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Medicine & Science in Sports & Exercise:
CLINICAL SCIENCES: Clinically Relevant

Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy


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School of Nursing, Oregon Health Sciences University and Oregon Cancer Center, Portland, OR

March 2000

August 2000

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SCHWARTZ, A. L., M. MORI, R. GAO, L. M. NAIL, and M. E. KING. Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy. Med. Sci. Sports Exerc., Vol. 33, No. 5, 2001, pp. 000–000.

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.

Everyday people experience fatigue. Fatigue is a symptom commonly associated with diseases such as depression, multiple sclerosis, arthritis and renal disease, and different medical and pharmacological treatments. Persons being treated for cancer experience a different and far more disruptive form of fatigue. Cancer treatment-related fatigue (fatigue) is the most prevalent and disturbing side effect of treatment for the majority of cancer patients (11,12,26). Fatigue leads to declines in emotional, psychosocial, and physical function (5,6,17,19,20). Fatigue is described as being relentless and intense; a type of fatigue that is more severe, unpredictable, and overwhelming than the fatigue experienced before cancer treatment (22,26).

Exercise is an intervention proposed to reduce fatigue (5,7,19,20,28,29). Exercise studies with cancer patients have reported positive effects of exercise on mood, chemotherapy side effect severity, weight gain, functional ability, and quality of life (5–7,17,19,20,26,28). However, in these studies, the conclusion that exercise decreases fatigue was based on a single composite score, which aggregated data over several days or weeks (5,7,19,20), or the method of measuring fatigue was not described (6). However, there is a dramatic day-to-day fluctuation in fatigue that is not addressed or captured using the aggregated approach (29). Understanding the relationship between exercise and fatigue within relatively brief time frames is essential in determining whether a dose of exercise could be prescribed to reduce fatigue and to determine the dose-response relationship.

The purpose of this study was to examine the relationship between exercise and fatigue over the first two cycles of chemotherapy in women receiving either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin and cyclophosphamide (AC) for stage I to III ductal carcinoma of the breast. Five research questions were examined: 1) Does exercise decrease level of fatigue on the same day? 2) Does the amount of exercise correlate with fatigue level? 3) Is there a cumulative effect of exercise on fatigue level? 4) Is the effect of exercise transient or long lasting? And 5) Is there a relationship between exercise intensity and fatigue level?

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A one-group pretest-posttest design was used to examine the relationship between fatigue and exercise in women with breast cancer who participated in a home-based exercise intervention. The one-group design was selected to minimize treatment diffusion, compensatory equalization, and resentful demoralization.

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Potential subjects were recruited to participate in an 8-wk home-based aerobic exercise program, from a university cancer center and private practice. All eligible subjects (chemotherapy naive, no previous radiotherapy, ambulatory with histologically documented breast cancer) were invited to participate in the study. Seventy-two women enrolled in the study. Results are presented on the 61 subjects who completed the study and maintained exercise and fatigue diaries. The 11 subjects who did not complete the study either did not complete the fatigue measures (N = 5) were lost to follow-up (N = 1) or withdrew from the study (N = 5). No differences in age, education, ethnicity, previous exercise history, stage of disease, or type of treatment (χ2 > 0.05) were observed between those who completed the study and those who did not. Subjects ranged in age from 27 to 69 yr old (mean = 47.3 yr old, SD = 7.9). The majority of subjects were married (72%), employed (64%), Caucasian (90%), and had attended some college (79%). Most participants were being treated on a 21-d cycle of AC (61%) for stage II (54%) infiltrating ductal carcinoma of the breast. All subjects had surgery at least 21 d before beginning the study, with 74% having modified radical mastectomy with nodal dissection. None of the subjects had received radiation therapy before study entry. Fifty-eight percent of the sample did not exercise at entry into the study. The subjects who were regular exercisers at baseline (42%) reported exercising an average of 38 min, 4 d·wk-1. Walking as part of their work or housework was the primary exercise for these women. Only two of these women met the current recommendations for physical activity (24).

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Demographic variables recorded included age, ethnicity, marital status, education, and previous exercise behavior. Chart review was used to obtain clinical information such as stage of disease and chemotherapy regimen.

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Functional ability.

The 12-min walk is a measure of the distance in feet an individual can cover in 12-min. Baseline and posttest measures were used to assess changes in functional ability resulting from exercise. All subjects followed a measured course, received consistent instructions and were encouraged only in the last 2 min of the walk. The tests were conducted indoors in a climate-controlled environment. The 12-min walk is strongly correlated (r = 0.9) with oxygen consumption (3), has been successfully used in studies with women with breast cancer (19,20,28), and is used extensively in cardiopulmonary rehabilitation as a measure of functional ability (1,30). The 12-min walking distance is relevant to daily activities and the test is easily administered in a clinical setting.

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Exercise intensity.

