Craft, L. L., Vaniterson, E. H., Helenowski, I. B., Rademaker, A. W., & Courneya, K. S. (2012). Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 21(1), 3-19.
Evaluate the current literature on antidepressant effects of exercise in cancer survivors. Also to explore potential moderating variables related to participant, cancer and exercise characteristics.
TYPE OF STUDY Combined systematic review and meta analysis
DATABASES Medline, Medline in Process, Psycinfo, Embase, CINAHL, Cochrane database, Cochrane central register of controlled trials, Allied and Complementary Medicine, Biosis Previews, Sports Discus
KEYWORDS terms related to cancer, exercise, and depression
INCLUSION CRITERIA Studies were eligible if they were a RCT of adults with cancer, compared exercise program with usual care, exercise program was chronic in nature (at least 4 weeks), reported depression pre and post intervention, used depression inventory or clinician interview to define depression symptom, English language
EXCLUSION CRITERIA studies that used quality of life or moods scales to measure depression
Study Aims Evaluate the current literature on antidepressant effects of exercise in cancer survivors. Also to explore potential moderating variables related to participant, cancer and exercise characteristics.
TOTAL REFERENCES RETRIEVED : N =60
METHOD OF STUDY EVALUATION AND COMMENTS ON LITERATURE USED Two investigators independently reviewed articles with discrepancies resolved by consensus.
All studies included aerobic exercise with some also including strength training. Exercise programs were implemented prior to or during treatment in 47% of the studies. Interventions varied from unsupervised home based to supervised facility based with frew having mixed supervision. Intervention length ranged mostly from 4-14 weeks, with the longest being 52 weeks.
FINAL NUMBER STUDIES INCLUDED: N = 14 articles describing 15 RCTS TOTAL SAMPLE SIZE: N = 1371 SAMPLE RANGE ACROSS STUDIES : 18-209, including exercise and control groups combined
KEY SAMPLE CHARACTERISTICS 60% (9) studies included breast cancer survivors. The average age was 51.6 years. 76.9 of those who reported race/ethnicity were Caucasian. Of those reporting cancer stage, 75% were patients with non-metastatic disease.
PHASE OF CARE Active Treatment
APPLICATIONS Late Effects and Survivorship
Effect size of -.22(p=0.04) was found comparing exercise group to control groups. Home based exercise had increased depressive symptoms (effect size(ES)e 0.16) compared to exercise location and facilities, laboratories, gyms (ES= -0.45, -0.77, -.014). Supervised exercise had the greatest effect (ES=-0.67) compared to mixed supervision (ES=-0.32) and unsupervised activity showed a small increase in depression (ES=0.25). Duration of greater than 30 minutes had a larger effect (ES=-.57) compared to less than or equal to 30 minutes (ES=0.01)
Overall, exercise had a small to moderate impact on depression symptoms which varied based on location of exercise, supervision, and duration.
Exercise at places where patients interact with others had a greater effect size associated with reduction of depression symptoms. It would be important to recognize this when intervening with exercise. Future research should measure the significance of social interaction during exercise and depression symptoms. Also, more work is necessary to understand if the exercise intervention improves QOL.
Co, J.L., Mejia, M.B., Que, J.C., & Dizon, J.M. (2016). Effectiveness of honey on radiation-induced oral mucositis, time to mucositis, weight loss, and treatment interruptions among patients with head and neck malignancies: A meta-analysis and systematic review of literature. Head and Neck, 38, 1119–1128.
STUDY PURPOSE: To synthesize the available literature to determine the role of honey in reducing oral mucositis, time to onset of mucositis, weight loss, and treatment interruptions among patients with head and neck cancers undergoing radiation with or without concomitant chemotherapy
TYPE OF STUDY: Meta analysis and systematic review
PHASE OF CARE: Active antitumor treatment
Honey was significantly better in lowering the risk for treatment interruptions and probably less weight loss but did not decrease the rate of the peak mucositis score. The results for prolonged onset of mucositis is favorable with the honey intervention in two studies, but one study did not show a significant difference.
