Cancer-Related Fatigue: Exercise and Psych Therapy Best

Roxanne Nelson, BSN, RN

March 02, 2017

UPDATED March 2, 2017 // Exercise and psychological interventions are effective methods for reducing cancer-related fatigue (CRF), according to the findings a new meta-analysis.

Used both during and after cancer treatment, these two interventions were significantly better than available pharmaceutical options, which were not associated with the same magnitude of improvement.

The study is published online March 2 in JAMA Oncology.

Fatigue related to cancer is one of the most common and disabling adverse effects experienced by patients during and after treatment and can persist for years after active therapy has ended.

The study authors note that several randomized clinical trials have examined the use of exercise, psychological, exercise plus psychological, and pharmaceutical interventions for the amelioration of CRF. However, while the results of these trials are promising, the "development and implementation of guidelines for clinical practice are challenging owing to the lack of a direct meta-analytic comparison of these 4 most commonly recommended behavioral and pharmaceutical treatments for CRF."

"Our evidence shows that exercise is the best treatment option for cancer-related fatigue, and so are psychological interventions," said lead author Karen M. Mustian, PhD, MPH, from the Wilmot Cancer Institute, University of Rochester Medical Center, New York. "This is somewhat contrary to what is often done."

Drugs are often the first-line choice, she told Medscape Medical News. "But these data show that the drugs we have currently studied are not as effective as exercise or psychological treatments."

Dr Mustian noted that their evidence does not address overall survival or any aspect of the disease itself. "It is only addressing what are the best available treatments we have for the debilitating fatigue that patients experience."

In the current study, Dr Mustian and colleagues conducted a meta-analysis to determine which of the four most commonly recommended treatments for CRF conferred the best results.

They analyzed 113 randomized clinical trials comprising 11,525 participants, with almost half (n = 53 [46.9%]) conducted in breast cancer.

Fifty of the studies (44.2%) enrolled patients with nonmetastatic cancer, 11 (9.7%) included those with metastatic disease, and 33 (29.2%) included both categories. The remaining studies did not provide staging information.

Overall, they found significant moderate improvements in CRF (weighted effect size [WES], 0.33; P < .001) across all studies included in their analysis. This was true for all four types of interventions that were examined.

The largest overall improvement in CRF was seen with studies that used exercise, with significant moderate effects (WES, 0.30; P < .001). Studies using psychological interventions also exhibited similar improvements in CRF (WES, 0.27; P < .001).

The combination of exercise plus psychological interventions was also effective and showed results similar to those seen with the two modalities used alone (WES, 0.26; P < .001).

Conversely, pharmaceutical interventions also yielded significant improvements, but they were very small (WES, 0.09; P = .05).

When all four interventions were compared, exercise, psychological, and exercise plus psychological interventions produced significantly greater improvements in CRF compared with pharmaceutical interventions.

Variables Play Role

Dr Mustian and colleagues also assessed 15 variables and how they were associated with the effectiveness of the different interventions.

They found that intervention effectiveness was associated with 8 of the variables: cancer stage (nonmetastatic, metastatic, or mixed), treatment status at baseline (during primary treatment, after primary treatment, and mixed), experimental treatment format (group or individual), primary delivery mode of experimental treatment (in-person, in-person plus other, or no in-person contact) psychological mode (psychoeducational, cognitive-behavioral, or eclectic), type of control condition, use of intention to-treat analysis, and fatigue scale used.

All patients and survivors included in the studies reported improvements in CRF, but those with early-stage disease and patients who had completed primary therapy reported the greatest benefit.

As for the types of exercise used by patients, Dr Mustian pointed out that current data suggest that both aerobic and anaerobic exercise work equally well. "Modes like walking, resistance training, yoga, and so on all seem to work well," she said.

The most effective mode of psychological intervention for reducing CRF was cognitive-behavioral therapy, she said. "But psychoeducational and eclectic therapy all worked."

For exercise, both aerobic and anaerobic exercise interventions were equally effective, and patients who were still receiving primary treatment seemed to derive the most benefit.

A growing body of evidence supports the premise that regular physical activity may play a protective role and decrease the risk for many types of cancer. Exercise may also temper the adverse effects of treatment and help in recovery and rehabilitation when cancer therapy has ended, and some data show that it is safe and beneficial for patients with breast and prostate cancer who are undergoing active treatment.

In addition, two studies showed that cancer survivors who are physically active not only reduce adverse effects from chemotherapy but improve their health-related quality of life.

But despite the evidence, clinicians are not prescribing exercise and psychological therapy, and it is "not as common as it should be," said Dr Mustian. "Pharmaceuticals are still often the first choice of providers and patients despite the better effects of the other modalities."

The study was funded by grants from the National Cancer Institute. The authors have disclosed no relevant financial relationships.

JAMA Oncol. Published online March 2, 2017. Abstract

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