CaltracTM accelerometers (Muscle Dynamics Fitness Network, Torrence, CA) were used to record the amount of energy (calories) expended, or exercise intensity, during the 12-min walks and in each exercise session. The Caltrac has demonstrated test-retest reliability, interinstrument reliability, and strong correlations with maximum oxygen uptake and doubly labeled water (10,21,23). Reliability and validity have been demonstrated for walking, running, and cycling (9,10,23). Subjects recorded calories expended during exercise, as measured by the CaltracTM, in an exercise log that included information about type and duration of exercise.

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Self-reported measures.

Fatigue diaries were used to record, on four 100-mm visual analog scales (VAS-F), the level of 1) fatigue at its worst in the past 24 h, 2) fatigue at its least in the past 24 h, 3) fatigue on the average over the past 24-h, and 4) fatigue right now. For consistency of measurement, subjects were instructed to complete the diary at the same time each night before they went to bed. This helped make recording fatigue part of their nightly routine and provided consistency in women’s evaluation of their fatigue. Subjects who recorded data for each day produced 56 measures each of worst, least, average, and fatigue right now. Visual analog scales have been successfully used in previous studies to measure cancer-related fatigue with reliability and validity (19,25,27).

The exercise diary was integrated into the fatigue diary. Subjects recorded exercise frequency, duration, and calories expended in the activity monitor mode of the CaltracTM accelerometer. This mode only provides a calculation of the number of calories expended in exercise minus the basal metabolic rate (BMR).

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After written informed consent was obtained, all baseline measures were obtained before the first dose of chemotherapy. These measures included: 12-min walking distance, CaltracTM accelerometry, and daily visual analog measures of fatigue. All women received instruction to exercise between 15 and 30 min, 3–4 d·wk-1, and to wear the CaltracTM accelerometer with each exercise session. Women were instructed to exercise at an intensity that did not aggravate their symptoms (e.g., pain, fatigue). To improve adherence to exercise and because the benefits of aerobic exercise are not determined by type of activity as much as by exercise intensity and duration, the women were encouraged to choose an aerobic activity they enjoyed. Instruction was provided about using the CaltracTM accelerometer. All of the women received information about contraindications to exercise and were given a 24-h contact number to call if they had questions regarding their exercise program or how to operate their Caltrac. Weekly telephone calls, conducted by a research assistant, were used to remind subjects to return their exercise and fatigue diaries and address barriers to exercise.

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Data Analysis

Only for the discussion of descriptive data were women divided into two groups, exercisers and nonexercisers. Exercisers were defined as women who increased the 12-min walking distance at posttest. Nonexercisers declined in their posttest performance on the 12-min walk.

The daily fatigue data were analyzed using unbalanced repeated measures analysis (13,14). Classic analytic techniques could not be used because of missing values. This technique allows parameterization of the covariation matrix and automatically incorporates time-varying covariates and incomplete data into the model (13,14).

Unbalance repeated measures allowed the inclusion of all women who recorded exercise in their exercise and fatigue diary (N = 61) regardless of their performance on the 12-min walk. Although measures of fatigue were obtained daily for 8 wk (56 d), we limited our analysis to the first 6 wk (42 d) of treatment to reflect two complete cycles of chemotherapy. Unbalance repeated measures analysis maximized the data and examined exercise in women who may not have been classified as exercisers by virtue of increasing the distance on the posttest 12-min walk. The presence or absence of exercise, number of minutes exercised, and cumulative amount of exercise were evaluated as time-dependent covariates in the analysis. This variance-covariance matrix was assumed to have a toeplitz structure with seven bands. The structure implies that the fatigued measures over 6 d are correlated, whereas the fatigue measures over more than 6 d are uncorrelated (e.g., the correlation between day 1 and day 7 is zero). Given that fatigue is a highly variable state and not a trait characteristic, this assumption seemed appropriate (22).

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Descriptive analysis of measures.

Using the criteria to categorize women as exercisers or nonexercisers, 61% (N = 37) of the women adopted the exercise program and demonstrated improvements in functional ability. The mean baseline 12-min walking distance for the group was 3449 ft (SD = 649, min·max = 1923–4990). Women who adopted the exercise program (N = 37) showed an increase in posttest 12-min walking distance (mean = 3914 ft, SD = 624, min·max = 2325–5747); demonstrating a mean increased functional ability at posttest of 15% (SD = 14.1, min·max = 1–58%, P < 0.001). Women who did not adopt the exercise program (N = 24) decreased the 12-min walking distance at posttest (mean = 2938 ft, SD = 679, min·max = 1763–3934); declining a mean of 16% (SD = 13% min·max = −2–48%, P < 0.001). Nine women who were regular exercisers at baseline did not continue to exercise during the study period. Although one of the women’s functional ability declined 37% (mean = 22%, SD = 13%), five of the women showed only modest declines (mean = 4%) in functional ability. These women may have been categorized as nonexercisers by virtue of the stringent criteria used to define those women who adopted the exercise program when they really maintained an exercise program but at a lower intensity, frequency, or duration than before beginning chemotherapy. The 35 women who were nonexercisers at baseline but adopted the exercise program demonstrated improvements in functional ability (mean = 15.8%, SD = 16.4, range = 1–58%) over the study period.

