Coping With Cancer

Can Exercise Help?

Kerry S. Courneya, PhD; John R. Mackey, MD; Lee W. Jones, MSc

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 5 - MAY 2000

In Brief: A comprehensive review of the recent literature reveals that exercise has a positive effect on a broad range of quality-of-life parameters after patients are diagnosed as having cancer. The general exercise prescription is moderate-intensity exercise, 3 to 5 days per week, 20 to 30 minutes per session. Conditions that warrant prescription modification include fatigue periods during treatment, acute or chronic physical impairments that may have resulted from surgery or adjuvant therapy, and the presence of bone cancer. Research suggests that physicians who prescribe exercise improve motivation and adherence in their patients who have cancer.

More than 1.2 million Americans were predicted to be diagnosed as having cancer in 1999 (1). Over their lifetime, Americans have about a 41% probability of developing cancer. Early detection and improved treatments for cancer have increased survival rates over the last few decades. The 5-year relative survival rate is about 60% for all cancers. Increased incidence and improved survival have resulted in 8.2 million Americans being alive today who have had cancer, which increases emphasis on quality-of-life issues.

Quality of Life and Fatigue

Cancer treatments such as surgery, chemotherapy, radiotherapy, and hormone therapy often last months or years and may greatly reduce quality of life. Common psychological and emotional sequelae of cancer include depression, anxiety, stress, body-image concerns, decreased self-esteem, and loss of a sense of control (2-4). The physical and functional effects of cancer may include asthenia, ataxia, cachexia, reduced cardiovascular and pulmonary function, muscle weakness and atrophy, weight change, difficulty sleeping, fatigue, nausea, vomiting, and pain (5-9). Although the side effects tend to peak during treatment, therapy-related symptoms may persist months or years following treatment (4).

Fatigue, an especially common and distressing symptom of cancer, occurs in 40% to 100% of patients undergoing treatment (10-15). In one study (14), 82% of patients experienced fatigue after their first cycle of chemotherapy, and 77% reported fatigue after their second cycle. As many as 40% of patients experience fatigue months or years after their treatment ends (16). The effects of fatigue on quality of life have also been documented. In one study (17), 70% of cancer patients reported that fatigue significantly (31%) or somewhat (39%) affected their daily routine.

Exploring Exercise Interventions

A number of quality-of-life interventions are available to help cancer patients cope with their disease and treatments, including cognitive-behavioral therapies, informational and educational strategies, individual and group psychotherapy, and other alternative treatments (18,19). Unfortunately, these interventions are largely psychological and not likely to address the physical and functional problems of cancer patients (20). Exercise has well-documented links to physical, functional, and psychosocial well-being in healthy older persons (21) and older persons with other chronic diseases (22). Until recently, exercise has not been considered an important, or even appropriate, quality-of-life intervention for cancer patients or survivors.

Clinical concerns about prescribing exercise to cancer patients have included: (1) the potential immunosuppressive effects of vigorous exercise, (2) the increased likelihood of pathologic bone fractures arising from compromised bone integrity, (3) possible exacerbation of cardiotoxicity from chemotherapy and/or radiotherapy, (4) severe pain, nausea, and fatigue that may be exacerbated by physical exercise, and (5) the inability and/or unwillingness of cancer patients to tolerate exercise given their weakened physical and emotional condition.

Recent research, however, is beginning to dispel many of the myths and early fears about the safety, feasibility, and efficacy of exercise as a quality-of-life intervention following cancer diagnosis.

Exercise and Quality of Life

We previously reviewed 24 studies on physical exercise and quality of life following cancer diagnosis that were published between 1980 and 1997 (20). Most of those studies examined early-stage breast cancer and aerobic exercise. We concluded that physical exercise has consistent, positive effects on a variety of quality-of-life outcomes including physical, functional, psychological, and emotional well-being. Specifically, 16 of 18 (89%) intervention studies and 5 out of 6 (83%) descriptive studies reported statistically significant results, oftentimes with small sample sizes.

We now provide an update of that literature with studies published from January 1998 through January 2000. We searched the literature using the CD-ROM databases CancerLit, CINAHL, Heracles, Medline, PsycINFO, and SPORT Discus. Key words that related to cancer (ie, cancer, oncology, tumor, neoplasm, carcinoma), rehabilitation (ie, rehabilitation, therapy, treatment, intervention, palliation), and physical exercise (ie, exercise, physical activity, physical therapy, sport) were combined and searched. Relevant articles were then hand searched for further pertinent references.

To be included in the review, studies had to examine exercise designed to improve cardiovascular and/or muscle fitness. We excluded studies that addressed only movement therapy and/or stretching and flexibility exercises for improving range of motion. Also excluded were studies that did not disentangle the effects of the exercise from other interventions such as diet, social support, and psychosocial counseling. Overall, 12 studies (23-34) met our criteria (table 1).

