Intervention for Cancer Related Fatigue

This paper critically appraises six systematic reviews pertaining to the usage of exercise as an intervention strategy for cancer related fatigue. The paper concludes with the implementation of the salient findings in the field of nursing and patient treatment.

Running head: INTERVENTION FOR CANCER RELATED FATIGUE
INTERVENTION FOR CANCER RELATED FATIGUE
Name of the Student:
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Executive Summary
The incidences of cancer related fatigue has been viewed as a highly debilitating condition, with
negative outcomes pertaining to the quality of treatment, rate of mortality and the quality of life
in general, in patients undergoing cancer treatment, or after survival of cancer. A number of
strategies have been recommended for the mitigation of the symptoms of cancer related fatigue,
with exercise being one of the most effective strategies, with beneficial impacts in the quality of
life of cancer patients. The following paper attempts to critically appraise six systematic reviews
pertaining to the usage of exercise as an intervention strategy for cancer related fatigue, followed
by a tabular summarization of the same and concluding with the implementation of the salient
findings in the field of nursing and patient treatment.

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Introduction
As stated by the Cancer Council of Western Australia, ‘cancer’ is characterized by
occurrences of debilitating conditions due to abnormalities in cell growth and division in the
human body (Carter et al., 2015). While traditional procedures of cell multiplication are
imperative for the growth, development and recuperation of essential tissues, cancer is defined
by a morbid distortion in these processes (Lebel et al., 2016). The resulting abnormalities, caused
due to a host of factors functioning at lifestyle and genetic platforms, escalate into formation of
malignant tumors, circulated via the vascular or lymphatic systems (Urrutia-Ortega et al., 2016).
The increased presence of certain components such as excessive alcohol ingestion and adherence
to smoking, faulty dietary and physical exercise habits, increased exposure to dangerous
environmental components, further heightened by genetic susceptibility are some of the reasons
advancing cancer affliction (Revenco et al., 2017). However, with advancements in science and
technology, patients victimized by cancer are gifted with a number of lucrative treatment
opportunities, such as surgical operations, endocrinal therapy, radiation treatment,
immunotherapy, targeted therapy and chemotherapy (Chesson&Zlosa, 2017).While most of these
treatments outline beneficial outcomes, individuals are burdened with several complications, of
which, cancer related fatigue continues to be widely prevalent (Berger et al., 2015).
The prevalence of cancer-related fatigue is not new upon the progress, as well as
completion of cancer treatment, as evident in occurrences in over 25 to 99 percent of the patient
population affected by cancer (Jones et al., 2016). Often, the presence of lasting symptoms of
fatigue and physiological distress, at magnitudes of moderate to severe, hinders the procedures of
treatment, further leading to discontinuation. While eradication of cancer related fatigue

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undertakes occurrences within a year pertaining to the conductance of treatment, individuals
afflicted by cancer have been observed to report symptoms for a decade (Pattanshetty, Moniz
&Patil, 2018). The prolonged prevalence of cancer related fatigue is associated with increased
mortality rates. The occurrence of cancer related fatigue is dependent upon the active
performance of pro-inflammatory cytokines and morbid regulatory mechanisms of cytokine
functioning (Dehkordi, Kahangi&Babashahi, 2018). Additionally, excessive damage of muscles
pertaining to cancer cachexia due to abnormally increased metabolic functioning, prevalence of
anemia and a dysfunctional axis of the hypothalamus, pituitary and adrenal glands, are some of
the key underlying factors (Minto, Wee & Stone, 2014).
There is a wide availability of treatment choices, each associated with beneficial impacts.
Ingestion of appropriate medications, psychological and psychosocial treatment and engagement
in physical activity are some of the procedures implicating significant benefits on the health of
patients suffering from cancer related fatigue (Spathis et al., 2014).With respect to evidences
concerning the beneficial implications on cancer patients partaking in exercising, a number of
variations have proven to be advantageous, such as engagement in home as well as laboratory
supervised physical activity routines, aerobic regimes, as well as resistance training (Tian et al.,
2016).In accordance to the Australian scenario, organizations such as ‘Exercise and Sports
Science Australia’ and the ‘Clinical Oncology Society of Australia’, have advocated clinical
professionals to incorporate physical activity amongst patients inflicted cancer related fatigue
(Braun et al., 2014). However, the incorporation of exercise is not without the presence of
considerable shortcomings in adequate literature and research, where there lies a conflict of
interest regarding the usage of exercise in patients exhibiting severely debilitating symptoms of

