Exercise interventions to combat cancer-related fatigue in cancer patients undergoing treatment: a review

Figures & data

Table 1. Comparison of commonly used scales to measure cancer-related fatigue.

Scale	No. of Items	Scale Type	Aspects of Fatigue Covered	Comment
BFI	9	Numerical	Physical Functioning	Validated for use in mixed cancer population.
EORTC QLQ	3	Likert	Physical Functioning	Subscale of a 30-item QOL scale. Not recommended for use in advanced cancer patients.
FSS	9	Numerical	Physical Functioning	Validated in chronic illness (non-cancer) population. Not recommended for measurement of CRF.
FACT-F	13	Numerical	Physical Functioning	Subscale of FACIT QOL scale. Recommended for intervention studies.
POMS-F	7	Likert	Physical Functioning	Fatigue subscale of a scale initially used to measure workforce health. Subscale is recommended for use in cancer population.
FQ	11	Likert	Physical and Mental	Initially used in general practice but has not normative date for cancer patients. Easy to administer.
FSI	13	Numerical	Physical and Mental	Validated in breast cancer population but is of questionable reliability.
VASF	18	Visual Analog Scale	Physical and Mental	Initially used in patients with sleep disorders, not recommended for use in cancer patients.
MAF	16	Numerical	Distress, Interference, Severity, Cognitive	Initially used in patients with rheumatoid arthritis, not recommended for use in cancer patients.
MFI-20	20	Likert	Cognitive, Physical and Emotional	Designed for cancer patients and has normative data available for reference.
MFSI-30	30	Likert	Cognitive, Physical and Mental	Designed for breast cancer patients but has been used in mixed cancer patients. Limited use in clinical studies.
PFS	22	Likert	Temporal, Intensity, Cognitive, Affective and Sensory	Revised scale that is validated in a group of breast cancer survivors. Limited use in non-breast cancer patients.
Schwartz CFS	28	Likert	Physical, Emotional and Cognitive	Validated in mixer cancer population receiving treatment. Utilized in a small number of studies.
Wu CFS	9	Likert	Physical and Emotional	Revised scale with reduced items but has not been used in any study.
Minton and Stone (37)

Table 2. Comparison of studies that utilize aerobic exercise as the exclusive intervention to combat cancer-related fatigue in cancer patients.

References	Cancer Type	Treatment	Size of Cohort	Exercise Intervention	Duration	Key Finding
Chang et al. (51)	Acute myelogenous leukemia (AML)	Chemotherapy	22	12 min of walking, 5 times per week. Target HR = Resting HR + 30 BPM	3 weeks	Exercise group increased 12-min walk time (12MWT) and maintained constant level of fatigue over 3 weeks. Control group decreased 12MWT and experienced significantly worse fatigue over 3 weeks.
Windsor et al. (52)	Prostate carcinoma	Radical radiotherapy	66	30 min of walking, minimum of 3 days per week. 60 − 70 % of max HR.	Duration of radiotherapy.	No significant difference between control and exercise group from beginning of program to week 4. Exercise group had no significant increase in fatigue over the course of radiotherapy whereas the control group had significant increase in fatigue.
Payne et al. (53)	Breast cancer	Hormonal treatment	20	Moderate intensity walking, 20 min, 4 times a week.	14 weeks.	No statistically significant difference in fatigue between control and exercise group over period of study.
Mock et al. (54)	Breast cancer	Adjuvant chemotherapy or radiation therapy	52	Individualized prescription. Majority beginning at 10-15 min of walking, 5-6 times per week. Progressing to 30 min per session, 5-6 times per week.	6 weeks for radiation therapy. 4–6 months for chemotherapy patients.	Significant difference in fatigue scores between groups. High walk group decreased fatigue. Low walk group exhibited increase in fatigue.
Monga et al. (55)	Prostate cancer	Radiotherapy	21	10-min warm up, 30 min of walking, 5–10-min cool down. 65% of heart rate reserve. 3 times per week.	8 weeks	Statistically significant improvement in exercise group compared with control group.
Headley et al. (56)	Metastatic breast cancer	Chemotherapy	38	30 min of moderate intensity seated exercise, 3 times a week.	12 weeks	Significant difference in the decline in fatigue between the exercise group and control group. Significantly smaller decline in fatigue in the exercise group.
Dimeo et al. (57)	Cancer patients with solid tumors or lymphomas	High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation	62	Bed ergometer, daily, 1 min on, 1 min off. 15 times. Minimum of 50% of heart rate reserve.	Length of hospitalization.	Exercise group showed no significant increase in fatigue during hospitalization. Control group showed significant increase in fatigue.
Courneya et al. (58)	Lymphoma patients	Chemotherapy	122	Progressive cycle ergometer. Initially, 15-20 min, 3 times per week, beginning at 60% of peak power output.	12 weeks.	Aerobic exercise group significantly improve fatigue compared with control group.

Table 3. Comparison of studies that utilize resistance exercise as the exclusive intervention to combat cancer-related fatigue in cancer patients.