TABLE 1. Studies of Exercise and Quality of Life After Cancer Diagnosis, January 1998 Through January 2000

Authors, Year Sample Design Exercise Program Outcome Variables Results

Descriptive Studies

Courneya et al (29), 1999 53 postsurgical colorectal cancer patients (77% on or starting adjuvant therapy) Prospective Self-reported, over 4 mo Physical, functional, emotional, social QOL, and life satisfaction Increase in frequency of light exercise from pre- to postsurgery correlated with QOL and life satisfaction

Courneya et al (27), 2000 25 cancer patients who had just completed chemotherapy and autologous bone marrow transplantation Prospective Self-reported cycle ergometry and walking during hospital stay Physical, functional, emotional, social QOL, depression, anxiety, and fatigue Exercise correlated with almost all QOL and social outcomes

Keats et al (31), 1999 53 adolescent cancer survivors (85% had completed treatment) Retrospective Self-reported, prediagnosis, during, and after treatment Depression and multiple self-concept indices Patients active at all three points had best psychosocial status

Pinto et al (23), 1998 71 breast cancer survivors, average 8 mo postdiagnosis Cross-sectional Self-reported, recent Mood, coping behaviors, cancer-related symptoms Exercise related to decreased confusion, increased vigor, and increased coping behaviors

Interventional Studies

Derman et al (32), 1999 6 cancer patients who had just completed chemotherapy Pre-post test with matched controls Supervised, 12 wk Physical performance and skeletal muscle structure and function At pretest, cancer patients had lower VO₂max and total power compared with controls; postprogram, patients increased both measures

Dimeo et al (33), 1998 5 cancer patients who reported fatigue; 3 were on treatment Pre-post test Daily treadmill walking for 6 wk, 15-30 min at 80% HR_max using interval training Physical performance and fatigue Significant increase in physical performance and decrease in fatigue

Dimeo et al (28), 1999 59 cancer patients who had just completed chemotherapy and bone marrow transplantation Randomized clinical trial Daily supervised recumbent biking during hospitalization for 30 min at 50% HR_reserve using interval training Psychological status and affective states Exercise group showed decrease in psychological distress; controls showed increased in fatigue and decrease in vigor

Durak and Lilly (34), 1998 20 cancer survivors who had just completed adjuvant therapy, average 14 mo postdiagnosis Pre-post test Supervised aerobic and weight training 2X/wk at own RPE for 10 wk Physical performance and QOL Significant increase in muscle strength, endurance, and QOL

Durak et al (30), 1999 25 prostate and leukemia cancer survivors (84% had completed treatment) Pre-post test Supervised aerobic and weight training 2X/wk at own RPE for up to 20 wk Time on machines, muscle strength, and QOL Increased overall strength by 38%-52%, increased time on machines by 24%-30%, and increased QOL, but only for leukemia patients

Schulz et al (24), 1998 28 nonmetastatic breast cancer patients Pre-post test Supervised, 2X/wk for 10 wk Physical fitness, anxiety, and depression Increase in physical fitness, decrease in anxiety and depression

Schwartz (25), 1999 27 breast cancer patients starting chemotherapy Pre-post test Home-based, 3-4X/wk for 8 wk, 15-30 min at low-moderate intensity Physical performance, weight, fatigue, symptoms, and QOL Exercise adherence showed increase in functional ability, decreased weight gain, decreased QOL decline, and decreased fatigue

Segar et al (26), 1998 24 sedentary breast cancer survivors, average 3.5 yr postsurgery Randomized clinical trial Unsupervised, 4X/wk for 10 wk, > 30 min at > 60% HR_max Depression, anxiety, and self-esteem Exercise adherence correlated with depression and anxiety compared with controls

QOL = quality of life; HR = heart rate; RPE = rating of perceived exertion

In this review, cancer survivors are defined as patients who have completed medical treatment with a successful outcome. Cancer patients are defined as those who are currently on medical treatment.

These more recent studies continue to focus on breast cancer survivors (23-26) and bone marrow transplant patients (27,28) but also involve colorectal cancer patients (29), prostate cancer survivors (30), and adolescent cancer survivors (31). Most studies were interventional (24,25,30,32-34); two were randomized clinical trials (26,28). As in studies published before 1998 (20), most interventions tested aerobic exercise (24-26,28,32,33), though two studies examined strength training (30,34).

Nearly all of the most recent intervention studies were initiated after cancer treatment (24,26,28,30,32-34), with one exception (exercise started before treatment) (25), and most evaluated supervised exercise programs (24,28,30,32-34). Intervention length ranged from 2 weeks (28) to 20 weeks (30). Outcome measures consisted of a wide range of quality-of-life indicators of physical and functional well-being (24,25,27,29,30,32-34) and emotional and psychological well-being (24-27,29-31,34).