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cancer related fatigue, where the very occurrence of fatigue may serve as a major barrier to the
performance by the patient (Sekse, Hufthammer&Vika, 2015).
The following paper aims to review the existing literature pertaining to the usage of
exercise as an intervention for the management of cancer related fatigue in the occurrences of
positive quality of life outcomes. A total of six researches were appraised critically, and their
findings summarized in a tabular form, followed by recommendations regarding the
implementations of the same in the field of practices pertaining to nursing.
Clinical Question
The PICOT format for the derivation of clinical questions has been considered useful for
researchers attempting to pursue novel research (Elias et al., 2015). The research question
required for the following clinical problem has been formulated with the utilization of the PICOT
format implying Population, Intervention, Comparison, Outcome and Time. Hence, for the
purpose of improvement of the quality of life of individuals suffering from cancer, there is
emergence of the following clinical question: For patients inflicted with cancer-related fatigue,
does the implementation of exercise, in comparison to usage of standard care, positively impact
their quality of life?
Search Strategy
The searching procedures of the required literatures were conducted electronically.
ClinicalKey for Nursing, COCHRANE, Medline and APAIS were some of the databases utilized
for the required research. The search for literature was also conducted with the usage of MeSH
such as ‘CANCER’, ‘CANCER-RELATED FATIGUE’, ‘EXERCISE’ and

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‘CANCERINTERVENTION’. The researches utilized for the critical appraisal were limited to
systematic reviews with meta-analysis, conducted during the years 2013 and 2018.
Upon conductance of the search, a total of 60 researches were uncovered, of which 6
systematic reviews were chosen, due to their adherence to the PICOT framework for clinical
research. Articles which focused only on randomized controlled trials without the absence of
reviews were excluded, as well as articles which did not assess the effects of exercise in the
presence of cancer related fatigue. The inclusion criteria of the articles was based upon studies
which highlighted the presence of systematic reviews assessing populations who were cancer
victims undergoing cancer related fatigue, and receiving exercise as the primary intervention
with the outcome of improvement of quality of life.
Critical appraisal and summary of study findings
The literature studies were selected after thorough monitoring concerning the availability
of valid data, the procedures conducted, the appropriate utilization of research procedures, and
lastly, the degree to which the researches were found to be credible and useful (Zeng et al.,
2015). Hence, upon due consideration of the above guidelines, as stated in accordance to the
Critical Appraisal Skills Program, the following six systematic reviews accompanied by meta-
analysis were utilized for the purpose of critical research appraisal.
An elaborate research was conducted by Kessels et al., (2018), which aimed at
conducting a systematic reviewand meta-analysis, in order to investigate the consequences of the
implementation of physical exercise strategies in patients who had survived cancer, in
comparison to conventional care strategies (Kessels, Husson&Feltz-Cornelis, 2018). There has
been a widespread recognition pertaining to the beneficial effects of exercise as an effective

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intervention strategy for beneficial health outcomes. The symptoms associated with cancer-
related fatigue have been linked to similarities with Chronic Fatigue Symptom, for which,
exercise has been implicated with beneficial effects (Lucas et al., 2015). The following
systematic review conducted by Kessels et al., (2018), was performed through searches utilizing
COCHRANE databases, followed by meta analysis. The systematic review was further
performed utilizing the PICOT framework, where the population included adults aged beyond 18
years of age, with the inclusion of randomized controlled trials ranging from the 1st of January
2000 to the 17th of August 2016. The cancer related fatigues symptoms were considered for the
following cancers: gynecological, prostrate, breast and mixed variants, followed by the exercises
intervention strategies classified into aerobic, resistance and a combination of both, in varying
intensities. The procedures of aerobic exercises are outlined by the active metabolism of oxygen,
for the performance of tasks such as running, walking, cycling and swimming (Keating et al.,
2015). Resistance training it outlined by anaerobic metabolism as a resultant of muscular
contractions (Schoenfeld et al., 2016).
The results of the systematic review conducted by Kessels et al., (2018), highlighted
positive health implications of exercise as effective intervention strategies pertaining to cancer
related fatigue. The results indicated positive implications for patients who underwent aerobic
exercise strategies, as compared to the resistance training, with 95% Confidence Interval of
0.235-0.975. However, the rate of patient adherence to exercise, was considered of important- as
evident by the beneficial results implicated in patients who displayed increased dedication
(Kessels, Husson&Feltz-Cornelis, 2018).
The systematic review performed by Kessels et al., (2018), was not absent without
shortcomings. A highly limited number of studies were included amounting to only 6 out of 11

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randomized controlled trials. In comparison to the exercise intervention strategies, there was no
specific mention regarding patient reception of palliative care and hence, non-exercise
intervention care included unspecified conditions such as the use of surgical operations, chemo
or radiation therapy. The details of the treatment procedures of the concerned patients were also
undefined. The research only mentioned that certain patients were undergoing cancer treatment,
without highlighting the details concerning the type of treatment utilized or the duration. Hence,
the beneficial effects of exercise of cancer related fatigue as reviewed by Kessels et al., (2018),
contained no specified treatment nature. The participants included were young adults and hence,
there is a need for further research regarding the effects of exercise on individuals below 18
years of age. Additional benefits included absence of effects pertaining to conductance of low
intensity exercises such as yoga or stretching, the effects of exercise in prolonged cancer
survivors as well as the health implications of alternative cancers. However, the systematic
review of exercise intervention strategies conducted by Kessels et al., (2018), provides evidence
of the various types of exercises along with their adherence. The review also establishes
impressive associations with the occurrences of chronic fatigue symptoms in individuals, which
may present underlying causes of inflammation and cytokine malfunctioning, paving the way for
future research concerning diagnosis and treatment procedures (Lucas et al., 2015).
Similar to Kessels et al., (2018), a systematic review accompanied by meta-analysis was
conducted by Kelley and Kelley (2016). The authors studied the execution of exercise
intervention strategies considering the usage of aerobic, resistant as well as a combination of
strategies upon individuals suffering from cancer related fatigue, concerning no specific type of
cancer (Kelley & Kelley, 2016).As opined by The National Comprehensive Cancer Network’s
Clinical Practice Guidelines in Oncology, there is an increasingly credible recommendation