The results showed that the honey intervention is effective in reducing treatment interruption. Other measures (weight loss, peak mucositis score, time to mucositis) need further meta-analysis to establish. Further well-designed research is needed to confirm the usefulness of honey preparations.
Coyne, P.J., Wan, W., Dodson, P., Swainey, C., & Smith, T.J. (2013). A trial of Scrambler therapy in the treatment of cancer pain syndromes and chronic chemotherapy-induced peripheral neuropathy. Journal of Pain and Palliative Care Pharmacotherapy, 27, 359–364.
To evaluate the effectiveness of Scrambler therapy on cancer pain, chemotherapy-induced peripheral neuropathy, neuropathic pain, and quality of life
Scrambler therapy is cutaneous electrostimulation that blocks the effect of pain information on the cutaneous nerves. In this study, all participants received the intervention to the affected area for 45 minutes daily for 10 consecutive days (Monday–Friday). Pain was measured before and after each intervention session.
Improvement in pain was found at all secondary endpoints (days 14, 30, 60, 90), with a statistically significant difference in pain between baseline and day 30 (p = 0.0049) and change over time (p = 0.0002). Sensory and motor components of the chemotherapy-induced peripheral neuropathy scale also were found to improve with statistically significant sensory improvement between baseline and day 30 (adjusted p = 0.0007) and change over time (p < 0.0001). For the motor component, significant findings included improvement between baseline and days 14, 30, and 60 (adjusted p = 0.0143, 0.1035, 0.0094, respectively) and change over time (p = 0.0019). Improvements in all components of the Brief Pain Inventory were found (i.e., “interference with normal life,” which were maintained for mood, sleep, relationships, etc). Pain interference with walking was improved significantly between baseline and day 30 (p = 0.0003). Use of opioids did not change.
Scrambler therapy improved acute and chronic pain among patients with cancer. Additionally, it had a lasting effect three months post-treatment. Quality of life also was improved with this pain treatment. Further study is needed to determine generalizability of these findings to other patients with cancer.
Scrambler therapy appears to be a promising intervention for cancer-related pain and has no adverse effects. Because who delivers this treatment and its expense are unclear from this article, the implications to nursing are unclear. However, nurses knowing about this treatment is important because it may become a common method for treating cancer-related pain in the future.
Coyne, P. J., Viswanathan, R., & Smith, T. J. (2002). Nebulized fentanyl citrate improves patients’ perception of breathing, respiratory rate, and oxygen saturation in dyspnea. Journal of Pain and Symptom Management, 23, 157–160.
To test the theory: \"Inhaled opioids usually are ineffective with report of respiratory depression; however, fentanyl may be more readily absorbed with less bronchospasm and thus relieve dyspnea.\"
Patients were given 25 mcg of fentanyl with 2 mL of saline via a nebulizer.
The study used a convenience sample, uncontrolled design.
Fentanyl improved all three measures and may offer substantial relief of dyspnea. No significant side effects were reported.
Clinical questions about repeated dosing and method of administration (mask or mouthpiece) remain.
Coyle, V.M., Lungulescu, D., Toganel, C., Niculescu, A., Pop, S., Ciuleanu, T., … Wilson, R.H. (2013). A randomised double-blind placebo-controlled phase II study of AGI004 for control of chemotherapy-induced diarrhoea. British Journal of Cancer, 108, 1027–1033.
To examine the effectiveness of the use of a controlled-release transdermal patch preparation of mecamylamine (AG1004)
Patients who had received at least one cycle of chemotherapy and experienced grade 1 or 2 diarrhea were randomized to receive transdermal mecamylamine (AG1004) 4 mg every 24 hours or placebo using an identical-looking patch. The patch was applied 24 hours prior to chemotherapy and reapplied daily for the duration of the treatment cycle. Patients were allowed to use loperamide, codeine phosphate, or octreotide on a rescue basis for any active episodes of diarrhea. During the next cycle, the AG1004 dose was increased to 8 mg per day. Evaluation was done at the end of the first day of each cycle and at the end of the overall cycle of chemotherapy. Daily logs were used to record bowel movements and use of rescue medication.