Functional ability at study entry correlated with frequency (r = 0.44, P = 0.0006) and duration (r = 0.30, P = 0.023) of exercise over the study period. Functional ability at posttest also correlated with the frequency (r = 0.37, P = 0.004) and duration (r = 0.42, P = 0.001) of exercise women reported. These correlations suggest that women adopted the exercise intervention and that patients were accurately reporting their exercise.

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Does exercise decrease level of fatigue on the same day?

A comparison of the four measures of fatigue on nonexercise and exercise days revealed a significant effect of exercise on fatigue (Table 1). All measures of fatigue were significantly reduced on the exercise days compared with the nonexercise days. Because subjects recorded their fatigue at night, it can be assumed that the declines in fatigue on exercise days were related to exercise and not simply that people exercised because they felt better or experienced fewer symptoms. There was no interaction between exercise and time (all P-values > 0.3), suggesting that the effects of exercise are stable over time. The effects of exercise remained significant even after adjusting for baseline level of fatigue and functional ability (all P-values < 0.001).

Table 1
Table 1
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Does the amount of exercise correlate with the fatigue level?

The amount of exercise, measured as the number of minutes exercised, was significantly associated with fatigue levels (Table 2). In general, the longer a woman exercised, the less fatigue she felt on that day. The exception was for current level of fatigue (fatigue now) which increased when exercise exceeded 60-min bouts.

Table 2
Table 2
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Is there a cumulative effect of exercise?

The analysis of cumulative amount of exercise, measured by cumulative days of exercise (mean = 12.12, SD = 11.43, min·max = 0–42) and cumulative minutes of exercise (mean = 434.63, SD = 610.15, min·max = 0–1878), showed a weaker and inconsistent association with reduced fatigue levels. No significant difference was observed for current level of fatigue. However, a significant decline of over 10 points was observed between women who exercised and those who did not on level of worst, average, and least fatigue (P < 0.05). The effect of exercise on fatigue was greatest on the day of exercise and did not necessarily carry over to subsequent days. The trend was for fatigue to decrease as the cumulative number of min of exercise increased.

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Is the effect of exercise transient or long-lasting?

To evaluate whether the effects of exercise persist from one day to the next, we categorized the data according to the presence or absence of exercise on the current or previous day (Table 3). Although there was a small carry-over effect of exercise to the next day, the impact of exercise on fatigue appeared to be more immediate than long-lasting. Fatigue was lowest when a woman exercised 2 d in a row; somewhat higher when she exercised one day but not the next day; and still higher when she did not exercise at all in the 2-d period (Table 4). These results show the immediate effect of exercise and a small but significant carry-over effect of exercise on fatigue.

Table 3
Table 3
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Table 4
Table 4
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Table 5
Table 5
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Is there a relationship between exercise intensity and fatigue level?

Exercise intensity was measured by the number of calories expended during exercise as recorded by the Caltrac accelerometer. The effects of the number of calories expended on the level of fatigue are summarized in Table 5. In general, as caloric expenditure increased, fatigue declined. However, the effects of exercise intensity were only significant for the least fatigue (P = 0.04) and the average daily fatigue (P = 0.03). These results suggest that when a woman exercises at moderate- to high-intensity levels her perceptions of worst and current level of fatigue are not changed, possibly reflecting changes in hydration and nutritional state that could contribute to fatigue.

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Although this study is limited by the single group design, results provide additional evidence that women undergoing chemotherapy for breast cancer will follow a home-based exercise intervention (19,20). The impact of exercise on all four types of fatigue was significant and reflects the effectiveness of low- to moderate-intensity regular exercise in maintaining functional ability and reducing fatigue in patients with breast cancer. Previous studies have consistently demonstrated reduced fatigue with exercise but with less frequency of measurement and longer periods of time between measures (5,7,19,20,28). The frequency of measurement used in this study provides examination of the day-to-day effect of exercise on fatigue and demonstrates remarkable magnitude of decline in all four types of fatigue by frequency and duration of exercise. Exercise reduced the intensity of fatigue between 14% and 35%, depending on type of fatigue, with the greatest declines in fatigue observed in levels of worst fatigue. Exercise was consistently associated with reducing fatigue the day of exercise and one day afterward.

The effects of exercise on current level of fatigue were somewhat inconsistent. Current level of fatigue increased when exercise exceeded 60 min. The reason for this is unclear, perhaps prolonged exercise provokes muscular fatigue and the feelings of fatigue associated with changes in nutrition and hydration states that could increase the sensation of current level of fatigue. None of these women were highly fit at study entry, so exercising beyond 60 min and continuing with their normal routine may have provoked the increase in fatigue. The inconsistent results observed in current level of fatigue may simply reflect that women recorded their fatigue at night, when one usually feels most tired.