Overall, the results of the 12 most recent studies are consistent with the 24 studies published between 1980 and 1997 (20). Specifically, all 12 of the present studies reported significant improvements in various quality-of-life outcomes. Physical and functional benefits included improved functional capacity (24,25,30,32-34), increased muscle strength (30,34), controlled body weight (25), and reduced fatigue (25,28,33). Psychological and emotional benefits included improvements in overall quality of life (25,27,29,30,34), self-concept (31), and patients' mood states including vigor (23), anxiety (24,26,28), and depression (24,26). Though effect sizes could not be summarized across studies because of diverse outcomes and the small number of studies, exercise effects are clearly robust and clinically significant. Results of many of the intervention studies were statistically significant despite small sample sizes (see table 1).

Exercise and fatigue. Fatigue merits special attention because it has primarily been treated with rest, which may exacerbate the problem over the long term. Consequently, we conducted a comprehensive literature review of studies (9,10,13,23,27,28,33,35-37) that have examined exercise in the management of fatigue following cancer diagnosis. We identified 10 such studies published since 1986 (table 2).

TABLE 2. Recent Studies of Exercise and Fatigue After Cancer Diagnosis

Authors, Year Sample Design Exercise Program Measure Results

Descriptive Studies

Courneya et al (27), 2000 25 cancer patients who had just completed chemotherapy and bone marrow transplantation Prospective Self-reported cycle ergometry and walking during hospital stay Functional Assessment of Cancer Therapy Fatigue scale Cycling duration per day correlated significantly with fatigue at discharge (r = -.27, P = .05)

Dimeo et al (10), 1997 78 consecutive cancer patients admitted for chemotherapy and bone marrow transplantation Cross-sectional Maximal performance assessed by treadmill test POMS Performance significantly correlated with fatigue (r = -.30, P = .05) even after controlling for age and sex

Pinto et al (23), 1998 71 breast cancer survivors, average 8 mo postdiagnosis Cross-sectional Self-reported recent POMS No difference, but regular exercisers scored significantly higher on vigor

Interventional Studies

Dimeo et al (33) 1998 5 cancer patients with severe fatigue, 3 on treatment Pre-post test Daily treadmill walking for 6 wk, 15-30 min at 80% HR_max using interval training Clinical observation Clinically meaningful improvements in fatigue for all 5 patients

Dimeo et al (28), 1999 59 cancer patients who just completed chemotherapy and bone marrow transplantation Randomized clinical trial Daily recumbent biking during hospitalization for 30 min at 50% HR_reserve using interval training POMS Fatigue and vigor in exercise group remained stable; controls showed significant increase in fatigue and significant decrease in vigor

Dimeo et al (35), 1997 32 cancer patients who underwent chemotherapy and bone marrow transplantation Controlled, nonrandomized trial Treadmill walking 5X/wk for 6 wk, 15-30 min at 80% HR_max using interval training Clinical observation and hemoglobin levels Hemoglobin level was significantly decreased in exercise group; no patients in exercise group, but 25% of controls, reported fatigue with usual daily activities

MacVicar and Winningham (37), 1986 10 stage 2 breast cancer patients on postsurgical chemotherapy Controlled, nonrandomized trial Supervised cycle ergometry 3X/wk for 10 wk at 60%-85% of
HR_max POMS Exercise group showed decreased fatigue and increased vigor compared with controls

Mock et al (9), 1994 14 breast cancer patients receiving postsurgical chemotherapy Randomized clinical trial Combined walking and support program 4-5X/wk for 4-6 mo, 10-45 min at own pace One item VAS of SAS Exercise group reported less fatigue than controls at mid- and postprogram

Mock et al (36), 1997 46 breast cancer patients receiving postsurgical radiation Randomized clinical trial Brisk walking 4-5X/wk for 6 wk, 20-30 min at own pace One item VAS of SAS; Piper Fatigue Scale Exercise group reported significantly decreased fatigue than controls postprogram; exercise significantly correlated with fatigue in both groups (r = -.45, P = .05)

Schwartz (25), 1999 27 breast cancer patients beginning chemotherapy Pre-post test Home-based, 3-4X/wk for 8 wk, 15-30 min at low-moderate intensity POMS, VAS, Schwartz cancer fatigue scale Exercise adherence correlated with decreased fatigue; exercise intensity and functional ability accounted for 73% of fatigue variance

POMS = profile of mood states; HR = heart rate; VAS = visual analogue scale (ranges from no fatigue to extreme fatigue); SAS = symptom assessment scale (VAS-based scale assessing 13 common symptoms of cancer)

Five studies examined mixed cancer patients after high-dose chemotherapy and bone marrow transplantation (BMT) (10,27,28,33,35), and 5 studies examined breast cancer patients or survivors (9,13,23,36,37). Seven studies were interventional (9,13,28,33,35,37), and 3 were descriptive (10,23,27). All examined aerobic exercise or fitness. The interventions were initiated during treatment in 5 studies (9,13,28,36-37) and posttreatment in 2 studies (33,35). Four interventions were supervised (28,33,35,37), and 3 were home-based (9,13,36). The length of the interventions ranged from 2 weeks (28) to 6 months (9). Fatigue was measured by various self-report scales (9,13,23,27,28,35,36) or clinical observation (33). Hemoglobin levels were assessed in 1 study (35).

