Seminars in Oncology Nursing, Vol 23, No 4 (November), 2007: pp 285–296
285
OBJECTIVE: To review the evidence of the effects of exercise interventions in patients with cancer in each of four quality-of-life domains: physical, psychological, social, and spiritual.
DATA SOURCES: Research articles, abstracts, literature review.
CONCLUSION: There is strong evidence to support positive effects of exercise on physical and psychological well-being. Exercise improves physical function, muscle strength, emotional well-being, self esteem, decreases fatigue, anxiety, and depression, and helps maintain weight. Data suggest exercise fosters social functioning and more research is needed on the relationship of exercise and spiritual well-being.
IMPLICATIONS FOR NURSING PRACTICE: There is sufficient evidence to support exercise as an intervention to enhance a cancer patient’s physical functioning and psychological well-being. Nurses should be encouraged to integrate physical activity recommendations into practice, tailored to the individual’s health condition and mutual goal setting.
KEYWORDS: Quality of life, physical activity, exercise, functional ability, psychosocial well-being M. Tish Knobf, RN, PhD, FAAN: American Cancer Society Professor of Oncology Nursing, Yale University School of Nursing, New Haven, CT. Rita Musanti, RN, PhD, APN-C: Adult Nurse Practitioner, Cancer Institute of New Jersey, New Brunswick, NJ. Jennifer Dorward, RN, MSN, ACNP: Acute Care Nurse Practitioner, Team Health Inc, Emergency Department, Long Beach Veterans Administration Hospital, Long Beach, CA. Dr. Knobf was supported in part by the American Cancer Society Professor of Oncology Nursing grant and Dr. Musanti was supported in part by an award from the Greater NYC Affiliate of the Susan G. Komen Breast Cancer Foundation, Inc. Address correspondence to M. Tish Knobf, RN, PhD, FAAN, Yale University School of Nursing, 100 Church St South, New Haven, CT 06536-0740; e-mail:
[email protected] Ó 2007 Elsevier Inc. All rights reserved. 0749-2081/07/2304-$30.00/0 doi:10.1016/j.soncn.2007.08.007
EXERCISE AND QUALITY OF LIFE OUTCOMES IN PATIENTS WITH CANCER M. TISH KNOBF, RITA MUSANTI, AND JENNIFER DORWARD
C
ANCER is a major stressor for the patient, the family, and persons in the patient’s support network. Cancer treatment is associated with both physical and psychosocial stressors. The responses to these stressors are dependent on multiple factors such as the patient’s coping styles, adaptation skills, developmental stage, availability of supportive resources, stage of disease, and intensity of treatment. For survivors who receive curative intent therapy, the end of treatment and transition to survivorship is similarly associated with psychological stress (eg, uncertainty, fear of recurrence). This transition period is often accompanied by persistent physical symptom distress and patients may be at risk for late organ system effects. Across the trajectory of the cancer experience, physical and psychological stressors are inextricably related and affect patient outcomes. Clinical interventions need to be comprehensive in addressing the complexity of stressors that cancer patients face and factors that influence their adaptive response.1 Exercise has been identified as an intervention that can promote adaptation to the stress of cancer and the effects of cancer treatment during and after therapy. Physical activity (PA) in non-cancer populations has been associated with improved physical fitness, social functioning, self esteem, body image, mood, stress response; a decreased risk of heart disease, diabetes and cancer; and lower levels of psychological distress, specifically depression and anxiety.2-4 In cancer patients, physical exercise has resulted in improved physical functioning, cardiovascular fitness, sleep, quality of life (QOL), psychological and social well-being, and self esteem, and significant decreases in fatigue, anxiety, and depression.5-10 The purpose of this article is to review current research on QOL outcomes of
286
M.T. KNOBF, R. MUSANTI, AND J. DORWARD
exercise and to highlight the interrelatedness of the physical and psychosocial outcomes of exercise interventions in cancer survivors.