Determining the optimal dose of exercise to reduce fatigue is elusive. Consistent with previous studies, the women in this study who exercised experienced less severe fatigue than nonexercisers (5,7,19,20,28). The somewhat inconsistent findings that there is not a cumulative effect of exercise on fatigue could lead one to speculate that daily or every-other-day exercise may be necessary to optimally reduce fatigue. As observed in Dimeo et al.’s study (7), even brief periods of exercise may be sufficient to reduce fatigue. It appears that exercising for longer duration reduces fatigue more, but providing an exercise recommendation that is realistic and achievable for women is paramount. Given the sedentary lifestyle of the majority of healthy persons, and the propensity for cancer patients to increase rest, the findings that minimal exercise reduces fatigue are encouraging (5,7,19,20,28). Breast cancer patients who begin an exercise program of regular, short bouts of low to moderate exercise and gradually increase duration as their fitness levels improve may reap the benefits of improved functional ability and markedly reduced fatigue.

In this study, women were instructed to exercise at an intensity that was symptom limited. Consequently, the majority of women who adopted the exercise program walked and engaged in other low- to moderate-intensity exercise. This exercise intensity was acceptable to the women, did not worsen their symptoms, and produced favorable outcomes; a finding concurrent with epidemiologic studies that have demonstrated the benefits of low- to moderate-intensity, regular exercise in promoting health and reducing morbidity (16,24).

As observed in other studies, a woman’s functional ability at the beginning of chemotherapy was predictive of the amount and frequency of exercise that she would engage in over the study period (8,14). Women who are already self-motivated to exercise may be more likely to follow a home-based exercise program than women who are not physically active. Although healthier, more functionally able individuals may be more likely to adhere to a home-based exercise program. For this reason, it is important for clinicians to screen patients to identify those with low functional ability before beginning chemotherapy (14,18). Inactive women who are beginning chemotherapy may benefit from a supervised, structured exercise program that would guide them through a progressive exercise regimen designed to enhance exercise self-efficacy and promote independent exercise in a self-monitored home-based program (15).

In this study, women were asked to follow the exercise intervention but were not admonished for failing to adhere. Although all the women who enrolled in the study expressed an interest in exercise and intent to exercise, clearly not all subjects were able to comply with the exercise prescription. For the most part, the women who did not exercise had a greater body mass index and were not previous exercisers, two factors that are the strongest predictors of who will adopt an exercise program (18). Identifying characteristics of women who would succeed in and benefit from a more structured supervised exercise programs will be important to promoting exercise for all women with breast cancer. The period of breast cancer diagnosis is a time when women evaluate their lifestyles and often decide to make positive changes. Exercise rehabilitation programs could minimize the weight gain observed in breast cancer patients (2,4,27) and lower their risks for cardiovascular disease, osteoporosis, and comorbidities associated with weight gain.

The generalizability of the study is limited by the one-group design. The use of self-reported measures of exercise and fatigue, although an inherent weakness of the study, were logistically necessary. However, the correlation between duration and frequency of exercise suggests that subjects accurately reported exercise. Home-based exercise programs are more convenient and cost effective but greatly limit control over the intervention. Although the Caltrac accelerometer monitoring is not an ideal method of measuring exercise intensity, heart rate monitoring is problematic because of the anemia that is caused by chemotherapy. Similar to previous exercise studies, the sample was predominantly Caucasian, further limiting generalizability. The problem of missing data in the last 2 wk of the study may reflect excessive subject burden of daily measures of fatigue and exercise or increasing overall fatigue.

The results of this study suggest the importance of short bouts of regular low- to moderate-intensity exercise to reduce fatigue in women with breast cancer receiving adjuvant chemotherapy. Although contrary to standard practice, it appears that women with breast cancer who are regular exercisers should be encouraged to continue their exercise program and women who are not regular exercisers should be given guidance and instruction to begin an exercise program. Clearly, a randomized trial is needed to validate these results. Encouraging patients to exercise during cancer treatment to maintain and improve functional ability appears to have a positive impact on fatigue and functional ability (5,7,19,20,26,28,31). These data suggest that daily or at least every-other-day, low- to moderate-intensity, symptom-limited exercise may be optimal to reduce fatigue in women with breast cancer receiving chemotherapy.

This work was supported in part by grants from the U.S. Army Medical Research and Materiel Command under DAMD17-96-1-6171, NIH/NINRF31 NR07159, and the Oncology Nursing Foundation.

Conflict of Interest: The results of this study do not constitute endorsement of the product by the authors of ACSM. The authors have no relationships with the companies that would constitute a conflict of interest.