This was a multisite, outpatient study conducted in the United Kingdom and Romania.
This was a double-blind, randomized, placebo-controlled study.
AG1004 was associated with less diarrhea compared to placebo on day one of chemotherapy cycles and did not appear to have significant adverse effects. AG1004 may be helpful in preventing chemotherapy-induced diarrhea.
The sample size was small with fewer than 100 participants.
This study demonstrated some promising results, suggesting that treatment with AG1004 may be useful in preventing chemotherapy-induced diarrhea in patients being treated for cancer with agents known to be associated with diarrhea. Further research is warranted to confirm these findings.
Cowan, C.C., Hutchison, C., Cole, T., Barry, S.J., Paul, J., Reed, N.S., & Russell, J.M. (2011). A randomised double-blind placebo-controlled trial to determine the effect of cranberry juice on decreasing the incidence of urinary symptoms and urinary tract Infections in patients undergoing radiotherapy for cancer of the bladder or cervix. Clinical Oncology, 24, e31–e38.
The purpose of this study was to evaluate the effectiveness of cranberry juice on the incidence of urinary tract infections and urinary symptoms in patients undergoing pelvic radiotherapy for cancer of the bladder or cervix.
Participants were randomized to receive cranberry juice, twice a day (morning and night) for the duration of their radiotherapy treatment and for two weeks after treatment (six weeks in total) or a placebo beverage, for the same duration. The primary study end point was the percentage of patients who experienced an increase in the Common Toxicity Criteria (CTC) grade of their urinary symptoms or developed a urinary tract infection during the period of six weeks. The laboratory diagnosis of a urinary tract infection was based on a significant isolate of a single organism (i.e., 100,000 ml or heavy growth) in a non-catheterized patient and/or other abnormal findings, such as pus cells in the urine with or without subjective symptoms. Patients were required to provide weekly urine samples and to keep a daily diary to record their bladder symptoms and compliance with drinking the juice.
A single-site outpatient setting in Scotland
Acute treatment
Randomized, double-blind, placebo-controlled trial
The incidence of increased urinary symptoms or urinary tract infections was 82.5% in the cranberry juice group and 89.3% in the placebo group (p = 0.24, adjusted odds ratio [cranberry/placebo] 0.48, 95% CI [0.14, 1.63]).
This study did not provide support for effect of cranberry juice for prevention of urinary tract infections in this group of patients.
This study did not support effectiveness of drinking cranberry juice for prevention of urinary tract infections in patients receiving pelvic irradiation. The study had multiple limitations. No conclusions can be drawn from this study report due to limitations and small sample size.
Courneya, K.S., Segal, R.J., Gelmon, K., Reid, R.D., Mackey, J.R., Friedenreich, C.M., . . . McKenzie, D.C. (2007). Six-month follow-up of patient-rated outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy. Cancer Epidemiology, Biomarkers and Prevention, 16, 2572–2578.
Primary aim: To determine if prior research findings of improvement in patient outcomes with exercise during adjuvant chemotherapy would be maintained at six-month follow-up
Secondary aim: To determine if patients who reported regular exercise during the follow-up period would report better outcomes at six-month follow-up
Participants who had initially been in a three-armed randomized controlled trial were recruited to participate in this study. Prior study groups were aerobic exercise, resistance exercise, and control. Exercise groups were supervised. Participants were mailed questionnaires to determine the frequency of exercise and to rate their quality of life, self-esteem, fatigue, anxiety, and depression. Participants were asked to recall their exercise of the past six months using a questionnaire, and were then categorized into meeting or not meeting current guidelines for aerobic exercise (>/= 60 minutes of vigorous or 150 minutes of moderate exercise per week).