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pertaining to the implementation of various types of aerobic, resistance and combination exercise
strategies, as non-medical strategies concerned with the improvement of quality of life (Ettinger
et al., 2016).The information required for the completion of this systematic review was
conducted through performance of a search electronically, utilizing over six databases such as
Cochrane, Sports Discus, Pub Med, Scopus, Proquest and Web Science, dating till July 2016.
The characteristics of the population concerned with this systematic review by Kelley and Kelley
(2017), including individuals who were above the age of 18 years and were ongoing or surviving
patients of cancer. A total of sixteen randomized controlled trials were selected where the
subjects were undertaking various forms of exercise for a period of a minimum three to a
maximum of fifty two weeks. The studies traced their origins to countries such as France,
Germany, Columbia, China and Netherlands (Kelley & Kelley, 2016).
With respect to the findings highlighted by Kelley and Kelley (2016), there was
observation of varied outcomes as compared to the specific positive health outcomes of exercise
intervention reported by Kessels et al., (2018), possibly due to the analysis of additional types of
cancers. For patients suffering from leukemia and colorectal cancers, there seemed to be a lack
of implication of positive health outcomes pertaining to the quality of life. With respect to all the
types of cancers highlighted in this review, the presence of beneficial health effects were not
dependent upon factors pertaining to the conductance of radiation therapy, the duration of the
exercise program or the frequency of exercise sessions. However, with respect to the usage of
resistance training, followed by the usage of sufficient theoretical strategies pertaining to their
effective conductance, there was a resultant beneficial effect in the alleviation of symptoms
pertaining to cancer related fatigue, with a standard mean deviation of -1.05 to -0.01, of which
52% meta-analysis, were statistically significant, with 95% confidence interval non-

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overlapping.Engagement in light to moderate rates of exercise were also reported to be
statistically significant, while execution of exercises devoid of any supervised theoretical
backgrounds yielded an absence of positive health outcomes (Kelley & Kelley, 2016).
However, certain sections of the studies reviewed by Kelley and Kelley (2016), yielded
varied outcomes stating enhanced exercise benefits with regards to the length and frequency of
the same, with a beneficial results in patients suffering from cancer related fatigue pertaining to
breast cancers, and additional implications concerned with the utilization of home based exercise
regimens. Hence, with regards to the credibility of findings, the systematic review performed by
Kelley and Kelley (2017), yielded impressive information. This systematic review sheds light on
supplementary factors such as duration and frequency of the exercise concerned, and focusing on
additional types of cancers. A greater number of randomized controlled trials were included
which further highlighted varied outcomes along with percentile information of the same.
Additionally, the systematic review by Kelley and Kelley (2016), utilized statistical methods of
prediction intervals, which recently, has been highlighted as inappropriate, in case of decreased
rates of heterogeneity (Quan, Srinivasan &Khosravi, 2014). The systematic review so conducted,
also researched on previous reviews and hence, may be subject to errors pertaining to previous
reviews. There was also an absence of alternative intervention strategies or low intensity
exercises, and their possible benefits for cancer related fatigue.
Based upon the salient research features outlined by Kelley and Kelley, as well as
Kessels et al., (2018), a similar systematic review accompanied by meta-analysis was conducted
by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014), highlighting the positive
health implications of exercise as intervention strategies for cancer-related fatigue. The criteria
of sample selection was determined utilizing the PICOT framework. The population selected as

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participants included in the randomized controlled trials reviewed were above the age group of
18 years, inflicted with any variation of cancer, irrespective of race, gender or ethnical
backgrounds. With respect to the type of exercise intervention employed, the aforementioned
research paper highlighted the health implications of conductance of multimodal forms of
exercise, which took into account, variations such as aerobic, resistance as well stretching
counterparts of the concerned exercise. The literature search conducted analyzed the databases of
EMBASE, OVID, CENTRAL and PubMed ranging from January 2014 to March 2014
(Meneses-Echávez, González-Jiménez &Ramírez-Vélez, 2014),
With respect to this systematic review, it was found that multimodal exercise relieved
cancer related fatigue symptoms, with 95% confidence interval -0.37 to -0.09, a standard mean
deviation of -0.23 and a p-value of 0.001. Statistically insignificant results were recorded for
resistance training only, with a p-value of 0.30.
The cancer patients assessed were primarily females undergoing chemotherapy in the age
group of 46 to 60 years. A majority of the studies, highlighted the beneficial impacts of exercise
performance in the conductance of intervention strategies for the management of cancer related
fatigue. Enhanced beneficial health implications were emphasized by the utilization of
resistance-based exercise modules, in the absence of supervised frameworks. A primary feature
researched was the conductance of exercise during ongoing chemotherapy procedures of the
patients, highlighting alleviation in the symptoms of cancer related fatigue during hospital stay.
Further, two of the researches reviewed by the authors for the aforementioned systematic
reviews, conducted the performance of follow up sessions, prior to six months after cancer
treatment. While one research reported beneficial outcomes, an additional reported beneficial
effects accompanied by increased levels of anxiety. Despite the essential information presented