Address for correspondence: Anna L. Schwartz, Ph.D., ARNP, Associate Professor, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd., Mailcode: SN-5N, Portland, OR 97201-3098.

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Oldervoll, LM; Loge, JH; Kaasa, S; Lydersen, S; Hjermstad, MJ; Thorsen, L; Holte, H; Jacobsen, AB; Fossa, SD
Bmc Cancer, 7(): -.
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Science & Sports
Physical activity and breast and colon cancer: Evidence-based physical activity
Duclos, M
Science & Sports, 24(6): 273-280.
Integrative Cancer Therapies
Muscle strength, body composition, and physical activity in women receiving chemotherapy for breast cancer
Visovsky, C
Integrative Cancer Therapies, 5(3): 183-191.
Journal of Clinical Nursing
Fatigue experience and coping strategies in Taiwanese lung cancer patients receiving chemotherapy
Lee, YH; Tsai, YF; Lai, YH; Tsai, CM
Journal of Clinical Nursing, 17(7): 876-883.
Journal of the National Cancer Institute
A systematic review and meta-analysis of the pharmacological treatment of cancer-related fatigue
Minton, O; Richardson, A; Sharpe, M; Hotopf, M; Stone, P
Journal of the National Cancer Institute, 100(): 1155-1166.
Cancer Treatment Reviews
Is exercise an acceptable and practical therapy for people with or cured of cancer? A systematic review
Maddocks, M; Mockett, S; Wilcock, A
Cancer Treatment Reviews, 35(4): 383-390.
European Journal of Cancer
Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients?
Oldervoll, LM; Kaasa, S; Hjermstad, M; Lund, JA; Loge, JH
European Journal of Cancer, 40(7): 951-962.
Oncology Nursing Forum
Evidence-based practice for fatigue management in adults with cancer: Exercise as an intervention
Stricker, CT; Drake, D; Hoyer, KA; Mock, V
Oncology Nursing Forum, 31(5): 963-974.
European Journal of Gynaecological Oncology
Hormone therapy/adjuvant chemotherapy induced deleterious effects on the bone mass of breast cancer patients and the intervention of physiotherapy: a literature review
Tonezzer, T; Pereira, CMAP; Filho, UP; Marx, A
European Journal of Gynaecological Oncology, 31(3): 262-267.

Cancer Investigation
Physical activity interventions following cancer diagnosis: Methodologic challenges to delivery and assessment
Irwin, ML; Ainsworth, BE
Cancer Investigation, 22(1): 30-50.
Physical Therapy
Exercise as an intervention for cancer-related fatigue
Watson, T; Mock, V
Physical Therapy, 84(8): 736-743.

Supportive Care in Cancer
Exercise and side effects among 749 patients during and after treatment for cancer: a University of Rochester Cancer Center Community Clinical Oncology Program Study
Mustian, KM; Griggs, JJ; Morrow, GR; McTiernan, A; Roscoe, JA; Bole, CW; Atkins, JN; Issell, BF
Supportive Care in Cancer, 14(7): 732-741.
Recruiting and retaining breast cancer survivors into a randomized controlled exercise trial - The yale exercise and survivorship
Irwin, ML; Cadmus, L; Alvarez-Reeves, M; O'Neil, M; Mierzejewski, E; Latka, R; Yu, H; DiPietro, L; Jones, B; Knobf, MT; Chung, GG; Mayne, ST
Cancer, 112(): 2593-2606.
Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue
Mustian, KM; Morrow, GR; Carroll, JK; Figueroa-Moseley, CD; Jean-Pierre, P; Williamse, GC
Oncologist, 12(): 52-67.
Oncology Nursing Forum
Exercise Effects on Bone Mineral Density in Women With Breast Cancer Receiving Adjuvant Chemotherapy
Schwartz, AL; Winters-Stone, K; Gallucci, B
Oncology Nursing Forum, 34(3): 627-633.
Cancer Treatment Reviews
Characteristics and methodological quality of 25 years of research investigating psychosocial interventions for cancer patients
Moyer, A; Sohl, SJ; Knapp-Oliver, SK; Schneider, S
Cancer Treatment Reviews, 35(5): 475-484.
Assessment and management of cancer-related fatigue in adults
Ahlberg, K; Ekman, T; Gaston-Johansson, F; Mock, V
Lancet, 362(): 640-650.

British Journal of Cancer
Fatigue and cancer: causes, prevalence and treatment approaches
Wagner, LI; Cella, D
British Journal of Cancer, 91(5): 822-828.
International Journal of Behavioral Medicine
Impact of Mindfulness-Based Stress Reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients
Carlson, LE; Garland, SN
International Journal of Behavioral Medicine, 12(4): 278-285.

