To identify and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical care to a family member with cancer

• PsycINFO, Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid MEDLINE, CINAHL, DARE (Database of Abstracts of Reviews of Effectiveness), related systematic and other reviews, and reference lists from published articles were used for the search. Only English-language articles in the databases were reviewed.
• Key words were cancer, intervention, program(me), evaluation, research, physical/practical care, needs, skills, home care, palliative care, end of life care, terminal care, cancer care, symptom management/control, skills, family (including spouse, husband, wife, partner), carers, caregivers, lay carers, and family support.
• Inclusion criteria were studies with male or female adults (age 18 or older) who provided care to family member with cancer; literature using family, family member, or significant other; and the carer was expected to live in the home with the patient to provide care.
• Literature on caregiver bereavement interventions was excluded.

The number of studies initially reviewed was not reported.

After an initial search and crossing of search terms addressing physical (practical) care by carers of patients with cancer, the final tally of 19 studies met the following inclusion criteria: the study reported on an empirical study or program development; focused on carers of a family member with cancer; reported on the development and/or evaluation of an intervention to help carers provide physical care to a family member with cancer; and appeared in the literature between 1990 and June 2008. A critical consideration of article quality occurred by comparing articles to recommendations developed by three published authors, but formal quality scoring was not undertaken.

Initial search terms seemed to be too broad, overlapping, and perhaps unclear to initiate the study. The authors desired to distinguish between physical and psychosocial care of carers, but many studies blended the two types of care as interventions. Studies were not scored on quality of research design due to the authors’ desire to focus on the content of the interventions in a narrative review.

• The report included 19 interventional studies.
• The total sample was 3,286 caregivers, with a sample range across studies of 34–750 caregivers.
• The sample was comprised of older adult patients with cancer and patients with end-stage cancer and their partners (patient/caregiver dyads).

The authors found four categories of intervention that allowed family carers to provide physical/practical care of a family member with cancer (one study): (a) interventions that included skills training for the caregiver (nine studies), (b) interventions to improve care through managing symptoms (five studies), (c) interventions with a problem-solving focus, and (d) interventions with a learning focus (four studies).

• Some studies of interventions for managing symptoms indicated some benefits to patients and/or caregivers.
• Interventions using problem-solving processes showed promise of benefit.
• To what degree educational interventions addressed physical or practical care, and how this influenced outcomes, was not clear.

The authors noted significant variability among included studies of terms defining the cancer experience (stage of cancer, point in cancer trajectory, type of cancer), specificity of the intervention, and measurement of distinct outcomes. This variability influenced the authors’ ability to interpret beneficial physical (practical) interventions for caregivers and patients. Furthermore, this variability, as well as limited article text that clearly specified the intervention, diminishes the ability to replicate those studies for further clarity on valuable caregiver interventions. The authors also admit to the complexity of dividing carer physical and psychosocial care for a family member with cancer, but believe such a division is important because of the limited literature on the physical role of carers.

The reality is that most carers learn “on the job” about ways to effectively care for a loved one. One might question the possible overlap of the four categories of interventions developed by the authors: they seem to address the urgent need for carer teaching and learning to meet both patient and carer needs. Realities in the United States (e.g., limited patient time with managed care, early patient discharge from acute agencies, push for more home care) may provide barriers to such teaching and assessment of carer learning. However, data from this narrative review support a mandate for nursing assessment of carer learning needs and then nursing follow-through to teach carers at each patient clinical encounter for the present cancer experience. With disease progression and even a changed carer/patient relationship, continued nursing assessment and teaching intervention can improve the quality of life for that carer/patient dyad. This review identifies a need for development and evaluation of well-defined interventions of practical skills. Given the range of needs of patients with cancer and carers, much of this work will need to address specific problems at particular points in the disease trajectory.

• FINAL NUMBER STUDIES INCLUDED = 12, 9 studies in meta-analysis
• TOTAL PATIENTS INCLUDED IN REVIEW = 846
• SAMPLE RANGE ACROSS STUDIES: 16–222
• KEY SAMPLE CHARACTERISTICS: Most had head and neck cancer or a hematopoietic cell transplantation.