EXERCISE AND HEALTH-RELATED QUALITY OF LIFE IN CANCER PATIENTS
H
ealth-related QOL is a multi-dimensional construct that commonly includes four common domains: physical, social, psychological, and spiritual aspects of one’s life. QOL represents an individual’s subjective perspective. Multiple instruments are available for QOL assessments but they reflect varying conceptualizations and thus differ in what they measure.11,12 It is critical to understand what instruments measure to interpret the findings. Well-being and functional ability or status are indicators of QOL that can relate to the four common domains,12 yet instruments often combine or limit the constructs of well-being and function into the domains as subscales. Common examples of QOL instruments in cancer include the Functional Assessment of Cancer Therapy (FACT-G) instruments,13 which have well-being subscales; the Medical Outcomes Short Form Health Survey (MOS-SF36),14 which is based on functional ability (ie, physical function, role function subscales); and the EORTC-QL-30, which includes both functional scales and physical symptom scales.15 All of these instrument examples provide a total summated score, often described as global QOL, general well-being, or
overall QOL. Figure 1 illustrates the relationship of exercise interventions outcomes and QOL domains, reflecting the different descriptions of outcomes based on the instruments measuring global QOL and/or specific domains. Exercise interventions in cancer survivors are generally associated with positive QOL outcomes, although the strength of the evidence varies by global QOL outcomes versus measures reflecting specific domains, such as physical and psychological functioning (Table 1).16-40 In cross-sectional retrospective studies, those subjects who exercised reported better QOL than those who did not engage in exercise or who did not routinely exercise.16,17,25,30,31,34,37,41 The samples from these studies included both men and women and diagnoses of breast, colorectal, and gynecologic cancer and lymphoma. Similarly, the findings from prospective quasi-experimental study designs report improvement in overall QOL29,33 or improved physical and psychological well-being and functional ability.21,28 And, the more rigorous experimental studies with randomized designs report significantly improved QOL for the intervention versus control group subjects20,22,24,26,36,39 In contrast to the majority of studies cited above, there are three studies23,32,38 that did not report improved QOL outcomes associated with exercise. In a longitudinal observational study designed to examine the natural course of exercise participation in breast cancer survivors after therapy, 35% of the sample did not meet guidelines for PA over the 12 months of the study, and the
Quality of Life Domains Physical
Psychological
Improved • Function • Well-being • Muscle Strength • Cardiovascular Fitness • Weight Management
Improved • Emotional Function • Well-Being • Self Esteem • Feelings of Control
Decreased • Fatigue
Decreased • Anxiety • Depression • Mood Disturbance
Social
Improved • Role Function • Social Function • Life Satisfaction
Spiritual
Improved • Empowerment • Confidence
Decreased • Uncertainty
Inconclusive • Sleep • Immune Function • Metabolic Risk Factors
FIGURE 1. The effects of exercise on QOL domains in patients with cancer.
TABLE 1. Quality of Life and Exercise in Cancer Survivors Study
Sample
Design
Results Women who exercised had a significantly higher QOL than non-exercisers. Women that exercised before diagnosis were more likely to maintain an active lifestyle and exercisers reported fewer perceived barriers compared with non-exercisers. 1) Levels of exercise declined from prediagnosis to active treatment and then increased from active treatment to post treatment; 2) Exercise during active treatment was associated with a higher QOL and with overall life satisfaction; 3) Maintenance of exercise across three time periods was the optimal pattern for enhanced QOL. Increases in mild and moderate exercise were associated with increases in QOL at the 4-month follow-up.
Young-McCaughan & Sexton, 1991, Oncology Nursing Forum16
N ¼ 71 Breast cancer survivors 86% # 24 mo since diagnosis Mean age, 60.2 yrs (SD 12 yrs)
Retrospective design Cross-sectional
Self reported exercise, Quality of Life Index, Perceived Barriers to Exercise Scale
Courneya et al, 1997, Journal of Psychosocial Oncology17
N ¼ 167 Women under 70 who completed adjuvant therapy
Retrospective study
Godin Leisure Time Exercise Questionnaire, Functional Assessment of Cancer Therapy and Satisfaction with Life Scale
Prospective correlational design Mailed questionnaires (about 2 mo postsurgery with a 4-mo follow-up) Prospective correlational design One group 8-wk home-based intervention
Godin Leisure Time Exercise Questionnaire, Functional Assessment of Cancer Therapy-Colorectal, Satisfaction with Life Scale
Randomized trial: walking program vs usual care for women during adjuvant chemotherapy or radiation therapy
Piper Fatigue Scale; 12-min walk test; Medical Outcomes Short Form (Functional ability, QOL); Profile of Mood States
Courneya et al, 1999, N ¼ 53 colorectal cancer Psychology, Health & Mean age, 60.7 yrs Medicine18 (SD 11.1 yrs) 60% male, 45% retired Mean time since surgery, 54.6 days (SD 23.9 days) Schwartz, 1999, N ¼ 27 Quality of Life Mean age, 47 yrs Research19 55% sedentary at baseline Pre- (baseline before chemotherapy) and post-test (8 wks) Mock et al, 2001, N ¼ 50 Cancer Practice20 Mean age, 48 yrs 66% employed Early stage breast cancer Data collected at baseline, mid, and end of treatment
12-min walk; Profile Mood States; Quality of life declined during treatment but Schwartz Cancer Fatigue Scale; subjects who adopted the exercise program Quality of Life Index; Side Effect improved their functional ability and had less Symptom Checklist decline in QOL scores.