Journal of Clinical Nursing
An exploration of the relationship between fatigue and physical functioning in patients with end stage renal disease receiving haemodialysis
O'Sullivan, D; McCarthy, G
Journal of Clinical Nursing, 16(): 276-284.
Journal of Pain and Symptom Management
Effects of a walking intervention on fatigue-related experiences of hospitalized acute myelogenous leukemia patients undergoing chemotherapy: A randomized controlled trial
Chang, PH; Lai, YH; Shun, SC; Lin, LY; Chen, ML; Yang, Y; Tsai, JC; Huang, GS; Cheng, SY
Journal of Pain and Symptom Management, 35(5): 524-534.
Annals of Oncology
Effects of an endurance and resistance exercise program on persistent cancer-related fatigue after treatment
Dimeo, F; Schwartz, S; Wesel, N; Voigt, A; Thiel, E
Annals of Oncology, 19(8): 1495-1499.
Medicine and Science in Sports and Exercise
Exercise in cancer survivors: An overview of research
Courneya, KS
Medicine and Science in Sports and Exercise, 35(): 1846-1852.
General Hospital Psychiatry
Cancer fatigue: a review for psychiatrists
Levy, M
General Hospital Psychiatry, 30(3): 233-244.
Impact of a Walking Intervention on Cardiorespiratory Fitness, Self-Reported Physical Function, and Pain in Patients Undergoing Treatment for Solid Tumors
Griffith, K; Wenzel, J; Shang, JJ; Thompson, C; Stewart, K; Mock, V
Cancer, 115(): 4874-4884.
Supportive Care in Cancer
Effects of endurance training on the physical performance of patients with hematological malignancies during chemotherapy
Dimeo, F; Schwartz, S; Fietz, T; Wanjura, T; Boning, D; Thiel, E
Supportive Care in Cancer, 11(): 623-628.
Annals of Behavioral Medicine
Effects of an oncologist's recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: A single-blind, randomized controlled trial
Jones, LW; Courneya, KS; Fairey, AS; Mackey, JR
Annals of Behavioral Medicine, 28(2): 105-113.

Journal of Applied Physiology
Low-intensity exercise training during doxorubicin treatment protects against cardiotoxicity
Chicco, AJ; Hydock, DS; Schneider, CM; Hayward, R
Journal of Applied Physiology, 100(2): 519-527.
Effects of weight training on quality of life in recent breast cancer survivors - The Weight Training for Breast Cancer Survivors (WTBS) Study
Ohira, T; Schmitz, KH; Ahmed, RL; Yee, D
Cancer, 106(9): 2076-2083.
Cancer-related fatigue - Evolving concepts in evaluation and treatment
Stasi, R; Abriani, L; Beccaglia, P; Terzoli, E; Amadori, S
Cancer, 98(9): 1786-1801.
Oncology Nursing Forum
The effect of seated exercise on fatigue and quality of life in women with advanced breast cancer
Headley, JA; Ownby, KK; John, LD
Oncology Nursing Forum, 31(5): 977-983.
Breast cancer survivors involved in vigorous team physical activity: Psychosocial correlates of maintenance participation
Culos-Reed, SN; Shields, C; Brawley, LR
Psycho-Oncology, 14(7): 594-605.
European Journal of Oncology Nursing
The effect of a multidimensional exercise programme on symptoms and side-effects in cancer patients undergoing chemotherapy - The use of semi-structured diaries
Andersen, C; Adamsen, L; Moeller, T; Midtgaard, J; Quist, M; Tveteraas, A; Rorth, M
European Journal of Oncology Nursing, 10(4): 247-262.
Effects of supervised exercise training on cardiopulmonary function and fatigue in breast cancer survivors during and after treatment
Schneider, CM; Hsieh, CC; Sprod, LK; Carter, SD; Hayward, R
Cancer, 110(4): 918-925.
Archives of Physical Medicine and Rehabilitation
Exercise prevents fatigue and improves quality of life in prostate cancer patients undergoing radiotherapy
Monga, U; Garber, SL; Thornby, J; Vallbona, C; Kerrigan, AJ; Monga, TN; Zimmermann, KP
Archives of Physical Medicine and Rehabilitation, 88(): 1416-1422.
Brazilian Journal of Medical and Biological Research
Effect of exercise on the caloric intake of breast cancer patients undergoing treatment
Battaglini, CL; Mihalik, JP; Bottaro, M; Dennehy, C; Petschauer, MA; Hairston, LS; Shields, EW
Brazilian Journal of Medical and Biological Research, 41(8): 709-715.

Cancer Investigation
Symptom control
Chang, VT; Ingham, J
Cancer Investigation, 21(4): 564-578.
Deutsche Zeitschrift Fur Sportmedizin
What is the role of physical activity in the prevention, therapy and rehabilitation of neoplastic diseases?
Dimeo, F
Deutsche Zeitschrift Fur Sportmedizin, 55(): 177-182.