PHASE OF CARE: Active antitumor treatment

The incidence of mucositis was less with chlorhexidine. Across all studies, the relative risk (RR) ranged from 0.097–0.771 in favor of chlorhexidine (p = 0.05), with an overall RR of 0.899 (95% confidence interval [0.656, 1.232]). The findings for severity of mucositis were mixed.

Chlorhexidine was not associated with reduced severity of mucositis. There was a trend toward lower incidence of mucositis with chlorhexidine.

• Mostly low quality/high risk of bias studies
• High heterogeneity
• Grade of mucositis not considered in analysis

There are overall mixed findings about the effects of chlorhexidine oral rinses on chemotherapy- and radiation therapy–induced mucositis, with limited evidence in each of these subgroups. It appears that chlorhexidine is not useful for the treatment of mucositis but may have some role in prevention.

To investigate the effects of an exercise prescription on fatigue, anxiety, depression, and quality of life in patients with breast cancer receiving adjuvant therapy and to explore the relationships between the volume of targeted exercise and the effects observed on these psychological outcomes.

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: MEDLINE, PsycINFO, Pascal, PSYarticles, and Cochrane

KEYWORDS: anxiety, breast cancer, depression, exercise, fatigue, and quality of life

INCLUSION CRITERIA: Participants were adult women diagnosed with breast cancer. Studies had a randomized, controlled experimental design. Intervention programs involving physical activity (yoga-based) were included, whereas relaxation-based interventions were not. An intervention program was scheduled during adjuvant cancer therapy (chemotherapy and/or radiotherapy). At least one psychological outcome among fatigue, anxiety, depression, and quality of life was observed. Pre- and post-intervention data were included to calculate standardized mean differences.

EXCLUSION CRITERIA: Not given

TOTAL REFERENCES RETRIEVED: N = 1,011

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: A quality score based on 10 methodologic criteria specifically chosen for the evaluation of exercise intervention randomized controlled trials and mostly derived from the PEDro scale was calculated for each included study. Targeted exercise volume was estimated using metabolic equivalent for task (MET), where 1 MET accounts for 3.5 ml O₂/kg/min. Corresponding MET values for a given exercise intervention were coded from the Compendium of Physical Activity. Five and 3.8 METs were, respectively, assigned to moderate- and low-intensity aerobic physical activity; strength-training physical activity was coded 3.5 METs; warm-up and cool-down were estimated 2.5 METs if no more detail related to their content was provided; yoga and stretching activities were coded 2.5 METs.                                                        

• N (studies) = 17
• TOTAL PATIENTS INCLUDED IN REVIEW: 748 subjects, 632 controls
• KEY SAMPLE CHARACTERISTICS: The median age of included patients was 50.5 years old. All patients with breast cancer had been diagnosed with nonmetastatic cancer and were undergoing adjuvant therapy (i.e., chemotherapy and/or radiotherapy during exercise intervention).                                                                                                                     

The methodologic quality of the studies had a median score of 7, ranging from 2–9.

PHASE OF CARE: Active anti-tumor treatment

Controlled comparisons of pre- and post-intervention indicated that exercise intervention significantly reduced fatigue, anxiety, and depression, but only borderline significance was reached for anxiety (P = 0.06). Moreover, exercise intervention significantly improved quality of life. Findings showed that higher dose and duration of exercise targets had greater effectiveness. Effect sizes were modest. When low-quality studies were eliminated, effects for fatigue no longer were significant.

Adapted physical activity programs can be expected to decrease fatigue and depressive symptoms and increase quality of life during chemotherapy and/or radiotherapy for patients with early-stage breast cancer. Reduction in anxiety symptoms also was observed, but the evidence still is limited.

A limitation of the study was the estimation of exercise dose. Targeted aerobic exercise intensity frequently was described within a range such as 50%–80% of the maximal heart rate, which did not enable considering it precisely. Except when it was explicitly stated as light or vigorous, intensity was considered moderate for dose calculation. Only targeted exercise doses were estimated instead of achieved exercise doses.

Exercise intervention may improve fatigue, depression, and quality of life in patients with breast cancer receiving adjuvant therapy, with findings suggesting that a prescription of relatively low doses of exercise (less than 12 MET h/week) consisting of about 90–120 minutes of weekly moderate physical exercise seems more efficacious in improving fatigue and quality of life than higher doses.

To study postmastectomy lymphedema using low-level laser therapy (LLLT).