Women were categorized into two groups: low walk ( 90 min /wk). Women who walked at least 90 min $ 3 days/wk had lower mood disturbance, higher functional ability, and better QOL than those who were more inactive.
EXERCISE AND QOL OUTCOMES IN CANCER PATIENTS
Instruments
287
288
TABLE 1. Continued Sample
Design
Instruments
Results
Courneya et al, 2000, Psychooncology21
N ¼ 25 bone marrow transplant patients during hospital treatment (multiple diagnoses) Mean age, 47 yrs 52% male, 80% married
Prospective one-group correlational design Walking or cycling Baseline and weekly data collection
Burnham & Wilcox, 2002, Medicine Science Sports Exercise22
N ¼ 18 Breast and colon cancer Mean age, 53.6 yrs Mean time since treatment, 9.7 mos N ¼ 69 early stage breast cancer after therapy Mean age, 57.5 yrs Mean days since diagnosis, 247.3 days
Lower body aerobic exercise 3x/wk for 10 wks compared with control group 12 mo prospective longitudinal observational study; no intervention. Data collected at baseline and every 3 mo
Women did not increase participation in exercise Profile Mood States, Memorial over 12 mo and the average number of min of Symptom Assessment Scale, exercise was below recommendations for Duke-UNC Functional Social physical activity. Exercise was associated with Support Questionnaire, Medical improved physical functioning but not a predictor Outcomes Short Form Health of mood disturbance or global distress Survey, Coping Inventory, (symptoms). Exercise Participation
N ¼ 155 Prostate cancer on androgen therapy Mean age, 67.9 yrs Mean time since diagnosis, 871.5 days N ¼ 352 Adult cancer survivors Mean age, 59.6 yrs (SD 12.7 yrs) Mean time since diagnosis, 2.26 yrs (SD 3.2 yrs) N ¼ 53 Breast cancer survivors Mean age, 59 yrs (SD 6 yrs) Mean time since treatment, 14 mo (SD 6 mo)
Randomized control trial 12-wk resistance (3x/wk) intervention vs wait list control group
Functional Assessment of Cancer Therapy (Fatigue and Prostate Scales) Muscular fitness
Health-related QOL and fatigue significantly improved for subjects in the intervention group compared with those in the control group.
Cross sectional, correlational design questionnaires
Exercise participation, Satisfaction with Life Domains Scale
Subjects who exercised 3x/wk for 30 min (57%) had higher QOL. Similarly, survivors who maintained or increased their exercise after diagnosis had higher reported QOL than those who did not.
Randomized trial exercise group (3x/wk cycle ergometer for 15 wks) compared with control group
Functional Assessment of Cancer Therapy (Fatigue and Breast Scales) Happiness Measure Rosenberg Self Esteem
Quality of life, happiness, and self esteem all significantly improved from baseline to the end of the intervention.
Pinto et al, 2002, Psychooncology23
Segal et al, 2003, Journal of Clinical Oncology24
Blanchard et al, 2003, Preventive Medicine25
Courneya et al, 2003, Journal of Clinical Oncology26
Godin Leisure Time Exercise Questionnaire, Functional Assessment of Cancer Therapy-BMT; Affect Balance Scale; Satisfaction with Life Scale; Center for Epidemiological StudiesDepression Scale, State Trait Anxiety Instrument Quality of Life Index Cancer Patients, Linear Analog Scale for Symptoms
Walking or cycling during treatment were positively correlated with physical and psychological wellbeing and negatively correlated with fatigue, anxiety, depression, and days hospitalized.
QOL improved significantly for subjects in the exercise group compared with control. Anxiety and fatigue significantly decreased for subjects in the exercise group.