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by this systematic review, there were several shortcomings. While chemotherapy patients were
extensively assessed for exercise, there was an absence of participants undergoing additional
cancer therapy procedures as well as patients surviving after treatment. Owning to the nine trials
researched, an additional error would be the large scale of heterogeneity and statistical tools
employed to evaluate the outcome measures of the concerned participants. There is also an
absence of specified effects of exercise regarding the varied types of cancers, as mentioned in the
previous systematic reviews.
The critical appraisals conducted for the systematic reviews of Kessels et al., (2018,
Kelley and Kelley (2017), and Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014),
revealed extensive analysis on the beneficial health implications of various types and forms of
exercise conducted as intervention strategies for the purpose of improvement in the quality of life
of cancer patients inflicted with cancer-related fatigue. However, similar to, with yet alternative
parameters, the systematic reviews accompanied by meta-analysis conducted by Hilfiker et al.,
(2017), assessed the health impact of exercise in cancer-related fatigue victims, in comparison to
additional non-medical procedures.Considering the availability of insufficient evidence
regarding the usage of medicinal strategies, the aforementioned systematic review was conducted
with the recent recommendations of advocating non-medicinal procedures for the treatment of
cancer related fatigue (Yennurajalingam et al., 2015). The research for the required literature was
conducted electronically with the usage of CENTRAL and PubMed databases, from their
conception to the 4th of January 2017. The trails researched were selected based on randomized
or quasi-randomized experimental evidences assessing individuals with any type of cancer,
assuming the occurrences of cancer-related fatigue, where the evaluation of exercise intervention
was conducted, along with additional treatment procedures such as relaxation strategies or

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cognitive behavioral treatments. Experiments which included the intervention of nutritional or
pharmaceutical intervention strategies were excluded, along with studies which were performed
for a period greater than 3 weeks. The population studied were patients suffering from various
types of cancer under the ongoing reception of chemotherapy or radiation therapy, or post
therapeutic maintenance patients (Hilfiker et al., 2017).
The researches selected were categorized in a time span ranging between the years 1989
and 2017, with the inclusion of patients suffering from cancers of the breast, prostate, colorectal,
haematopoietic stem cell transplantation, along with combination types. The various types of
intervention strategies were cognitive behavioral theory, multi-modal exercise strategies,
resistance and anaerobic training procedures, relaxation strategies with inclusion of meditation,
yoga, dance, and music and also, massage therapies. It was observed that, during treatment,
relaxation yielded strongest results, with a standard mean deviation of -0.77, with 95% Credible
interval of -1.22 to -0.31, followed by therapies with the inclusion of massage with -0.78
standard mean deviation and 95% credible interval-1.55 to -0.01, a combination intervention
strategy of exercise and cognitive behavioral therapy with -0.72 deviation, -1.34 to -0.09 credible
interval, multimodal exercise strategies with -0.67 deviation, 95% credible interval of -1.01 to -
0.34, resistance training with -0.53 deviations, 95% CI -1.02 to -0.03, exercises with aerobic
interventions with -0.53 deviation, 95% CI , and yoga with -0.51 deviation, and 95% CI -1.01 to
0.00. During post treatment phases of the patients, yoga was observed to yield beneficial results
with -0.68 deviation and 95% CI -0.93 to -0.43. Negligible health implications were recorded for
aerobic or resistance exercise alone (Hilfiker et al., 2017).
One of the major strengths of the systematic review and meta-analysis conducted by
Hilfiker et al., (2017), was the utilization of ranking procedures via Bayesian strategies, which

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will prove to be beneficial in the process of recommendation of various intervention strategies by
clinicians to their cancer patients (Newcombe et al., 2017). Additionally, a greater availability of
varied intervention strategies will be beneficial for patients in opting for the same, with respect to
their individual physiological capabilities. An additional beneficial information was the yielding
of relaxation procedures as beneficial intervention strategies during cancer treatment in patients,
with however reduced effect post treatment, hence, empowering the requirement for usage of
additional exercise intervention strategies. Hence, the assessment of a number of intervention
strategies proved to be a major advantage of this systematic review. However, the specifications
of various strategies remained highly undefined, with the inclusion of relaxation strategies under
cognitive behavioral therapy. There was an also an absence of assessment of the health
implications resulting from high or low intensity training modules. Furthermore, the large scale
of heterogeneity is a major shortcoming due to the varied populations examined, followed by the
access of merely two databases, hence highlighting the lack of sufficient information availability.
An additional systematic review was conducted by Meneses-Echávez, González-Jiménez
and Ramírez-Vélez (2015), which focused on a specific type of cancer. The systematic review
and meta-analysis conducted, evaluated the symptoms of cancer related fatigue in breast cancer
survivors, as a result of exercise associated with supervision. The prevalence of breast cancer,
has been an emerging phenomena worldwide, with fatal implications. As opined by the World
Health Organization, breast cancer inflicts 23% of the global population, with over 14% of
succumbing to the condition (Ginsburg et al., 2017).The symptoms of cancer related fatigue
yield detrimental impact on the concerned patients, often serving as an indicator of high
susceptibility to mortality. The literature searches conducted for the following was based
between the periods of December 2013 and January 2014, with the utilization of databases such