The control group received a placebo with one block of sham therapy followed by an eight-week period of rest and then one week of LLLT. The study group received two blocks of LLLT separated by an eight-week period of rest.

• The study sample (N = 61) was comprised of female patients who were randomized to the control group (n = 28) and the study group (n = 33). 
• Patients were included in the study if they were aged 18 years or older, female, and had clinically manifested postmastectomy. 
• Patients were excluded from the study if they had current metastases, a history of severe trauma to the arm, instability of condition, or cellulitis within past three months.
• Lymphedema was defined as a greater than 200 ml difference between arms. 

The study took place in Australia.

The study used a double-blind, randomized, placebo-controlled trial design, with 30 weeks of follow-up measurements.

• Objective measurements were taken at the beginning and end of every session.
• Perometry measured limb circumference.
• Bioimpedence provided an objective measure of fluid distribution.
• Tonometry provided indication of the compliance of the skin.
• Data were analyzed using analysis of variance and multiple regressions; p < 0.05 was determined using t-tests.

There was no significant effect of placebo treatment or just one cycle of LLLT treatment on mean affected limb volume. There was no significant decrease in limb volume immediately after two treatments of LLLT. Limb volume at three months after two LLLT treatments were significantly less than after placebo treatment (p < 0.017). Limb extracellular fluid (ECF) was significantly decreased in placebo and with one treatment of LLLT; however, the mean ECF was most reduced after two LLLT cycles. Significant decreases in tonometry readings (indicating increased tissue hardness) were noted in patients treated with placebo or one LLLT. Participants receiving two LLLT cycles had an increased tonometry reading, which indicates softening of the tissues. There was no significant effect on range of motion.

Two cycles of LLLT improved the condition of the lymphedema-affected limbs.

• The study sample was small.
• Special training is required.
• Use of laser makes costs higher.

The guidelines, which relate to the use of opioids to treat cancer pain, are the result of revision of previous European Palliative Care Research Collaborative guidelines.

• In the development of the revised guidelines, collaborators assigned 22 topics to groups of reviewers, who completed the systematic review using a standardized method. The evidence profile of each relevant outcome was reviewed and became the basis of the final recommendations. The Scientific Advisory Board of the European Palliative Care Research Collaborative and the Board of Directors of the European Association for Palliative Care reviewed the recommendations. Upon revision, the recommendations were again distributed to the groups for comment and/or approval.
• The data search completed in connection with the project was a systematic retrieval of randomized and nonrandomized trials and meta-analyses that
  • Involved adults with chronic cancer pain
  • Contained data on efficacy, side effects, and the treatments considered
  • Described outcomes.
• Databases searched were MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).
• Search keywords were terms relevant to each outcome. Outcomes related to the following: World Health Organization (WHO) step II opioids, WHO step III opioid of first choice, opioid titration, role of transdermal opioids, role of methadone, opioid switching, relative opioid analgesic potencies, alternative systemic routes of opioid administration, opioids for breakthrough pain, treatment of opioid-related emesis, treatment of opioid-related constipation, treatment of opioid-related central nervous system symptoms, use of opioids in patients with renal failure, role of paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in addition to step III opioids, role of adjuvant drugs for neuropathic pain (antidepressants and anticonvulsants), and spinal route of opioid administration.
• Studies were excluded if they dealt with the role of opioids in liver failure and the use of opioid combinations. (Data were of insufficient quality to support a recommendation regarding these topics.) Reviewers excluded a literature review regarding the treatment of opioid-related constipation; its content completely overlapped that of a Cochrane review. The role of ketamine was not included because resources to complete the work were unavailable.
• Authors made 16 recommendations based on evidence profiles.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for palliative care, late effects and survivorship, and elder care.

Findings are submitted as a general framework to help clinicians make informed decisions regarding cancer pain management.