Overall, the results demonstrated that increased physical exercise is associated with less fatigue during and after cancer treatment. Specifically, descriptive studies showed significant negative relationships between cycling duration during hospitalization and subsequent fatigue (27) and between functional capacity and fatigue at one time point (10), and a positive relationship between aerobic exercise and vigor (23). The intervention studies demonstrated decreased fatigue from pre- to postintervention in the exercise group (33,37), increased fatigue from pre- to postintervention in the control group (28,37), higher hemoglobin levels (35) and lower fatigue in the exercise group as compared with the control group postintervention (9,36), and less fatigue in those who adhered to the exercise intervention compared with those who did not (13).

In summary, the 36 previously mentioned studies that examined the relationship between exercise and quality of life following cancer diagnosis consistently demonstrated that exercise has beneficial effects on a wide variety of quality-of-life outcomes regardless of the exercise prescription, cancer site, cancer treatment, or intervention timing (during or following treatment). Though these studies have some limitations, and many important questions remain to be answered (20), additional research is not likely to overturn the fundamental conclusion that exercise is a safe, feasible, and beneficial quality-of-life intervention for most cancer patients and survivors.

Exercise Prescription Recommendations

Of the 36 studies on exercise after cancer diagnosis, 26 had prescribed exercise interventions. Unfortunately, all 26 compared a single exercise prescription to a "no-exercise" condition; thus, there is no direct evidence concerning the optimal type, frequency, duration, intensity, or progression of exercise for this population.

No research to date has included cancer patients who had extensive disease or who were receiving palliative care. Clearly, determining the optimal exercise prescription for cancer survivors and patients at various stages of the disease is an important direction for future research. Nevertheless, some general recommendations (table 3) can be drawn from the exercise and cancer literature (38-41), as well as the literature on exercise in healthy older adults (21) and older adults with other chronic diseases (22).

TABLE 3. Exercise Prescription Guidelines for Early-Stage Cancer Patients and Cancer Survivors

Parameter Recommendation and Comment

Mode Most exercises involving large muscle groups are appropriate, but walking and cycling are especially recommended because they are safe and tolerable for patients. Exercises are modified based on acute or chronic treatment effects from surgery, chemotherapy, and/or radiotherapy.

Frequency At least 3-5X/wk, but daily exercise may be preferable for deconditioned patients who do lighter intensity and shorter duration exercises.

Intensity Moderate, depending on current fitness level and medical treatments. Guidelines recommend 50% to 75% VO₂max or HR_reserve, 60% to 80% HR_max, or an RPE of 11 to 14. HR_reserve is the best guideline if HR_max is estimated rather than measured.*

Duration At least 20-30 min of continuous exercise; however, deconditioned patients or those experiencing severe side effects of treatment may need to combine short exercise bouts (eg, 3-5 min) with rest intervals.

Progression Patients should meet frequency and duration goals before they increase exercise intensity. Progression should be slower and more gradual for deconditioned patients or those who are experiencing severe side effects of treatment.

*HR_reserve = maximal heart rate (HR_max) minus standing resting heart rate (HR_rest). Multiply HR_reserve by .60 and .80. Add each of these values to HR_rest to obtain the target heart rate range. HR_max can be estimated as 220 minus age (years).
HR = heart rate; RPE = rating of perceived exertion

Most studies on cancer patients and survivors involved walking or cycle ergometer programs. Walking has been prescribed for the home-based programs and is the preferred and most common exercise for cancer patients. (See "Cancer Patient Case Studies: Exercise Goals Lead to Documented Improvements," below.) Walking, a natural choice, directly relates to activities of daily living.

Most studies prescribing cycle ergometry have been laboratory based, and the most likely reasons for prescribing this type of exercise are the availability of the equipment and that the patients studied were recovering from breast cancer. The sitting leg-exercise position may be preferable for patients who have ataxia; limitations in upper-extremity movement caused by breast, axillary, or thoracic surgery; central venous access catheters; or arm lymphedema. Other cancer patients, such as those who have just had rectal or prostate surgery, may not be able to perform cycle ergometry.

The key consideration when prescribing an exercise mode in cancer patients and survivors is acute or chronic physical impairments such as ataxia, anemia, or limited range of motion that may have resulted from surgery or adjuvant therapy (eg, chemotherapy, radiotherapy, or hormone therapy).