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as EMBASE, CENTRAL, Scopus, MEDLINE and PubMed. Additional journals such as Journal
of Breast Cancer, The Lancet Oncology, and Journal of the National Cancer Institute and Journal
of Clinical Oncology were also assessed. The selection criteria included patients who had
survived breast cancer, without the specification of any particular cancer stage, undertaking
exercising strategies with supervision as an intervention program in comparison to conventional
treatment care procedures. A total of nine studies were selected, with countries of Australia,
North America, Turkey, the United Kingdom and Finland as their origins of conductance. The
patients were under the age group of 48 and 60 years, with the reception of radiation or
chemotherapy (Meneses-Echávez, González-Jiménez &Ramírez-Vélez, 2015),
The supervised exercise strategies ranged for 3 weeks, lasting over 40 minutes, with the
incorporation of relaxation, resistance and aerobic training strategies. The systematic review
uncovered the beneficial effects of exercise intervention, with resistance training implicated
highest rates of impacting the quality of life of patients inflicted with cancer related fatigue., with
a standard mean deviation of -0.41, and confidence interval of 95% ranging from -0.76 to -
0.05.Resistance training, accompanied by supervision has been found to yield beneficial health
implications upon breast cancer patients, with the advancement of strength in the muscular
system, further enhancing body composition (Steindorf et al., 2014). The utilization of
supervision is essential for the management of effective exercise treatment, due to the increased
rates of confidence, safety and adherence experienced by cancer patients. Exercise also
empowers breast cancer survivors with positive consequences in their quality of life, through
greater wellbeing and decreased anxiety and fatigue (Casla et al., 2015).However, due to limited
number of trials conducted, there is still a need for research pertaining to the occurrences of
depression and body mass index in individuals suffering from cancer related fatigue (Kang et al.,

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2016). While the low quantity of research conducted and the large occurrences of heterogeneity
prove to be major shortcomings in this systematic review, there is also an absence in the
assessment of cytokine evaluation and biomarkers as a response to exercise. Concerning the fact
that cancer related fatigue has underlying inflammatory causes, it is imperative to consider that
exercise may yield further enhancement of such pro-inflammatory regulations (Repka&
Hayward, 2018).
The coordinated efforts of exercise along with nutritional procedures have been found to
yield beneficial effects for alleviating the symptoms of cancer related fatigue. While extensive
availability of recent research advocate the positive health implications of exercise procedures,
additional diet therapy strategies are often not taken under consideration (Berger et al., 2015).
The following systematic review conducted by Baguley et al., (2017), explored the consequences
of supervised exercise and nutrition on cancer-related fatigue in patients with prostate cancer.
While numerous varied treatment procedures have been advocated for treatment of prostate
cancer, such as radiation therapy, chemotherapy, androgen deprivation therapy and surgical
procedures, the resultant debilitating complications of cancer related fatigue negatively affect the
quality of life of cancer patients. The research for the aforementioned literature review was
conducted with the utilization of six online databases, such as CENTRAL, EMBASE, Proquest,
CINAHL, PubMed and EMtree. The criteria of selection was determined utilizing the PICOT
frame work, which included male patients inflicted with any stage of prostate cancer, with the
reception of any form of supervised exercise and structure dietary modifications, in comparison
to a patient group with the provision of conventional care, devoid of exercise intervention
strategies. A total of 20 researches were taken under inclusion for the purpose of this systematic
review, of which 17 studies utilized exercise only as an intervention strategy, 2 researches

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utilized a combination of diet and exercise and only one research studied the health implications
of only diet for the treatment of cancer related fatigue (Baguley et al., 2017).
Upon assessing the results investigated in this systematic review, it was uncovered that a
combination strategy, utilizing the coordinated effects of resistance as well as aerobic exercise
training, has been found to be beneficial in improving the symptoms of cancer related fatigue,
with a p-value of 0.0.80.The utilization of supervision in the implementation of exercise training
is imperative to enhance patient adherence and dedication (Casla et al., 2015). However, the
positive health benefits exhibited by intervening with exercise, seems to be irrespective upon
additional factors, such as duration or frequency. Nevertheless, combination training strategies
and resistance training alone have been associated with yielding positive life quality impacts in
cancer related fatigue patients of prostate cancer. The studies pertaining to combination
intervention strategies of diet as well as exercise, displayed beneficial but inconclusive results.
Hence, greater research is required prior to recommendation of the same.
However, the review stated limited research on the implications of dietary modifications.
A single review paper suggesting the implementation of soy supplementation in prostate cancer
patients, yielded beneficial results, but was associated with low adherence and adverse follow up
outcomes. A diet rich in phytonutrients derived from fruits and vegetables, followed by intake of
fatty fish, have been recommended traditionally for cancer prevention and treatment, pertaining
to the inflammatory processes associated with the detrimental health impacts of cancer (Zhnag et
al., 2015). However, the availability of negligible research, related to the same in relation to its
effects on cancer related fatigue, empowers the need for greater future study (repka& Hayward,
2018). While this systematic review was one of the first of its kind to reveal the effects of
exercise coordinated with nutritional interventions in cancer related fatigue, the limited research