Lung Cancer
Motivational readiness for physical activity and quality of life in long-term lung cancer survivors
Clark, MM; Novotny, PJ; Patten, CA; Rausch, SM; Garces, YI; Jatoi, A; Sloan, JA; Yang, P
Lung Cancer, 61(1): 117-122.
Clinical Journal of Oncology Nursing
Pathophysiology of Cancer-Related Fatigue
Wang, XS
Clinical Journal of Oncology Nursing, 12(5): 11-20.
Breast Cancer Research and Treatment
Three versus six months of exercise training in breast cancer survivors
Sprod, LK; Hsieh, CC; Hayward, R; Schneider, CM
Breast Cancer Research and Treatment, 121(2): 413-419.
Journal of Pain and Symptom Management
Patient-related barriers to fatigue communication: Initial validation of the Fatigue Management Barriers Questionnaire
Passik, SD; Kirsh, KL; Donaghy, K; Holtsclaw, E; Theobald, D; Cella, D; Breitbart, W
Journal of Pain and Symptom Management, 24(5): 481-493.
PII S0885-3924(02)00518-3
Sleep Medicine Reviews
Insomnia and its treatment in women with breast cancer
Fiorentino, L; Ancoli-Israel, S
Sleep Medicine Reviews, 10(6): 419-429.
Oncology Nursing Forum
The effects of a comprehensive exercise program on physical function, fatigue, and mood in patients with various types of cancer
Hanna, LR; Avila, PF; Meteer, JD; Nicholas, DR; Kaminsky, LA
Oncology Nursing Forum, 35(3): 461-469.
Clinical Journal of Oncology Nursing
Management of Cancer-Related Fatigue
Barsevick, AM; Newhall, T; Brown, S
Clinical Journal of Oncology Nursing, 12(5): 21-25.
Exercise for cancer patients
Adamietz, IA
Onkologe, 16(2): 189-202.
Cancer Practice
Exercise counseling and programming preferences of cancer survivors
Jones, LW; Courneya, KS
Cancer Practice, 10(4): 208-215.

Effects of fatigue on physical activity and function in patients with Parkinson's disease
Garber, CE; Friedman, JH
Neurology, 60(7): 1119-1124.

Supportive Care in Cancer
Support group for cancer patients. Does it improve their physical and psychological wellbeing? A pilot study
Lindemalm, C; Strang, P; Lekander, M
Supportive Care in Cancer, 13(8): 652-657.
Oncology Nursing Forum
Strength, physical activity, and age predict fatigue in older breast cancer survivors
Winters-Stone, KM; Bennett, JA; Nail, L; Schwartz, A
Oncology Nursing Forum, 35(5): 815-821.
Clinical Journal of Oncology Nursing
Symptom Management in Hepatocellular Carcinoma
Sun, VCY; Sarna, L
Clinical Journal of Oncology Nursing, 12(5): 759-766.
Supportive Care in Cancer
Pilot study of Panax quinquefolius (American ginseng) to improve cancer-related fatigue: a randomized, double-blind, dose-finding evaluation: NCCTG trial N03CA
Barton, DL; Soori, GS; Bauer, BA; Sloan, JA; Johnson, PA; Figueras, C; Duane, S; Mattar, B; Liu, HS; Atherton, PJ; Christensen, B; Loprinzi, CL
Supportive Care in Cancer, 18(2): 179-187.
Journal of Clinical Oncology
Physical exercise in cancer patients during and after medical treatment: A systematic review of randomized and controlled clinical trials
Knols, R; Aaronson, NK; Uebelhart, D; Fransen, J; Aufdemkampe, G
Journal of Clinical Oncology, 23(): 3830-3842.
Supportive Care in Cancer
The effect of a multidimensional exercise intervention on physical capacity, well-being and quality of life in cancer patients undergoing chemotherapy
Adamsen, L; Quist, M; Midtgaard, J; Andersen, C; Moller, T; Knutsen, L; Tveteras, A; Rorth, M
Supportive Care in Cancer, 14(2): 116-127.
Physical activity for cancer patients
Dimeo, FC; Thiel, E
Onkologe, 14(1): 31-+.
Psychological Bulletin
Cancer-related fatigue: A systematic and meta-analytic review of non-pharmacological therapies for cancer patients
Kangas, M; Bovbjerg, DH; Montgomery, GH
Psychological Bulletin, 134(5): 700-741.
A pilot study of group exercise training (GET) for women with primary breast cancer: Feasibility and health benefits
Kolden, GG; Strauman, TJ; Ward, A; Kuta, J; Woods, TE; Schneider, KL; Heerey, E; Sanborn, L; Burt, C; Millbrandt, L; Kalin, NH; Stewart, JA; Mullen, B
Psycho-Oncology, 11(5): 447-456.
Lancet Oncology
Cancer-related fatigue: can exercise physiology assist oncologists?
Lucia, A; Earnest, C; Perez, M
Lancet Oncology, 4(): 616-625.