As with older patients who have chronic disease, safety must be the primary issue (21,22). Swimming should be avoided by patients who have nephrostomy tubes, non-indwelling central venous access catheters, and urinary bladder catheters. Swimming is not contraindicated for patients who have continent urinary diversions, ureterostomies, or colostomies, but patients should wait 8 weeks postsurgery and avoid open-ended pouch appliances. Those who have primary or metastatic bone cancer should avoid high-impact exercises and contact sports. Clinically, it is probably safest for most cancer patients to prescribe walking or cycle ergometry. Though information on the efficacy of weight training is only beginning to emerge, the optimal rehabilitation program for older persons who have chronic diseases, including cancer, will likely combine aerobic and weight training (22).

The frequency, intensity, and duration of exercise prescribed for cancer patients has closely followed American College of Sport Medicine guidelines (42). Most studies have prescribed moderate-intensity exercise, 3 to 5 days per week, 20 to 30 minutes per session.

This prescription generally appears appropriate for cancer patients (39-41,43) but may need to be modified based on current medical treatments, comorbid conditions, and fitness level. Many cancer patients will not feel like exercising at certain times during their chemotherapy cycles. These "down days" are different for each patient and may vary from cycle to cycle. The key point is to build flexibility into the exercise prescription so that cancer patients can modify the frequency, intensity, or duration of exercise depending on their response to treatment.

High-intensity exercise should be avoided during cancer treatment because of potential immunosuppressive effects (44), but it is not contraindicated for cancer survivors. Many cancer patients will not be able to perform 30 minutes of continuous exercise at the start of their treatments, especially if they have been sedentary. Many researchers have used intermittent or interval training—alternating short bouts of exercise and rest—for patients during chemotherapy (9,37) or immediately following bone marrow transplantation (28,35) as a way for patients to accumulate 30 minutes of daily exercise. This approach is recommended for older deconditioned people who have chronic diseases (21,22) and may be optimal for cancer patients who have been sedentary or are receiving palliative care (40,43).

Cancer patients exercise as much for psychological benefit as for physical health (45-47), and it is important to consider this aspect when prescribing exercise. As a general guideline, physicians should prescribe exercise that is enjoyable, builds confidence, develops new skills, incorporates social interaction, and takes place in an environment that engages the mind and spirit.

Exercise Contraindications

Although exercise may be an effective quality-of-life intervention for many cancer patients and survivors, mitigating factors may make exercise unwise or dangerous for some. Besides the general contraindications that are relevant for older populations (21), additional contraindications apply to cancer patients (table 4). Cancer patients who have such conditions may benefit from an appropriately designed and supervised exercise program, but the risk-benefit ratio may be higher, and close medical supervision may be required.

TABLE 4. Contraindications to Physical Exercise Following Cancer Diagnosis

Contraindication Comment

Complete blood counts

      Hemoglobin level < 8.0 g/dL Avoid activities that require significant oxygen transport (ie, high intensity)

      Absolute neutrophil count
      < 0.5 x 10⁹/microliters Avoid activities that may increase risk of bacterial infection (eg, swimming)

      Platelet count
      < 50 x 10⁹/microliters Avoid activities that increase risk of bleeding (eg, contact sports or high-impact exercises)

Fever > 38°C (100.4°F) May indicate systemic infection and should be investigated; avoid high-intensity exercise

Ataxia, dizziness, or peripheral sensory neuropathy Avoid activities that require significant balance and coordination such as treadmill exercise

Severe cachexia (loss of > 35% of premorbid weight) Loss of muscle mass usually limits exercise to mild intensity, depending on degree of cachexia

Dyspnea Investigate cause; exercise to tolerance

Bone pain Avoid activities that increase risk of fracture such as contact sports and high-impact exercises

Severe nausea Investigate cause; exercise to tolerance

Extreme fatigue and/or muscle weakness Exercise to tolerance

Appropriately, early research took a cautious approach to exercise in cancer patients. The current medical literature contains reports of exercise tests and programs that cover more than 700 cancer patients undergoing various treatments and have reported no major adverse events linked to exercise. In our own lab, more than 250 cancer patients have undergone submaximal treadmill testing, many during chemotherapy, radiotherapy, or hormone therapy, and they have encountered no major adverse events.

The Physician's Role

The effectiveness of exercise as a quality-of-life intervention following cancer diagnosis depends largely on the participants' motivation and adherence, which are major challenges for health professionals, regardless of patient health status or exercise purpose (48). The negative effects of cancer and its treatment likely decrease exercise adherence even more following cancer diagnosis. In fact, recent research (31,49,50) has documented a significant decline in exercise volume between prediagnosis and active treatment that is not recovered even years after treatment is completed.

Though a variety of factors are linked to exercise motivation and adherence following cancer diagnosis (45-47,51), the role of the physician will likely be important. Clinical trials of physician-based exercise counseling in the general population have shown demonstrated benefits (52). No clinical trials have been conducted of physician-based exercise counseling for cancer patients; however, preliminary data indicate that it may be effective.