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findings, high scale of heterogeneity and lack of research with regards to the amount, duration
and frequency of physical exercise execution, are some of the major shortcomings of this
systematic review.
Implementation of evidence into nursing practice
Level 1 evidence and summary of results: The systematic reviews highlighted above
can be classified under level 1 evidence, with due respect to the large number of randomized
controlled trials included in the above researches (Barton et al., 2015). While Kessels et al.,
(2018) highlighted the benefits of aerobic training on cancer related fatigue, with further
emphasis of associated mechanisms of chronic fatigue symptom (Kessels et al., 2018). it is to be
noted that Kelley and Kelley (2016), studies the negligible effects of the same on additional
cancers such as leukemia and colorectal cancers, as well as the need to implement supervision
without prioritized emphasis on the duration and frequency of exercise (Kelley & Kelley, 2016).
The review conducted by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2014),
emphasized the need for multimodal intervention strategies as a beneficial module of exercise
procedures in cancer patients (Meneses-Echávez, González-Jiménez&Ramírez-Vélez, 2014).
However, the systematic review by Hilfiker et al., (2017) sheds an impressive light on the usage
of additional procedures such as relaxation techniques, which have proven to yield beneficial
effects during the treatment of cancer patients, followed by implementation of resistance training
post treatment to alleviate the symptoms of cancer related fatigue (Hilfiker et al., 2017).Meneses-
Echávez, González-Jiménezand Ramírez-Vélez (2015), systematically reviewed the effects of
exercise in the treatment of breast cancer patients (Meneses-Echávez, González-Jiménez
&Ramírez-Vélez, 2015).Finally, Baguley et al., (2017), emphasized the need for future dietary

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protocols combined with exercise as intervention strategies, hence paving the way for further
nutritional research of the same (Baguley et al., 2017).
Strategies for implementation: Hence, as evident from the above results, exercise as an
intervention strategy for the implication of positive health outcomes in cancer related fatigue,
should be implemented, with the utilization of the following strategies, for the purpose of usage
in an Australian medical setup. Hence, concerning the implementation of recommending
exercise as implementation strategies forcancer related fatigue, it is imperative for the nurse to
educate herself adequately concerning the guideline pertaining to the ongoing treatment
procedures of the oncology patient, the stage of cancer and treatment and individual intervention
preferences. Nursing practice will require the utilization of empathy and establishment of
clarified communication strategies concerning the patient’s needs and interests (Runowicz et al.,
2016). Considering the documented evidence regarding the beneficial implications of resistance
training in the muscle recuperation and body composition in breast cancer survivors, as opined
by Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2015), nurses may communicate
the same to the patient (Meneses-Echávez, González-Jiménez&Ramírez-Vélez, 2017).During the
ongoing process of treatment, as documented by Hilfiker et al., (2017), the usage of relaxation-
based intervention strategies such as stretching, yoga and cognitive behavioral therapy have been
found to be beneficial, and hence the concerned nurse may implement a multidisciplinary
approach to involve additional professionals for the implementation of the same in radiation or
chemotherapy patients (Hilfiker et al., 2017).Documenting evidence from, Kelley and Kelley
(2016), as well as Meneses-Echávez, González-Jiménezand Ramírez-Vélez (2015), the nurse
may also recommend resistance and multimodal exercise patterns (Kelley & Kelley, 2016), since
the utilization of a combination of various exercise intervention strategies have been proven to be

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beneficial for the alleviation of cancer related fatigue (Meneses-Echávez, González-
Jiménez&Ramírez-Vélez, 2015).
Barriers and Incentives: One of the key barriers for the implementation of exercise in
the treatment of cancer-related fatigue, is the need for supervision, as evident from the results
above. Hence, prior to the recommendation of the sufficient exercise patterns for cancer related
fatigue, the implementation of supervision is imperative for which, the nurse may require
additional professional aid, since the utilization of adequate supervision has been found to yield
beneficial effects on the rates of adherence and confidence (Zhang et al., 2018). Hence, a major
strategy required for the removal of such barriers may be the integration of exercise training for
cancer-related fatigue in the nursing curriculum, or the addition of a supplementary course. The
time period of such changes will be dependent upon the duration of the nursing course in
Australia, which is generally four years. Nevertheless the supplementary course may be
integrated as an additional diploma course of 1 year for the purpose of exercise education, with
the provision of incentives for nurses who have undertaken such course. An additional barrier
may be the requirement of a multidisciplinary team for the purpose of supervising exercise to
patients, which may further increase hospital costs. Hence, hospitals may need to establish
collaborations with various exercise and fitness centers for this purpose (Casla et al., 2015).
Patient preferences: For the purpose of assessing the preference of the patient, the
nurses and associated clinicians may first engage in imparting knowledge and awareness
concerning the need for exercise in cancer related fatigue. This may be followed by the usage of
feedback procedures such as interview, surveys or questionnaires, in order to evaluate the needs
and interests of the patient. Additionally, follow up studies may be used for the purpose of