Patients were undergoing the transition phase of care after initial treatment.
This was a descriptive study for follow-up from a previous randomized controlled trial.
Of the sample, 20.9% reported meeting both aerobic and resistance exercise guidelines, 8% reported meeting only resistance exercise guidelines, 28.9% reported meeting only aerobic guidelines, and 42.3% reported not meeting any exercise guidelines. Those who originally were in a group given supervised aerobic exercise training (AET) had fewer reporting that they met exercise guidelines during follow-up (p = 0.034). Those who had received resistance exercise training (RET) reported higher self-esteem at six months (p = 0.032). The AET group reported significantly lower anxiety at six months than either the control or RET group members (p = 0.049). All other changes in self-reported outcomes at six months favored the exercise groups, but were not statistically significant. Those who reported that they met exercise guidelines reported higher quality of life (p = 0.025) and less fatigue (p = 0.013). They also reported less anxiety, but this difference was not significant. At six months, those in the AET group reported that anxiety was lower by 4.7 points and depression was reduced by 2.7 points.
Exercise training during chemotherapy treatment may have longer-term effects on anxiety and self-esteem. Consistent exercise meeting recommended guidelines appears to benefit patients in terms of a positive effect on symptoms of fatigue and general quality of life.
Findings suggest that ongoing exercise according to guidelines appears to have positive effects on patients’ quality of life, fatigue, anxiety, and self-esteem. Nurses can educate patients about these potential benefits.
Courneya, K.S., Segal, R.J., Mackey, J.R., Gelmon, K., Friedenreich, C.M., Yasui, Y., . . . McKenzie, D.C. (2014). Effects of exercise dose and type on sleep quality in breast cancer patients receiving chemotherapy: A multicenter randomized trial. Breast Cancer Research and Treatment, 144, 361–369.
To compare the effects and doses of a three-arm exercise trial to improve sleep quality in patients with breast cancer receiving active chemotherapy
The three-group design of the CARE trial compared the standard dose of 25–30 minutes of aerobic exercise (STAN) to higher doses of activity that included 50–60 minutes of aerobic exercise (HIGH) and 50–60 minutes of combined-dose of aerobic and resistance exercise (aerobic and strength training three times per week) (COMB). COMB strength training was part of the 50–60 minute session and included two sets of 10–12 repetitions of nine different strength exercises at 60%–75% of the estimated one-repetition max (RM). All groups received three weekly treatments with outcomes measures to determine primary and secondary outcomes. Interventions continued for the duration of chemotherapy. Data were collected at baseline, midpoint 1, midpoint 2, and postintervention.
Blinded, randomized, controlled trial
296 patients completed the study with complete data. Baseline global sleep scores were M = 6.2 (SD = 4.1) with 52% of participants reporting poor sleep at baseline (PSQI > 5). The main effects of the study showed that the HIGH group had statistically better outcomes compared to the STAN group for primary sleep global scores (d = 0.22; p = 0.039), sleep quality (d = 0.26; p = 0.028), and sleep latency (d = 0.18; p = 0.049). The COMB group barely scored significantly higher than the STAN group for global sleep quality, sleep duration, and sleep efficiency (d = 0.24; p = 0.04) and percent of poor sleepers (d = 0.20; p = 0.045). The HIGH group was statistically better than COMB for sleep latency only (d = 0.20; p = 0.04) . Significant moderators included surgery, baseline aerobic fitness, baseline aerobic exercise guidelines, baseline strength guidelines, and number of comorbid conditions. The effect size for the HIGH group compared to the STAN group was larger for global sleep quality for lumpectomy patients with no comorbid conditions, those meeting aerobic exercise guidelines, and those who were fitter at baseline. Scores in the COMB group were higher than those of the STAN group for lumpectomy patients meeting strength exercise guidelines. The overall effect for each arm was small.
Higher doses of exercise and the combination of exercise and strength training were associated with better overall sleep quality compared to the standard dose of 50–60 minutes of aerobic exercise. Different sleep components appeared to be most affected by the type of exercise intervention, and no single intervention impacted all the sleep components measured.