A number of studies have indicated that most cancer patients are not counseled to exercise by their healthcare providers. For example, one study (53) noted that nearly 70% of breast cancer survivors said they received little or no information on exercise from their healthcare providers. A similar study (54) reported that 59% of breast cancer survivors said their physicians did not mention exercise to them as part of their rehabilitation. Even a more recent study (26) found that 50% of breast cancer survivors said that their physician made no exercise recommendation during cancer treatment. These results have been reported in numerous other studies (25,27,30).

Despite the research suggesting that physicians and other healthcare providers do not recommend exercise to cancer patients and survivors, this same research indicates its potential importance. For example, one study (53) noted that the women who reported receiving information on the role of exercise in breast cancer recovery tended to return to exercise more quickly after treatment. Similarly, another study (26) found that the amount of exercise performed by breast cancer survivors who received a physician recommendation to exercise was significantly higher than that of women who did not receive such a recommendation. Finally, using the theory of planned behavior (55) as a framework, a series of studies have reported that perceived physician approval for exercise significantly correlated with perceived social pressure to exercise in breast (47) and colorectal (46) cancer patients, with intentions to exercise in breast cancer (47) and bone marrow transplantation (51) patients, and with self-reported exercise behavior in breast cancer patients (47).

Promising Outlook

Good evidence exists for promoting exercise to enhance quality of life following cancer diagnosis. Currently, 36 studies have addressed this issue using primarily intervention designs. Despite limitations in the studies, the evidence suggests that physical exercise will improve various quality-of-life parameters, including fatigue, both during and following cancer treatment.