20INTERVENTION FOR CANCER RELATED FATIGUE
evaluating the health implications of undertaking the exercise preferred by the patient (Ross et
al., 2018).
PARIHS Framework: Hence, for the implementation of the above changes for the
purpose of improved nursing practice, the PARIHS Framework can be used. Hence, based on the
principle of evidence on the current study of exercise in cancer related, it can be observed that
the systematic reviews used utilized sufficient amount of randomized controlled trials over large
population groups, further highlighting the credibility of the evidence. Hence the change in
nursing practice must be advocated in the context of hospitals providing cancer treatments
(Harvey &Kitson, 2015). With respect to the principle of context, the above reviews focused on a
relevant problem of cancer related fatigue which is widely prevalence in hospitals upon
commencement of treatment. The evidence also clearly elaborated on the detailed organizational
structure in the clinical settings outlined in the reviews, where nurses and medical practitioners
actively engaged in patient supervision of exercise intervention. Sufficient feedback and follow
up were also gathered from the patients. Hence, for implementation of change in nursing
practice, nurses and clinicians should clearly delegate the roles of staff engaged in required
exercise intervention, followed by gathering consent from patients and the required feedback to
assess the outcome in cancer related fatigue. In accordance to the PARIHS framework, the
required change must be facilitated through the usage of sufficient communication and empathy,
followed by adoption of a flexible approach to suit the needs of the patients in exercise
intervention (Tian et al., 2017).
Sustainability of changes over time: Cancer related fatigue is said to occur over a
continuous period of almost a year and hence, it is expected that usage of exercise as intervention
will lead to beneficial changes of a prolonged time period of one year, unless there is occurrence

21INTERVENTION FOR CANCER RELATED FATIGUE
of relapse. However, with respect to the usage of exercise amongst patients with severe fatigue,
there may a lack of sustainability over due to lack of adherence by such a individuals, which may
lead to occurrences of disuse syndrome. However, the implementation of mild exercise methods
such as yoga or stretching, have been found to be equally beneficial and sustainable due to their
less strenuous effects, and hence can be executed in patients with severe cancer related fatigue
with greater benefits (McNeely et al., 2015).
Conclusion
In conclusion, exercise has been considered as an essential intervention tool, with
sufficient documented evidence highlighting its beneficial implications. However, further
research is required concerning the effects on additional types of cancers, as well as the
coordinated efforts of nutrition in improving the efforts of cancer related fatigue.

Running head: INTERVENTION FOR CANCER RELATED FATIGUE
PICOT Question:For patients inflicted with cancer-related fatigue, does the implementation of exercise, in comparison to usage of standard
care, positively impact their quality of life?
Study Study Design Population/Setting Number
of
Patients
Primary
Outcomes
Measured
Relevant
Findings
Strengths and
Limitations
Level of
Evidence
rating
Kessels et al., (2018) Systematic
review and
meta-analysis
Individuals above
18 years of age,
with gynecological,
breast, prostate and
mixed cancer
variants
788
patients
of which
411
underwe
nt
exercise
and 377
underwe
nt
conventi
onal
care
strategie
s
Quality of
life after
implement
ation of
resistance
training,
aerobic
exercises
and
combinatio
n of both,
as
interventio
n strategy
for the
treatment
cancer
related
fatigue.
Positive
impacts in
quality in
life upon
implement
ation of
strong
adherence
to aerobic,
resistance
and
combinati
on
exercise
strategies,
for cancer
related
fatigue.
(S)
Establishment of
association
between cancer
related fatigue
and chronic
fatigue symptom
along with
underlying
inflammatory
procedures
(S) Evaluation
of various
exercise
strategies as
intervention
procedures
(L) Limited
number of trails
assessed
(L) Lack of
research
pertaining to
effects of
conventional
care and
additional
1

