Anna L. Schwartz

Nutrition and physical activity guidelines for cancer survivors

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EXERCISE REDUCES DAILY FATIGUE IN WOMEN WITH BREAST CANCER RECEIVING CHEMOTHERAPY

PURPOSE Cancer treatment-related fatigue is the most prevalent and distressing symptom of cancer therapy. Interventions to minimize fatigue are needed. The purpose of this study was to examine the relationship between exercise and fatigue over the first three cycles of chemotherapy in women receiving either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin and cyclophosphamide (AC) for breast cancer. METHODS Seventy-two newly diagnosed women with breast cancer were instructed in a home-based moderate-intensity exercise intervention. Measures of functional ability, energy expenditure, and fatigue were obtained at baseline and posttest. Subjects maintained daily records of four types of fatigue, and exercise duration, intensity, and type. RESULTS Exercise significantly reduced all four levels of fatigue (P < 0.01). As the duration of exercise increased, the intensity of fatigue declined (P < 0.01). There was a significant carry-over effect of exercise on fatigue, but the effect lasted only 1 d. The level of fatigue at study entry was not associated with number of days of exercise or amount of exercise a woman engaged in. CONCLUSIONS The impact of exercise on fatigue was significant and suggests the effectiveness of a low- to moderate-intensity regular exercise program in maintaining functional ability and reducing fatigue in women with breast cancer receiving chemotherapy.

Fatigue mediates the effects of exercise on quality of life.

Purpose: Fatigue is a common side effect of cancer treatment that impacts quality of life. Exercise is one approach suggested to improve fatigue. The purpose of this study was to explore the relationship of exercise to fatigue and quality of life. Methods: Thirty-one subjects with breast cancer were enrolled prior to beginning chemotherapy and 27 completed the study. All baseline measures were obtained before the first chemotherapy treatment. Subjects were instructed on a home-based, 8-week exercise program. Results: Women who adopted the exercise program (60%) showed significant increases in functional ability and less weight gain. Exploratory, stepwise multiple regression analyses suggested that the maximum effect of exercise on quality of life outcomes may be mediated by fatigue. Conclusions: The low-to-moderate intensity, home-based exercise program was feasible for some women with breast cancer receiving chemotherapy. The results suggest that exercise may affect quality of life and that this effect may be mediated by the effects of exercise on fatigue. Better retention of functional ability and better weight control are additional possible benefits of exposing breast cancer patients to increased exercise. A randomized, controlled clinical trial is needed to establish confidence in these observed relationships.

Psychometric testing of fatigue instruments for use with cancer patients

BACKGROUND Cancer treatment-related fatigue (CRF) is a common side effect of cancer treatment. A problem identified in most reviews of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state. The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study. The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment. OBJECTIVES The aims of this study were to determine the reliability, validity, and responsiveness of each instrument and to determine the ability of each instrument to capture CRF. METHODS Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale (F_POMS-sf), Multidimensional Assessment of Fatigue (MAF), Lee Fatigue Scale (LFS), and the Multidimensional Fatigue Inventory (MFI). Data were collected at a university-based clinical cancer center and a freestanding comprehensive cancer center. Subjects completed all study instruments, which were presented in random order, at a time when CRF was expected to be high and again when it was expected to be low. A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data. RESULTS Reliability estimates using Cronbachs alpha indicated that all instruments examined had good internal consistency. Test-retest correlations showed good stability for total scores on all the instruments, but some subscales of the LFS and MFI had marginal stability. Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity. All of the instruments showed responsiveness to changes in CRF related to treatment. CONCLUSIONS The results of the study provide researchers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF.

Fatigue Patterns Observed in Patients Receiving Chemotherapy and Radiotherapy

Abstract The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.

Interferon-induced fatigue in patients with melanoma: a pilot study of exercise and methylphenidate.

PURPOSE/OBJECTIVES To examine the effect of exercise and methylphenidate on fatigue, functional ability, and cognitive function in patients with melanoma. DESIGN Pilot study with comparison to historic controls. SETTING University-based cancer center. SAMPLE 12 patients with melanoma entered and completed the study. The mean age was 44 years. METHOD Eligible patients were recruited before their first dose of interferon-a (IFN-a). Patients were instructed to take 20 mg sustained-release methylphenidate every morning and follow an aerobic exercise program four days a week for 15-30 minutes. Measures included a 12-minute walk, the Schwartz Cancer Fatigue Scale, Trail Maker Forms A and B, Medical Outcomes Study 36 Short Form, body weight, and daily logs. Fatigue scores were compared to usual care historical controls with melanoma receiving only IFN-a. MAIN RESEARCH VARIABLES Fatigue, functional ability, and cognitive function. FINDINGS 66% adhered to exercise and methylphenidate; all adhered to exercise. Fatigue was lower for the exercise and methylphenidate group than historic controls. Functional ability increased 6% for all patients and 9% for the exercise and methylphenidate group. Cognitive function was stable for the exercise and methylphenidate group. The exercise-only group showed marked cognitive slowing. CONCLUSION The combination of aerobic exercise and methylphenidate may have a positive effect on fatigue, cognitive function, and functional ability. A larger sample size and randomized trial is needed to more rigorously evaluate the results of exercise and methylphenidate alone or in combination. IMPLICATIONS FOR NURSING Although further study is needed, a combination of exercise and methylphenidate may be a practical intervention for patients receiving IFN-a for melanoma.