References

American Cancer Society: Cancer Facts and Figures. Atlanta, American Cancer Society, 1999
Glanz K: Psychosocial impact of breast cancer: a critical review. Ann Behav Med 1992;14:202-212
Grassi L, Rosti G, Albertazzi L, et al: Psychological stress symptoms before and after autologous bone marrow transplantation in patients with solid tumors. Bone Marrow Transplant 1996;17(5):843-847
Spiegel D: Psychosocial aspects of breast cancer treatment. Semin Oncol 1997;24(1 suppl 1):S1-S47
Ferrell BR: The impact of pain on quality of life: a decade of research. Nurs Clin North Am 1995;30(4):609-624
Jenney ME, Faragher EB, Jones PH, et al: Lung function and exercise capacity in survivors of childhood leukaemia. Med Pediatr Oncol 1995;24(4):222-230
Morrow GR, Dobkin PL: Anticipatory nausea and vomiting in cancer patients undergoing chemotherapy treatment: prevalence, etiology, and behavioral interventions. Clin Psych Rev 1988;8:517-556
Pelletier C, Lapointe L, LeBlanc P: Effects of lung resection on pulmonary function and exercise capacity. Thorax 1990;45(7):497-502
Mock V, Burke MB, Sheehan P, et al: A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy. Oncol Nurs Forum 1994;21(5):899-907
Dimeo F, Stieglitz RD, Novelli-Fischer U, et al: Correlation between physical performance and fatigue in cancer patients. Ann Oncol 1997;8(12):1251-1255
Irvine D, Vincent L, Graydon JE, et al: The prevalence and correlates of fatigue in patients receiving treatment with chemotherapy and radiotherapy: a comparison with the fatigue experienced by healthy individuals. Cancer Nurs 1994;17(5):367-378
Nail LM, Winningham ML: Fatigue and weakness in cancer patients: the symptoms experience. Semin Oncol Nurs 1995;11(4):272-278
Schwartz AL: Patterns of exercise and fatigue in physically active cancer survivors. Oncol Nurs Forum 1998;25(3):485-491
Greene D, Nail LM, Fieler VK, et al: A comparison of patient- reported side effects among three chemotherapy regimens for breast cancer. Cancer Pract 1994;2(1):57-62
Berglund G, Bolund C, Fornander T, et al: Late effects of adjuvant chemotherapy and postoperative radiotherapy on quality of life among breast cancer patients. Eur J Cancer 1991;27(9):1075-1081
Broeckel JA, Jacobsen PB, Horton J, et al: Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol 1998;16(5):1689-1696
Vogelzang N, Breitbart W, Cella D, et al: Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey: The Fatigue Coalition. Semin Hematol 1997;34(3 suppl 2):4-12
Fawzy FI, Fawzy NW, Arndt LA, et al: Critical review of psychosocial interventions in cancer care. Arch Gen Psychiatry 1995;52(2):100-113
Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 1995;14(2):101-108
Courneya KS, Friedenreich CM: Physical exercise and quality of life following cancer diagnosis: a literature review. Ann Behav Med 1999;21(2):171-179
American College of Sports Medicine Position Stand: Exercise and physical activity for older adults. Med Sci Sports Exerc 1998;30(6):992-1008
Petrella RJ: Exercise for older patients with chronic disease. Phys Sportsmed 1999;27(11):79-102
Pinto BM, Maruyama NC, Engebretson TO, et al: Participation in exercise, mood, and coping in survivors of early stage breast cancer. J Psychosoc Oncol 1998;16(2):45-58
Schulz KH, Szlovak C, Schulz H, et al: Implementation and evaluation of an ambulatory exercise therapy based rehabilitation program for breast cancer patients (in German). Psychother Psychosom Med Psychol 1998;48(9-10):398-407
Schwartz AL: Fatigue mediates the effects of exercise on quality of life. Qual Life Res 1999;8(6):529-538
Segar ML, Katch VL, Roth RS, et al: The effect of aerobic exercise on self-esteem and depressive and anxiety symptoms among breast cancer survivors. Oncol Nurs Forum 1998;25(1):107-113
Courneya KS, Keats MR, Turner AR: Physical exercise and quality of life in cancer patients following high dose chemotherapy and autologous bone marrow transplantation. Psycho-Oncology 2000;9:127-136
Dimeo FC, Stieglitz RD, Novelli-Fischer U, et al: Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer 1999;85(10):2273-2277
Courneya KS, Friedenreich CM, Arthur K, et al: Physical exercise and quality of life in postsurgical colorectal cancer patients. Psychol Health Med 1999;4(2):181-187
Durak EP, Lilly PC, Hackworth JL: Physical and psychosocial responses to exercise in cancer patients: a two year follow-up survey with prostrate [sic], leukemia, and general carcinoma. JEPonline 1999;2(1) Available at http://www.css.edu/users/tboone2/asep/jan12b.htm. Accessed March 15, 2000
Keats MR, Courneya KS, Danielsen S, et al: Leisure-time physical activity and psychosocial well-being in adolescents after cancer diagnosis. J Pediatr Oncol Nurs 1999;16(4):180-188
Derman WE, Coleman KL, Noakes TD: Effects of exercise training in patients with cancer who have undergone chemotherapy, abstracted. Med Sci Sports Exerc 1999;31(5):S368
Dimeo F, Rumberger BG, Keul J: Aerobic exercise as therapy for cancer fatigue. Med Sci Sports Exerc 1998;30(4):475-478
Durak EP, Lilly PC: The application of an exercise and wellness program for cancer patients: a preliminary outcomes report. J Strength Cond 1998;12(1):3-6
Dimeo FC, Tilmann MH, Bertz H, et al: Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. Cancer 1997;79(9):1717-1722
Mock V, Dow KH, Meares CJ, et al: Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum 1997;24(6):991-1000
MacVicar MG, Winningham ML: Promoting the functional capacity of cancer patients. Cancer Bull 1986;38:235-239
Hicks JE: Exercise for cancer patients, in Basmajian JV, Wolf SL (eds): Therapeutic Exercise, ed 5. Baltimore, Williams & Wilkins, 1990, pp 351-369
Mock V: The benefits of exercise in women with breast cancer, in Dow KH (ed): Contemporary Issues in Breast Cancer. Sudbury, MA, Jones & Bartlett, 1996, pp 99-106
Winningham ML: Exercise and cancer, in Elliot DL, Goldberg L (eds): Exercise for Prevention and Treatment of Illness. Philadelphia, FA Davis Co, 1994, pp 301-315
Winningham ML, MacVicar MG, Burke CA: Exercise for cancer patients: guidelines and precautions. Phys Sportsmed 1986;14(10):125-134
American College of Sports Medicine Position Stand: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975-991
Winningham ML: Walking program for people with cancer: getting started. Cancer Nurs 1991;14(5):270-276
Shephard RJ, Shek PN: Exercise, immunity, and susceptibility to infection: a J-shaped relationship? Phys Sportsmed 1999;27(6):47-71
Courneya KS, Friedenreich CM: Determinants of exercise during colorectal cancer treatment: an application of the theory of planned behavior. Oncol Nurs Forum 1997;24(10):1715-1723
Courneya KS, Friedenreich CM, Arthur K, et al: Understanding exercise motivation in colorectal cancer patients: a prospective study using the theory of planned behavior. Rehab Psychol 1999;44(1):68-84
Courneya KS, Friedenreich CM: Utility of the theory of planned behavior for understanding exercise during breast cancer treatment. Psycho-Oncology 1999;8(2):112-122
Robison JI, Rogers MA: Adherence to exercise programmes: recommendations. Sports Med 1994;17(1):39-52
Courneya KS, Friedenreich CM: Relationship between exercise during treatment and current quality of life among survivors of breast cancer. J Psychosoc Oncol 1997;15(3/4):35-57
Courneya KS, Friedenreich CM: Relationship between exercise pattern across the cancer experience and current quality of life in colorectal cancer survivors. J Altern Complement Med 1997;3(3):215-226
Courneya KS, Keats MR, Turner AR: Social cognitive determinants of physical exercise in cancer patients following high dose chemotherapy and autologous bone marrow transplantation. Int J Behav Med, to be published
Simons-Morton DG, Calfas KJ, Oldenburg B, et al: Effects of interventions in health care settings on physical activity or cardiorespiratory fitness. Am J Prev Med 1998;15(4):413-430
Cooper H: The role of physical activity in the recovery from breast cancer. Melpomene J 1995;14(1):18-20
Young-McCaughan S, Sexton DL: A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. Oncol Nurs Forum 1991;18(4):751-757
Ajzen I: The theory of planned behavior. Organ Behav Hum Decis Processes 1991;50:179-211