• Data reveal no differences regarding the use of morphine, oxycodone, and hydromorphone; any can be used as step III treatment.
• Guidelines include a weak recommendation regarding oral opioids:
  • Immediate- and slow-release oral opioids can be used for dose titration.
  • Transdermal fentanyl and buprenorphine are step III alternatives, and some patients may prefer them.
  • Methadone can be used as a step III opioid but only by experienced providers, given its complex pharmacokinetic profile.
• Guidelines include a weak recommendation regarding patients who are not getting adequate analgesia: These patients may benefit from opioid switching.
• Guidelines include strong recommendations regarding route of administration:
  • The subcutaneous route should be the first choice when alternate routes of administration are needed.
  •  Breakthrough pain can be managed with oral, immediate-release opioids or buccal or intranasal fentanyl.
• Guidelines include a weak recommendation about additions to step III opioids: Add NSAIDs or paracetamol to step III opioids. However, guidelines note that efficacy is not well documented.
• Guidelines include a strong recommendation regarding neuropathic pain: Consider using amitriptyline or gabapentin for patients with neuropathic pain that is only partially responsive to opioids. 
• Guidelines include a weak recommendation regarding epidural and intrathecal opioids: Consider using an epidural or intrathecal opioid with a local anesthetic in cases of intractable pain or intolerable adverse effects.

• Pharmaceutical industry sponsorships were noted.
• The guidelines do not evaluate treatment costs.
• The process evidenced lack of consensus regarding methods of pain assessment.

Patients were given oral paroxetine/placebo 10 mg for one week pre-interferon treatment, paroxetine/placebo 20 mg during the first week of interferon treatment, and then paroxetine/placebo 20 to 40 mg for all subsequent weeks of interferon therapy. Total length of treatment with paroxetine was 12 weeks. The study was based on the hypothesis that, as a selective serotonin reuptake inhibitor (SSRI), paroxetine may improve the neuropsychiatric and neurovegetative symptoms associated with interferon-alpha treatment.

• The study included 38 patients (paroxetine group, n = 18; placebo group, n = 20); there were equal numbers of men and women.
• Mean age was 50 years (25–74).
• Most patients were married, and approximately 50% were college educated.
• Approximately 25% of the sample had a history of major depression.
• All patients were receiving a course of interferon-alpha consisting of 20 million units/m² five days per week for four weeks, followed by eight weeks of interferon-alpha at a dose of 10 million units/m² three days per week.

• Single site
• Major academic cancer center

Patients were undergoing the active treatment phase of care.

The study was a randomized, double-blind, placebo-controlled trial.

Neurotoxicity Rating Scale (NRS) was used to measure various depressive symptoms, cognitive disturbances, and vegetative symptoms, including fatigue.

When compared with the control group, pretreatment with paroxetine was effective in preventing interferon-induced mood and cognitive symptoms, as well improving pain. Paroxetine had less effect on the development of interferon-alpha–related neurovegetative symptoms, including fatigue, as measured by the NRS. Fatigue and somatic symptoms increased in both depressed and nondepressed patients.

Across the twelve weeks of the study, seven patients from the placebo group and one patient from the paroxetine group withdrew due to severe depression or neurotoxicity.

• The study had a small sample size.
• The study used an instrument with a single item to measure fatigue.
• The study used a wide, uncontrolled paroxetine dose range.
• The study excluded patients with a diagnosis of schizophrenia or bipolar disorder; a Mini-Mental State Exam (MMSE) of 24 or less; and uncontrolled neurological, cardiovascular, endocrine, hematologic, hepatic, or renal disease.

No special training is required. There are costs related to drug acquisition.

To evaluate the efficacy of tropisetron in treating acute vomiting among children with solid tumors receiving chemotherapy

Tropisetron (5 mg for patients < 20 kg and 10 mg for patients > 20 kg) was given intravenously daily over 15 minutes 30 minutes before chemotherapy administration. No other antiemetics were given except for steroids in three patients with Hodgkin lymphoma and two patients with non-Hodgkin lymphoma. Data were collected hourly in the first 24 hours following chemotherapy.

• N = 50   
• MEDIAN AGE = 5.8 years (range = 6 months to 19 years)
• MALES: 27 (54%), FEMALES: 23 (46%)
• KEY DISEASE CHARACTERISTICS: Central nervous system tumor, retinoblastoma, neuroblastoma, and chondrosarcoma (n = 30); Wilms tumor (n = 7); rhabdomyosarcoma (n = 4); Hodgkin disease (n = 3); non-Hodgkin lymphoma (n = 2); Ewing sarcoma (n = 2); and hepatoblastoma (n = 2)
• OTHER KEY SAMPLE CHARACTERISTICS: All patients received either moderately or highly emetogenic chemotherapy.

