NURS90070 - Exercise Intervention for Cancer-Related Fatigue Review

This report critically appraises six systematic reviews examining exercise as an intervention for cancer-related fatigue and its effect on the quality of life of cancer patients. It highlights the prevalence and debilitating nature of cancer-related fatigue, emphasizing the potential of exercise, particularly aerobic exercise, to mitigate symptoms. The review considers studies utilizing the PICOT framework, exploring the benefits of aerobic and resistance training. While acknowledging limitations such as sample size and unspecified treatment details in some studies, the report underscores the evidence supporting exercise as a valuable strategy. It also discusses the importance of patient adherence and potential underlying causes of inflammation and cytokine malfunctioning. The report concludes with recommendations for implementing these findings in nursing practice to improve patient outcomes.

Running head: INTERVENTION FOR CANCER RELATED FATIGUE
INTERVENTION FOR CANCER RELATED FATIGUE
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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