M.T. KNOBF, R. MUSANTI, AND J. DORWARD
Study
TABLE 1. Continued Study
Sample N ¼ 108 Group psychotherapy, N ¼ 48 Group psychotherapy þ exercise, N ¼ 60
Adamson et al, 2003, Supportive Cancer Care28
N ¼ 82 Mixed diagnoses Median age, 40 yrs (range, 18-63 yrs) N ¼ 62 Mixed cancer diagnoses and stages 50% male, 50% female Mean age, 59.1 yrs (SD 13.5 yrs) N ¼ 386 Endometrial cancer Mean age, 64.5 yrs (SD 10.6 yrs) 1/3 employed, 2/3 retired 62% < 5 yrs since diagnosis
Young-McCaughan et al, 2003, Oncology Nursing Forum29
Courneya et al, 2005, Gynecologic Oncology30
Vallance et al, 2005, Psychooncology31
N ¼ 438 Non-Hodgkin’s lymphoma survivors Mean age, 61.1 yrs (SD 13.1 yrs) 52% male Mean time since diagnosis, ¼ 62 mo (SD 25.3 yrs)
Instruments
Results
Randomized trial group psychotherapy classes to group psychotherapy (GP) or GP þ exercise (10-wk, home-based, moderateintensity program) Multidimensional intervention (9 hr weekly for 6 wks) One group design Prospective repeated measures design. 12-wk exercise program modeled after phase II cardiac rehabilitation program Cross sectional Correlational design
Functional Assessment of Cancer Therapy, Center for Epidemiological StudiesDepression Scale, State Trait Anxiety Instrument, Godin Leisure Time Exercise Questionnaire Medical Outcomes Short Form Health Survey, European Organization for Research and Treatment QOL Questionnaire Exercise tolerance, Actigraph (sleep), Cancer Rehabilitation Evaluation System-Short Form Data collected at baseline, wks 4, 8, and 12
For the GP þ exercise group, significant interactions for functional well-being and fatigue and borderline significant interactions for physical well-being, satisfaction with life, and flexibility.
Leisure Score Index Functional Assessment of Cancer Therapy
Retrospective survey design 53% response rate
Functional Assessment Cancer Therapy (Anemia and General Scales), Godin Leisure Time Exercise Questionnaire
Only 30% of subjects met public health guidelines for physical activity. There was a positive association between subjects who met public health guidelines for physical activity and QOL outcomes. 72% of subjects were overweight or obese and there was a negative association between obesity and QOL. Before diagnosis, 34% of subjects met public health exercise guidelines compared with 6% during treatment and 24% after treatment. Lymphoma cancer survivors who met public health exercise guidelines reported higher QOL compared with those who did not follow guidelines.
There were significant improvement in treatmentrelated symptoms and improvements in general well-being, physical, emotional, and role functioning. QOL significantly improved for subjects completing the exercise program (74%). Subjectively, participants reported that the intervention gave them confidence in their ability and enhanced their physical and psychological functioning.
EXERCISE AND QOL OUTCOMES IN CANCER PATIENTS
Courneya et al, 2003, Psychooncology27
Design
289
290
Continued Study Thorsen et al, 2005, Journal of Clinical Oncology32
Damusch et al, 2006, Psychooncology33
Kendall et al, 2005, Quality of Life Research34
Korstjens et al, 2006, European Journal of Cancer Prevention35
Ohira et al, 2006, Cancer36
Sample N ¼ 111 Mean age, 39 yrs (SD 8.5 yrs) 1/3 male, 2/3 female Mean days since end of treatment 28.7(intervention group), 27.4 (control group) Mixed cancer diagnoses N ¼ 34 Breast cancer survivors Mean age, 59.6 yrs (SD 66 yrs) Mean time since diagnosis, 3.1 yrs
Design
Randomized control trial European Organization for 14-wk supervised homeResearch and Treatment QOL based training program Questionnaire, Hospital Anxiety ($ 2-30 min sessions per and Depression Scale wk) vs standard care
One group, pre-/post-test design Intervention: 3 weekly self-management sessions followed by 3 telephone calls at wks 4, 6, and 10 N ¼ 374 Follow-up with subjects in Long term (>10 yrs) breast a case-control study of women originally cancer survivors Mean age, 49.7 yrs (SD 3.7 yrs) diagnosed