References	Cancer Type	Treatment	Size of Cohort	Exercise Intervention	Duration	Key Finding
Segal et al. (61)	Prostate cancer	Androgen deprivation therapy	155	9 exercises, 2 sets of each exercise, 8-12 reps per set, 60-70% of 1RM, 3 times per week.	12 weeks	Significant difference in fatigue scores between exercise and control group. Control experienced increased fatigue and reduced muscular fitness, exercise group experienced reduced fatigue and increased muscular fitness.
Segal et al. (62)	Prostate cancer	Radiotherapy with/without androgen deprivation therapy	121	Resistance arm: 10 exercises, 2 sets, 8-12 repetitions per set, 60-70% of 1RM, 3 times per week. Intensity progressively increased. Aerobic arm: Cycle ergometer, treadmill, or elliptical trainer, 50-60% of VO2 max, initially beginning at 15 min per session, 3 times per week. Volume and intensity progressively increased.	24 weeks	Resistance and aerobic groups experienced improvement in fatigue from baseline to 12 weeks. From baseline to 24 weeks, resistance group exhibited the greatest improvements in fatigue.
Wisekemann et al. (63)	Breast cancer	Radiotherapy	146	Resistance arm: 8 resistance machine exercises, 3 sets, “intensity of 12 repetitions maximum” Relaxation arm: Progressive muscle relaxation (Jacobsen method), no aerobic or resistance exercise.	12 weeks	No significant difference between resistance trained group and relaxation group in fatigue scores.
Schmidt et al. (64)	Breast cancer	Chemotherapy	81	Resistance and endurance groups: 60 min, two times a week. Endurance group: cycle ergometer, 11-14 on the Borg scale. Resistance Group: 10 exercises, 1 set per exercise with 20 repetitions per set, 50% of 1RM.	12 weeks	No intervention resulted in an improvement in fatigue scores.

Table 4. Comparison of studies that utilize a multi-modal exercise intervention to combat cancer-related fatigue in cancer survivors.

References	Cancer Type	Treatment	Size of Cohort	Exercise Intervention	Duration	Key Finding
Culos-Reed et al. (65)	Prostate cancer	Androgen deprivation therapy	100	Home-based program: walking, stretching and light resistance exercises. Moderate intensity, 3-5 times per week. Weekly group session: 1 h of activity (similar to home-based session) plus 30 min of education/discussion portion.	16 weeks	Intervention group exhibited no significant change in relation to symptoms of fatigue.
Culos-Reed et al. (66)	Prostate cancer	Androgen deprivation therapy	31	Home-based program: walking, stretching and light resistance exercises. Encouraged to perform exercise 3-5 times per week. Group session: Once a fortnight, 1-h activity (similar to home program) plus 30 min of education/discussion portion.	12 weeks	Fatigue scores decreased from baseline to week 12. From baseline to 4 months, fatigue severity increased.
Mustian et al. (67)	Women with breast cancer and men with prostate cancer	Radiation therapy	40	Walking, 60-70% of heart rate reserve, 3-5/10 RPE, 7 days a week. Aim to increase steps by 5-20% each week. Resistance band program: low to moderate progressive resistance exercise, 7 days a week. 11 exercises. Individual starting volume. Progressively increase volume and intensity over duration of program.	4 weeks	Exercise group improved symptoms of fatigue from baseline to post intervention and exhibited continued improvement to 3 month follow-up. Control group exhibited smaller improvement from baseline to post intervention but displayed worsened fatigue from baseline to 3 month follow-up.
Adamsen et al. (68)	21 different cancer diagnoses	Adjuvant chemotherapy or treatment for advanced disease	235	3 days a week: 90 min high-intensity resistance and cardiovascular training followed by 30 min relaxation. 1 day a week: 90 min of body awareness followed by 30 min of massage. In total, 9 h per week, 43 MET hours per week.	6 weeks	Exercise group significantly reduced fatigue.
Hwang et al. (69)	Breast cancer	Radiotherapy after various operations for breast cancer	40	Supervised exercise, 3 times a week. 10-min warm-up. 30-min main block (stretching, aerobic exercise and strengthening) and 10-min relaxation cool down. Heart rate between 50-70% of age predicted maximum heart rate.	5 weeks	Significant difference in fatigue between two groups. Fatigue decreased in exercise group and increased in control group.
Battaglini et al. (70)	Breast cancer	Surgery and chemotherapy and/or radiation	20	Cardiovascular exercise (6-12 min), stretching (5-10 min) and resistance exercise (15-30 min). 40-60% of patients’ maximum exercise capacity. 2 days per week.	15 weeks	Significant relationship between total calorie intake and fatigue. The greater change in total calorie intake, the less severe the symptoms of fatigue the patients experienced.
Galvao et al. (71)	Prostate cancer	Androgen suppression therapy	57	Resistance: 8 exercises, progress from 12 to 6 repetition maximum for 2-4 sets. Twice per week. Aerobic: 15 − 20 min, cycling and walking, 65-80% of max HR. Twice per week.	12 weeks	Exercise group significantly improved symptoms of fatigue.
Van Vulpen et al. (72)	Colon cancer	Chemotherapy	33	Individualized program. 10-min warm up. 40 min aerobic and muscle strengthening and 10-min cool down. Twice per week. Aerobic training was interval training of alternating intensity. Resistance training was for all major muscle groups. Beginning at 2 sets x 10 repetitions (65% of 1RM), then 1 sets x 10 repetitions (75% of 1RM) and finally to 1 sets x 20 repetitions (45% of 1RM) Patients were also advised to be active for at least 30 min on 3 other days of the week.	18 weeks	From baseline to week-18, exercise group exhibited significantly less fatigue compared with control group. At week-36, exercise group still displayed less fatigue than control group, but the difference was not significant.

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