Nurses often suggest maintaining activity during treatment, but there is little information about the effectiveness of this recommendation on sleep-wake disturbances. This study provided a large sample of patients with breast cancer that narrowed down the doses needed to affect sleep. The overall results of this study suggest that exercise can improve sleep during chemotherapy treatment. However, the limitations of this study need to be taken into consideration before recommending the actual interventions used.
Courneya, K.S., Sellar, C.M., Trinh, L., Forbes, C.C., Stevinson, C., McNeely, M.L., . . . Reiman, T. (2012). A randomized trial of aerobic exercise and sleep quality in lymphoma patients receiving chemotherapy or no treatments. Cancer Epidemiology Biomarkers & Prevention, 21, 887–894.
To test the hypothesis that aerobic exercise would be better than usual care for improving sleep quality, and to examine potential moderators of intervention effects
Patients were stratified by lymphoma type and whether the patient was receiving chemotherapy and then randomized to receive the exercise intervention or usual care. The intervention consisted of supervised aerobic sessions three days per week for 12 weeks. Prescriptions for unsupervised exercise were provided for patients who were unable or unwilling to attend supervised sessions, and these sessions were not counted in adherence evaluation. Usual care patients were asked to not change baseline exercise habits and were offered supervised exercise after final study assessments.
Aerobic exercise resulted in a small (d = -0.19) but not significant improvement in global sleep quality. In the intervention group, the exercise program improved global sleep quality in patients receiving chemotherapy (p = .013), but not for those who were off therapy. Exercise improved global sleep quality in those who were poor sleepers at baseline (p = .007), but not in those who were good sleepers at baseline. Analysis further showed that positive effects of exercise were seen in patients with shorter time since diagnosis, patients who were obese, and patients who had less aggressive disease.
Aerobic exercise did not significantly improve sleep quality in this study of patients with lymphoma. Exercise appeared to have some benefits for sleep quality in individuals who were in active treatment.
Findings show that overall, participation in aerobic exercise does not improve overall sleep quality in patients with lymphoma. Some benefit may exist for patients during chemotherapy treatment and for individuals who have baseline poor sleep quality. For these types of patients, nurses should consider suggesting aerobic exercise or providing exercise prescriptions.
Courneya, K. S., Friedenreich, C. M., Sela, R. A., Quinney, H. A., Rhodes, R. E., & Handman, M. (2003). The group psychotherapy and home-based physical exercise (group-hope) trial in cancer survivors: physical fitness and quality of life outcomes. Psycho-Oncology, 12, 357–374.
Patients were randomized to receive either 10 weeks of group psychotherapy and exercise (home-based, moderate intensity, 20 to 30 minutes, three to five times per week, and tailored across the intervention to promote progression toward the goal of achieving a heart rate during exercise of 65% to 75% of the estimated heart rate maximum) or group psychotherapy only. The group psychotherapy intervention consisted of stress management and relaxation training or expressive supportive therapy. Both group psychotherapy interventions had a psychoeducational focus. Patients in the group psychotherapy only arm received a personalized exercise plan after study completion. To control for possible contamination between the experimental conditions, groups of patients who had registered for a group psychotherapy program at a large cancer center, rather than individual patients, were randomized.
Patients were undergoing the active treatment and long-term follow-up phases of care.
This was a randomized, controlled trial with a crossover for the control group receiving group psychotherapy alone.
Functional Assessment of Cancer Therapy–Fatigue (FACT-F)
No difference existed between expressive supportive therapy and stress management and relaxation therapy in group psychotherapy effect in either group. Group psychotherapy and exercise improved quality of life beyond group psychotherapy only in cancer survivors (active treatment and long-term follow-up). The group psychotherapy intervention did not significantly reduce fatigue; however, the addition of moderate-intensity exercise resulted in a statistically significant improvement in fatigue.