Annals of Oncology
Fatigue in cancer patients receiving chemotherapy: an analysis of published studies
Iop, A; Manfredi, AA; Bonura, S
Annals of Oncology, 15(5): 712-720.
Journal of Surgical Oncology
Improving the physical status and quality of life of women treated for breast cancer: A pilot study of a structured exercise intervention
Turner, J; Hayes, S; Reul-Hirche, H
Journal of Surgical Oncology, 86(3): 141-146.
Assessment of cancer-related fatigue: Implications for clinical diagnosis and treatment
Jean-Pierre, P; Figueroa-Moseley, CD; Kohli, S; Fiscella, K; Palesh, OG; Morrow, GR
Oncologist, 12(): 11-21.
Rheumatic Disease Clinics of North America
Treatment of fatigue in fibromyalgia
Guymer, EK; Clauw, DJ
Rheumatic Disease Clinics of North America, 28(2): 367-+.
PII S0889-857X(01)00007-2
Oncology-New York
Physical function in men and women with cancer - Effects of anemia and conditioning
Evans, WJ; Reynolds, DW
Oncology-New York, 16(9): 109-115.

Cancer Investigation
Physical activity after a cancer diagnosis: Psychosocial outcomes
Schwartz, AL
Cancer Investigation, 22(1): 82-92.
Oncology-New York
Psychiatric assessment and symptom management in elderly cancer patients
Winell, J; Roth, AJ
Oncology-New York, 19(): 1477-1488.

European Journal of Cancer Care
Exercise stage of change, barriers, expectations, values and preferences among breast cancer patients during treatment: a pilot study
Rogers, LQ; Courneya, KS; Shah, P; Dunnington, G; Hopkins-Price, P
European Journal of Cancer Care, 16(1): 55-66.
European Journal of Cancer
Cancer-related fatigue
Stone, PC; Minton, O
European Journal of Cancer, 44(8): 1097-1104.
Medicine and Science in Sports and Exercise
Effects of exercise on physiological and psychological variables in cancer survivors
Burnham, TR; Wilcox, A
Medicine and Science in Sports and Exercise, 34(): 1863-1867.
Supportive Care in Cancer
Aerobic exercise for a patient suffering from metastatic bone disease
Crevenna, R; Schmidinger, M; Keilani, M; Nuhr, M; Fialka-Moser, V; Zettinig, G; Quittan, M
Supportive Care in Cancer, 11(2): 120-122.
Cancer Investigation
Physical activity interventions in the elderly: Cancer and comorbidity
Penedo, FJ; Schneiderman, N; Dahn, JR; Gonzalez, JS
Cancer Investigation, 22(1): 51-67.
Cancer Causes & Control
Exercise interventions for cancer patients: systematic review of controlled trials
Stevinson, C; Lawlor, DA; Fox, KR
Cancer Causes & Control, 15(): 1035-1056.

Oncology Nursing Forum
Conceptualizing and measuring physical functioning in cancer survivorship studies
Bennett, JA; Winters-Stone, K; Nail, L
Oncology Nursing Forum, 33(1): 41-49.
Surgical Oncology-Oxford
A systematic review of pre-surgical exercise intervention studies with cancer patients
Singh, F; Newton, RU; Galvao, DA; Spry, N; Baker, MK
Surgical Oncology-Oxford, 22(2): 92-104.
Medicine & Science in Sports & Exercise
Age-Related Differences in Exercise and Quality of Life among Breast Cancer Survivors
Medicine & Science in Sports & Exercise, 42(1): 67-74.
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American Journal of Physical Medicine & Rehabilitation
Physiological Basis of Fatigue
Evans, WJ; Lambert, CP
American Journal of Physical Medicine & Rehabilitation, 86(1): S29-S46.
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Cancer Nursing
Cardiopulmonary Responses and Adherence to Exercise in Women Newly Diagnosed With Breast Cancer Undergoing Adjuvant Therapy
Kim, C; Kang, D; Smith, BA; Landers, KA
Cancer Nursing, 29(2): 156-165.

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Cancer Nursing
Nursing Intervention for Fatigue During the Treatment for Cancer
de Nijs, EJ; Ros, W; Grijpdonck, MH
Cancer Nursing, 31(3): 191-206.
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Cancer Nursing
A Randomized Controlled Trial of Home-Based Exercise for Cancer-Related Fatigue in Women During and After Chemotherapy With or Without Radiation Therapy
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Cancer Nursing, 33(4): 245-257.
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Exercise treatment to counteract protein wasting of chronic diseases
Zinna, EM; Yarasheski, KE
Current Opinion in Clinical Nutrition & Metabolic Care, 6(1): 87-93.

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The Journal of Strength & Conditioning Research
Effects of Aerobic Training Prior to and During Chemotherapy in A Breast Cancer Patient: Acase Study
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Nursing Research
Motivational Interviewing to Increase Physical Activity in Long-Term Cancer Survivors: A Randomized Controlled Trial
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