• SITE: Not stated
• SETTING TYPE: Not specified    
• LOCATION: Not reported

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

Descriptive

• Antiemetic effects were monitored by nurses and patients.
• Effects were classified as total control (TC, absence of acute vomiting), major control (MC, one to two acute vomiting episodes), or no control (NC, three or more acute vomiting episodes). 

Overall frequency: TC was obtained in 154 out of 189 chemotherapy courses (85%), MC in 7.5% of courses, and NC in 7.5% of courses.

Dosage: Patients who received greater than 8 mg/m² of tropisetron achieved TC significantly more often (92%) than patients receiving 6–8 mg/m² of tropisetron (78%) or 6 mg/m² (69%) (p = 0.0072).

Emetic potential: TC was achieved in 85% of patients receiving highly emetic chemotherapy, 81% of patients receiving moderately emetic chemotherapy, and 100% of patients receiving slightly emetic chemotherapy. NC was achieved in 6% of patients receiving highly emetic chemotherapy and 12% of patients receiving moderately emetic chemotherapy.  

Time of administration: TC was achieved in 91% of patients with initial chemotherapy while TC was achieved in 81% of patients who received an antiemetic medication for earlier chemotherapy (p > 0.05).

Age: The youngest age group (aged 0–5 years) achieved TC and MC 98% of the time while children aged 6–10 years achieved TC and MC 90.5% of the time and children aged greater than 10 years achieved TC and MC 84% of the time (p = 0.0235). Side effects of acute vomiting occurred immediately at the start of chemotherapy among one patient receiving tropisetron at 13.5 mg/m². 

Tropisetron was an effective antiemetic medication for pediatric patients receiving highly emetic chemotherapy. It was mostly effective for patients receiving moderately emetic chemotherapy. The medication was more effective in younger children (aged 0–5 years). The dosage should range from 8–12 mg/m² and be used with the initial chemotherapy course.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement/methods not well described

Tropisetron was an effective antiemetic medication that should be administered prior to the initial chemotherapy course.

To detect the optimal timing for the initiation of an exercise training intervention

This was a 12-week lifestyle intervention consisting of five components: physician referral and clinic support, health education, behavior change support, social support through group-based settings, and an individualized exercise program based on patient need. Patients were asked to attend exercise sessions twice a week with additional at-home implementation of the exercise regimen twice more per week. The individualized exercise programs consisted of progressive resistance-training programs with a short, moderate intensity warm-up followed by two sets of 8 repetitions for 10 exercises. Progression of the regimen occurred at weeks 4, 6, and 9, as appropriate. In addition to attending the exercise sessions, participants were required to attend six education sessions after their exercise sessions.

• N = 60   
• AGE = 56.1 years (SD = 9.2 years)
• MALES: 81.7%, FEMALES: 20.3%
• CURRENT TREATMENT: Chemotherapy, radiation, combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Head and neck cancer

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: University of Calgary

PHASE OF CARE: Multiple phases of care

The study design is a randomized, controlled exercise trial in which patients were randomly assigned to either the immediate lifestyle intervention (ILI) group or the delayed lifestyle intervention (DLI) group.

• Godin Leisure-Time Exercise Questionnaire
• Functional Assessment of Cancer Therapy (FACT)
• FACT-Anemia (FACT-An)
• FACT Head/Neck Symptom Index-22 (FHNSI-22)
• FACT-An Trial Outcome Index
• Center for Epidemiological Study Depression Scale (CESD)
• Patient-Generated Subjective Global Assessment (PG-SGA)
• Intervention survey
• Body composition, fitness, functional, flexibility tools

No significant differences were reported for lean body mass or percentage body fat during the 24 weeks. A main effect of time for lean body mass, body mass index, and percentage body fat was detected (lean body mass: F[2,74.5] = 54.141, p < 0.001; BMI: F[2,74.5] = 67.955, p < 0.001; percent body fat: F[2,74.5] = 29.679, p < 0.001). No between group statistical difference was detected for fitness outcomes, the six-minute walk test (6MWT), or the sit-to-stand test (SST), which may be because of the small sample size. No statistical differences were observed between the two groups’ quality of life during the 24-week period. A significant effect was observed on depression, but no associated difference was observed between study groups.