Cancer Patient Case Studies: Exercise Goals Lead to Documented Improvements

A study examining the effect of a 10-week home-based exercise program on the quality of life of cancer patients attending group therapy sessions provides an opportunity to single out and gauge the effect on individual patients. Though the physical exam procedure reflects the study design, a similar protocol may be useful to physicians prescribing exercise to cancer patients.

Patient 1
History. A 57-year-old woman was diagnosed as having colon cancer and was undergoing radiotherapy. Her activity history consisted of regular walking at a leisurely pace.

Preexercise physical examination. On submaximal treadmill testing, the patient's time to 70% of age-predicted maximal heart rate was 216 seconds. The patient's total skinfold measurement, measured with calipers from five sites, was 55.7 mm. Her combined handgrip strength, measured on dynamometer, was 53 kg, and her flexibility on the sit-and-reach test was 39.5 cm.

Assessment. This was a classic case of a patient needing to resume exercise after cancer treatment. She wanted to get strong for recreational dancing. Her cardiovascular fitness was fairly good considering her treatment background, though she had room for improvement.

Exercise prescription. Because the patient's main goal was to resume dancing, she was advised to begin aerobic training (walking and some cycle ergometry), 3 to 5 days per week, for 30 to 60 minutes per session, at 70% to 85% of her maximum heart rate.

Postexercise physical examination. Ten weeks after the exercise program began, the patient's time to 70% of age-predicted maximal heart rate was 597 seconds (an improvement of 381 seconds). Skinfold measurement (from five sites) increased to 73.6 mm. Handgrip strength increased to 58 kg, and her flexibility on the sit-and-reach test did not change.

Comments. The patient said that she liked being accountable to the program and thought exercise to be extremely important. At the beginning of the program, she exercised once a week for an hour each time at a moderate intensity. The patient gradually increased her duration. At the end of the program, she was exercising three times a week, for 2 hours each time, at moderate intensity. It's unclear why her skinfold measurement increased. One of many possible reasons may be that her appetite improved, which is a desirable outcome for many patients who have cancer.

Patient 2
History. The patient was a 62-year-old woman who had received radiotherapy for mandible cancer. Her activity history included walking at a leisurely pace.

Preexercise physical examination. The patient's time to 70% of age-predicted maximal heart rate was 514 seconds. Her skinfold measurement (from five sites) was 82.4 mm. Her combined handgrip strength was 58 kg.

Assessment. The patient had completed cancer treatment some time before resuming exercise, but treatment was continuing for other medical complications. She wanted to remain fit and active throughout treatment but had limited access to exercise facilities.

Execise prescription. Based on limited facilities and her exercise goals, a brisk walking program was prescribed. The patient was advised to walk 3 to 5 days per week and progress in duration at moderate intensity.

Postexercise physical examination. Ten weeks after starting her walking program, the patient's time to 70% of age-predicted maximal heart rate was 759 seconds (up by 245 seconds). Her skinfold measures (from 5 sites) increased slightly to 84.8 mm. Handgrip strength (combined) decreased slightly to 55 kg.

Comments. The patient said she found the walking program very motivational and that exercise kept her mind off treatments and boosted her strength. At the beginning of the program she was exercising five times a week for 45 minutes at mild intensity; by the end of the program she was exercising four times a week for 30 minutes at moderate intensity.

Dr Courneya's research program is supported by the National Cancer Institute of Canada (NCIC) with funds from the Canadian Cancer Society (CCS) and the CCS/NCIC Sociobehavioral Cancer Research Network. Dr Mackey's research program is supported by the NCIC and the Alberta Cancer Board.

Dr Courneya is a professor in the faculty of physical education, Dr Mackey is an assistant professor of medicine in the department of oncology, and Mr Jones is a doctoral student in the faculty of physical education at the University of Alberta in Edmonton. Address correspondence to Kerry S. Courneya, PhD, Faculty of Physical Education, University of Alberta, E-401 Van Vliet Center, Edmonton, Alberta, T6G 2H9, Canada; e-mail to kerry.courneya@ualberta.ca.

RETURN TO MAY 2000 TABLE OF CONTENTS