Review question:

Are exercise interventions effective in enhancing health-related quality of life (HRQoL) among adult, post-treatment cancer survivors?

Nursing Implications:

Due to early detection and effective treatment, many people survive a cancer diagnosis. However, it is common for this population to experience a long list of physical and psychosocial adverse effects such as anxiety, fatigue, pain, sexual dysfunction and sleep dysfunction. These effects, although not life threatening, are a relevant problem for nurses because they impact upon overall quality of life for this group of patients. Physical exercise has increasing been evaluated positively as an intervention that has widespread physical and psychological benefits for a growing number of cancer populations.

Study Characteristics:

This is a summary of a Cochrane systematic review. The review examined 40 randomised and quasi-randomised controlled trials of exercise interventions initiated after completion of active cancer treatment and involved 3,694 adult cancer survivors. The review included studies of participants over the age of 18 years of any gender and with any tumor site, tumor stage, or treatment history. Studies that included people who were terminally ill, receiving hospice care, or undergoing active treatment were excluded.

Exercise was defined as physical activity designed to maintain or enhance health-related outcomes involving a planned or structured movement of the body performed in a systematic manner in terms of frequency, intensity, and duration resulting in an increase in energy expenditure. Aerobic, anaerobic or combination exercise interventions were represented by prescribed programs of aquatic exercise, running, strength training, resistance training, walking, cycling, yoga, Qigong, Tai Chi, and Pilates. Interventions could be compared against no exercise, another intervention, or usual care that did not include an exercise program.  There were no requirements related to duration or intensity of exercise.

The outcome of interest was overall HRQoL (self-reported) or at least one HRQoL domain such as (but not limited to): anxiety, emotional well-being/mental health change, fatigue pain, sexuality, sleep disturbance, and social functioning.  Follow-up had to be reported at up to 12 weeks, more than 12 weeks but less than 6 months, 6 months and more than 6 months.

The findings of the review need to be interpreted with caution due to a high risk of bias. Due to the variation between studies in terms of the interventions utilised, their duration and intensity and outcome measures, meta-analysis was only undertaken where possible. The authors of the review chose to use the most commonly used instrument to include in the Standardised Mean Difference (SMD) meta-analyses.

Summary of Key Evidence:

When exercise interventions were compared to controls, there was a statistically significant benefit in favour of exercise on:

• global HRQoL at 12 weeks (SMD 0.48; 95% confidence intervals (CI) 0.16 to 0.81) in 11 trials and at 6 months follow-up (SMD 0.46; 95% CI 0.09 to 0.84) in 2 trials.
• breast cancer concerns at 12 weeks to 6 months follow-up (SMD 0.99; 95% CI 0.41 to 1.57, 1 trial).
• body image between 12 weeks and 6 months (SMD -0.74; 95% CI -1.30 to -0.18, 1 trial) and more than 6 months follow-up (SMD -0.49; 95%CI -0.86 to -0.13, 1 trial).
• emotional well-being at 12 weeks’ follow-up (SMD 0.33; 95% CI 0.05 to 0.61, 8 trials).
• sexuality change at 6 months’ follow-up (SMD 0.40; 95% CI 0.11 to 0.68, 2 studies).
• sleep disturbance at 12 weeks’ follow-up (SMD -0.46; 95% CI -0.72 to -0.20, 8 studies).
• social functioning at 12 weeks’ (SMD 0.45; 95% CI 0.02 to 0.87, 5 trials) and 6 months’ (SMD 0.49; 95% CI 0.11 to 0.87 , 2 trials) follow-up.

When intervention follow-up values were compared by comparison group, the following statistically significant benefits were demonstrated:

• reduced anxiety at 12 weeks’ follow-up (SMD -0.26; 95% CI -0.07 to -0.44, 4 trials).
• decreased fatigue at 12 weeks’ (SMD -0.82; 95% CI -1.50 to -0.14, 10 trials and between 12 weeks’ and 6 months’ (SMD -0.42; 95% CI -0.02 to -0.83, 3 trials) follow-up.
• reduced pain at 12 weeks’ follow-up (SMD -0.29; 95% CI –0.55 to -0.04, 4 trials).

No significant results were demonstrated for cognitive function, general health, physical functioning, role function and spirituality.

Best Practice Recommendations:

This review extends the evidence in support of a wide range of exercise interventions, but due to a high risk of bias, results should be interpreted with caution. Healthcare professionals should recommend regular exercise to their patients particularly those whom experience anxiety, fatigue, sexual dysfunction, body image/self-esteem issues, sleep disturbances, emotional wellbeing and pain. Not all forms of exercise intervention have been evaluated for all quality of life domains, however, the positive evidence from the global HRQoL measures is moderately strong enough to indicate that many forms of exercise provide benefits. This suggests that individual patient preference and access should be strongly considered. Additional research is still indicated to further knowledge in relation to intensity and special groups.

Summary Author

Marilynne N. Kirshbaum, RN (New York), RGN (UK), BSc, MSc, PhD DipAdultOnc.
Reader in Nursing
University of Huddersfield
School of Human and Health Sciences
Huddersfield, West Yorkshire, UK

A member of the Cochrane Nursing Care Field (CNCF)