain tumor experienced a grade 3 seizure after cardiovascular training. "We must therefore advise patients with brain tumors or brain metastases not to participate in high-intensity exercise interventions," the researchers note.
Nine Hours of Training Each Week
The study involved 269 patients with a variety of different cancers being treated at 2 Copenhagen university hospitals. There was a broad range of diagnoses and disease statuses, the researchers note. There were 27 patients with ovarian cancer, 28 with hematological malignancies, and 15 with testicular cancer; the remainder had cancer affecting the esophagus, brain, cervix, pharynx, pancreas, or stomach.
All of the patients were receiving chemotherapy, either as treatment for advanced disease or as adjuvant therapy, and there was a wide range of regimens in use.
Half of the patients were randomly assigned to the exercise program, which was supervised by trained nurse specialists and physiotherapists. It lasted for 6 weeks and involved 9 hours of training each week. The patients had to follow the program exactly; they could not pick and choose the activities they preferred, the researchers note. "The intervention was offered as a package and must be viewed as an entity [in which] each component has a role in the outcomes," they explain.
On Mondays, Wednesdays, and Fridays, there was a high-intensity physical training session lasting 90 minutes, followed by 30 minutes of relaxation training. The high-intensity session involved resistance training on machines, such as leg and chest presses, and cardiovascular training on a stationary exercise bike. On Tuesdays, there was a body awareness training session (which included stretching and exercises based on yoga and Pilates) lasting 90 minutes, followed by 30 minutes of relaxation training. On Mondays and Fridays, patients had 30 minutes of massage, which could include scar tissue massage and venous pump massage.
Larger Effect on Fatigue Than Seen in Previous Studies
Fatigue was the primary outcome, and was measured on a scale of 0 to 100. In this study, it was the most frequently reported symptom and, at baseline, 65% of study participants reported a fatigue level greater than that of the general population (mean score, 21), and 29% of participants reported severe fatigue (mean score, >60).
After 6 weeks on the exercise program, the patients who participated reported a significant improvement in fatigue, with ratings falling by an average of 6.6 points (P = .02; size effect, 0.33). The researchers note that this size effect could be clinically important. Although the intervention reduced fatigue, the mean score for these patients was 34.6, which is still higher than that for the general population.
This reduction in fatigue is greater than has been seen in previous studies, the researchers note. A meta-analysis of several studies (Cancer Epidemiol Biomarkers Prev. 2005;14:1588-1595) found an effect size of only 0.13, which may be "too small to be clinically meaningful," they write. In addition, 2 recent studies of moderate exercise in women with breast cancer who were receiving adjuvant therapy found no significant improvement in fatigue (BMJ. 2007;334:517-520; J Clin Oncol. 2007;25:4396-4404).
When asked about the differences between the results from the latest study and those from previous studies, Dr. Adamsen suggested that her team found a larger effect on fatigue because the exercise program they used involved high-volume training (9 hours per week) and because it involved a combination of high- and low-intensity elements.
The researchers believe that this is the first study to incorporate a high-intensity design; none of those mentioned in a review of 26 studies of exercise in cancer patients did (J Clin Oncol. 2005:23:899-909).
We found a reduction in fatigue that we consider to be of importance to the patients' daily lives.
"We found a reduction in fatigue that we consider to be of importance to the patients' daily lives, even though no change was seen in the global health status/quality of life," the researchers conclude.
"Being diagnosed with cancer and exposed to chemotherapy disrupts the patient's life, affecting physiological and psychological functioning and contributing to negative effects on global health status/quality of life," they point out. "Improvements in this measure may have been too ambitious a goal in this short-term clinical trial."
The researchers have disclosed no relevant financial relationships.
BMJ. 2009;339:b3410. Abstract
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