1INTERVENTION FOR CANCER RELATED FATIGUE
cancer related
fatigue
intervention
strategies
Kelley & Kelley, (2016) Systematic
review and
meta-analysis
Individuals above
18 years of age
undergoing cancer
treatment or post
treatment survival
633
patients
undergoi
ng
exercise
intervent
ion
varying
from 3
to 52
weeks
Quality of
life after
implement
ation of
resistance
training,
aerobic
exercise
and a
combinatio
n of both,
as
interventio
n strategies
for the
treatment
of cancer
related
fatigue.
Positive
impacts in
quality of
life, with
greater
effect
upon
implement
ation of
aerobic
exercise as
an
interventio
n strategy
for cancer
related
fatigue.
(S) Intervention
assessment in
various types
cancer
(S) Assessment
of various types
of exercise
intervention
strategies
(L) Undefined
cancer treatment
procedures
(L) Lack of
research
regarding
additional
intervention
strategies
(L) High
incidence of
errors due to
researching of
reviews
(L) Usage of
prediction
intervals
1
Meneses-Echávez,
González-
Jiménez&Ramírez-Vélez,
(2014)
Systematic
review and
meta-analysis
Individuals in the
age group of 46 and
60 years,
722
patients
Quality of
life after
implement
Positive
impacts in
quality of
(S) Assessment
of multimodal
exercise
1

2INTERVENTION FOR CANCER RELATED FATIGUE
undergoing
chemotherapy
ation of
multimodal
exercise as
interventio
n strategy
for the
treatment
of cancer
related
fatigue
during
treatment.
life upon
implement
ation of
multimoda
l
exercises,
with
increased
effect
upon
supervisio
n, as an
interventio
n strategy
for cancer-
related
fatigue
intervention
strategies
(S) Assessment
of supervised
exercise
intervention
strategies
(L) Increased
concentration of
breast cancer
and women
participant
(L) large scale
of heterogeneity
(L) Undefined
stages of cancer
stages and
treatment
(L) Lack of
research
pertaining to
post treatment
cancer related
fatigue
Hilfiker et al., (2017) Systematic
review and
meta-analysis
Individuals above
18 years of age,
undergoing cancer
treatment as well as
post treatment
survival
748
patients
Quality of
life after
implement
ation of
exercise as
well as
alternative
non-
pharmacol
Positive
impacts in
quality of
life, upon
implement
ation of
relaxation
techniques
during
(S) Comparative
evaluation of
exercise and
additional
intervention
strategies
(S)
Establishment of
appropriate
1

3INTERVENTION FOR CANCER RELATED FATIGUE
ogical
methods as
interventio
n strategy
in cancer
related
fatigue
during and
after
treatment.
treatment,
and
resistance
training
after
treatment,
as
interventio
n
strategies
in cancer
related
fatigue.
intervention
strategies during
and after
treatment
(L) Large scale
of heterogeneity
(L) Limited
usage of
databases
(L) Undefined
parameters of
relaxation
strategies
Meneses-Echávez,
González-
Jiménez&Ramírez-Vélez,
(2015)
Systematic
review and
meta-analysis
Women who had
survived breast
cancer, in the age
group of 48 and 60
years.
1156
patients
(556
patients
as
survivor
s of
breast
cancer
and 460
patients
in
control
groups
Quality of
life after
implement
ation of
resistance,
aerobic
and
combinatio
n exercises
as
interventio
n strategies
for cancer
related
fatigue
during
chemother
apy.
Positive
impacts in
quality of
life,
muscle
strength
and body
compositi
on, upon
implement
ation of
resistance
training as
interventio
n strategy
in the
cancer
related
fatigue.
(S)
Establishment of
beneficial
effects of
resistance
training in
muscle and body
composition in
breast cancer
patients
(S)
Establishment of
beneficial
effects of
supervision in
exercise
intervention
strategies
(S) Large scale
of heterogeneity
1

4INTERVENTION FOR CANCER RELATED FATIGUE
(S) Lack of
associations
between
exercise, cancer
related fatigue
and depression
(S) Lack of
research
concerning
cytokine
biomarker
effects in
response to
exercise
intervention in
breast cancer
related fatigue
Baguley et al., (2017) Systematic
review and
meta-analysis
Men undergoing
prostate cancer
treatment, ranging
in the age group of
65 and 73 years
1397
patients
(17 trials
utilizing
exercisi
ng only,
2 trials
utilizing
diet and
exercise,
and 1
trial
utilizing
only diet
as
intervent
Quality of
life after
implement
ation of
only
supervised
diet, only
supervised
exercise
and
combinatio
n of both
as
interventio
n strategies
for cancer
Positive
impacts in
quality of
life, upon
implement
ation of
supervised
exercise
training as
interventio
n strategy
in cancer
related
fatigue.
Inconclusi
ve and
(S)
Establishment of
associations
between
nutrition and
exercise
intervention
strategies
(S) Assessment
of effects of
supervision in
diet and exercise
as intervention
strategies
(L) Limited
research in diet
1

5INTERVENTION FOR CANCER RELATED FATIGUE
ion
strategie
s)
related
fatigue
during the
treatment
of prostate
cancer.
negligible
results in
the
implement
ation of
diet and
exercise,
and only
diet as
interventio
n
strategies.
only
intervention
strategy for
cancer related
fatigue
(L) Lack of
research in
effective
nutritional
interventional
strategies for the
treatment of
cancer related
fatigue
(S) Large scale
of heterogeneity
due to usage of
large number of
randomized
trials.
Appendix 1: Table of Study Characteristics
(As designed by the Author)

Running head: INTERVENTION FOR CANCER RELATED FATIGUE
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