Measurement of Fatigue: Determining Minimally Important Clinical Differences

The purpose was to determine the minimally important clinical difference (MICD) in fatigue as measured by the Profile of Mood States, Schwartz Cancer Fatigue Scale (SCFS), General Fatigue Scale, and a 10-point single-item fatigue measure. The MICD is the smallest amount of change in a symptom (e.g., fatigue) measure that signifies an important change in that symptom. Subjects rated the degree of change in their fatigue over 2 days on a Global Rating Scale. 103 patients were enrolled on this multisite prospective repeated measures design. MICD was determined following established procedures at two time points. Statistically significant changes were observed for moderate and large changes in fatigue, but not for small changes. The scales were sensitive to increases in fatigue over time. The MICD, presented as mean change, for each scale and per item on each scale is: POMS = 5.6, per item = 1.1, SCFS = 5.0, per item = 0.8, GFS = 9.7, per item = 1.0, and the single item measure of fatigue was 2.4 points. This information may be useful in interpreting scale scores and planning studies using these measures.

Implementing the Exercise Guidelines for Cancer Survivors

In 2009, the American College of Sports Medicine convened an expert roundtable to issue guidelines on exercise for cancer survivors. This multidisciplinary group evaluated the strength of the evidence for the safety and benefits of exercise as a therapeutic intervention for survivors. The panel concluded that exercise is safe and offers myriad benefits for survivors including improvements in physical function, strength, fatigue, quality of life, and possibly recurrence and survival. Recommendations for situations in which deviations from the US Physical Activity Guidelines for Americans are appropriate were provided. Here, we outline a process for implementing the guidelines in clinical practice and provide recommendations for how the oncology care provider can interface with the exercise and physical therapy community.

Prospective surveillance and management of cardiac toxicity and health in breast cancer survivors

Breast cancer is commonly diagnosed in postmenopausal women, the majority of whom express 1 or more cardiovascular disease risk factors. Cardiovascular disease poses a significant competing risk for morbidity and mortality among nonmetastatic breast cancer survivors. Adjuvant systemic therapies may result in late‐cardiac toxicity decades after treatment completion. The cumulative incidence of treatment‐related cardiotoxic outcomes may be as high as 33% after some adjuvant breast cancer therapies. Breast cancer treatment–induced cardiotoxicity may manifest as cardiomyopathy, coronary ischemia, thromboembolism, arrhythmias and conduction abnormalities, and valvular and pericardial disease. Evidence indicates that preexisting cardiovascular conditions such as hypertension or left ventricular dysfunction may compound the adverse effects of cardiotoxic treatments. There are currently no published clinical practice guidelines that address ongoing cardiac surveillance for cardiotoxicity after breast cancer, and existing guidelines for monitoring and promoting cardiovascular health in older women are often not followed. The multidisciplinary prospective surveillance system proposed elsewhere in this supplement would allow for earlier detection of cardiotoxicity from treatment and may improve monitoring of cardiovascular health in the growing population of breast cancer survivors. Cancer 2012;118(8 suppl):.

Strength, Physical Activity, and Age Predict Fatigue in Older Breast Cancer Survivors

PURPOSE/OBJECTIVES To determine whether clinical characteristics, physical fitness, or physical activity predict fatigue in older, long-term breast cancer survivors. DESIGN Cross sectional. SETTING National Cancer Institute-designated cancer center in Portland, OR. SAMPLE 47 women (X age = 69 years) who were at least one year beyond treatment completion, including surgery, radiation, chemotherapy, or hormone therapy, for early-stage breast cancer. METHODS Participants completed one two-hour testing session to determine fatigue ratings, clinical information, submaximal aerobic fitness, lower-extremity muscle strength, body composition, and physical activity levels. MAIN RESEARCH VARIABLES Self-reported fatigue assessed by the Schwartz Cancer Fatigue Scale, cancer and treatment history obtained by self-report, submaximal aerobic fitness assessed by 12-minute walk distance, lower-extremity muscle strength assessed by number of chair stands completed in 30 seconds, body composition assessed as percentage of body fat, and physical activity levels assessed by self-reported hours per week. FINDINGS Fatigue was significantly correlated with all independent variables, with the exception of aerobic fitness. Fatigue was higher with lower age, greater percentage of body fat, fewer years after diagnosis, more adjuvant treatments, poorer lower-extremity muscle strength, and less physical activity. In regression analyses, lower-extremity muscular strength, physical activity levels, and age each were significant independent predictors of fatigue. Lower-extremity muscle strength, physical activity, and age all were inversely related to fatigue and accounted for 15%, 7%, and 15% of the variance in fatigue scores, respectively. CONCLUSIONS In this sample of older breast cancer survivors, fatigue was linked to physical activity and muscle strength; women with better lower-extremity muscle strength, higher physical activity levels, and advanced age reported less fatigue. IMPLICATIONS FOR NURSING A physical activity program aimed at improving lower body strength could mitigate persistent fatigue in older, long-term breast cancer survivors.