The intervention did not demonstrate an effect on patient outcomes.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable

This study did not show efficacy of an intervention involving exercise and supportive interventions. The findings are limited by study design aspects and sample size.

To observe the benefits of implementing an oral care protocol in the identification and treatment of stomatitis in patients with head and neck cancer receiving radiation and chemotherapy

Databases searched were CINAHL, the Cochrane Central Register of Controlled Trials, and Medline.

Search keywords were stomatitis, mucositis, mucous membrane, treatment protocols, clinical practice guidelines, radiation therapy, and chemotherapy.

A protocol was developed based on the literature. Nursing education was conducted regarding grading stomatitis based on World Health Organizaiton (WHO) guidelines and interventions for each grade. Patient education was developed regarding the key components of oral hygiene, along with creation of a stomatitis brochure. Chart audits were evaluated for a 20-day period pre- and post-intervention.

After protocol implementation, more cases of stomatitis were identified and stomatitis was identified at an earlier stage of severity.

Protocol use gives nurses the tools to identify high-risk patients and provide treatment.

Daily oral assessment and protocol use reduces the severity of stomatitis resulting in improved patient outcomes. This project could have been expanded and carried one step further by looking at both patients' and nurses' satisfaction and perceived effectiveness of the program.

To examine the effectiveness of an eight-week aquatic exercise program on cancer-related fatigue and physical and psychological outcomes in patients with breast cancer.

Patients were randomly assigned to exercise groups or usual care control groups. The intervention consisted of an eight-week program of water-based exercises, three times per week, in a heated deep swimming pool. Sessions lasted 60 minutes each and included a warm-up and cool-down. Exercise intensity was maintained according to recommendations for moderate exercise as stated by the American College of Sports Medicine and American Heart Association. Groups of 10 to 12 women participated in the exercise program. Data were collected at baseline, eight weeks, and six months.

• The sample was comprised of 61 participants.
• Mean participant age was 48 years.
• All participants were female.
• All participants had breast cancer. 
• The majority had undergone radiation and chemotherapy after surgery. 
• All had completed treatment other than ongoing hormone therapy.
• Of the participants, slightly more than 60% were married and 70% to 75% were postmenopausal.
• At baseline, all patients reported 32 to 38 minutes of activity per day. 
• All had completed treatment within the previous 18 months.

• Single site
• Outpatient
• Spain

Patients were undergoing the transition phase after active treatment.

This was a single-blind, randomized, controlled trial.

• Piper Fatigue Scale
• Profile of Mood States (POMS)
• Multiple sit-to-stand test
• Trunk curl static endurance test

• ANOVA showed a significant difference in all dimensions of fatigue and overall fatigue over time, between groups, with greater improvement in fatigue in the aquatic exercise group (p < 0.001). The overall effect size for total fatigue was d = 1.51 (95% confidence interval [CI] [1.13, 1.90]) at eight weeks. The overall effect size for severity of fatigue was d = 0.68 (95% CI [1.14, 1.22]). The intergroup effect size for total fatigue at six months was d = 0.87 (95% CI [0.48, 1.26]).
• Leg and abdominal muscle endurance for the sit-to-stand and abdominal curl tests was significantly higher in patients in the exercise group (p < 0.001).
• Groups showed a significant difference over time in favor of exercise (p = 0.029).
• The six-month follow-up revealed no effect of exercise on depression.

Deep-water exercise reduced fatigue, provided a short-term improvement in leg and abdominal muscle endurance, and resulted in some short-term reduction in depression. Effects on muscle endurance and depression declined after the eight-week program. Apparent effects on fatigue lasted six months.

• The study had a small sample size, with less than 100 participants.
• The study had a risk of bias due to lacking an appropriate attentional control condition.
• Unintended interventions or applicable interventions not described would influence results.
• The authors either did not know the components of patients' ongoing physical activities or did not describe them.
• The authors provided no information about adherence to the exercise program.
• The authors did not present an intention-to-treat analysis.
• The sample was very homogeneous, which limited the generalizability of the study.
• The authors did not address whether the exercise itself or involvement in group activity affected depression. 

The study adds to the large body of evidence showing the effectiveness of various types of exercise in the treatment of fatigue in patients with breast cancer. Nurses can recommend various types of exercise for their patients.