Understand the Evidence for Exercise in Gynecologic Cancer-Related Fatigue
Cervical cancer is the fourth most common cancer in women and the seventh most common overall. Cancer-related fatigue (CRF) has an estimated prevalence of 50%–90% in all patients and has been reported to affect 17%–33% of women with gynecologic cancers for as long as three to eight years after diagnosis.
Many national guidelines from organizations such as the American College of Sports Medicine, American Cancer Society, National Institute for Health and Care Excellence, and ONS all recommend exercise to improve fatigue in patients with cancer. But no research has synthesized the evidence for exercise as an intervention for fatigue specifically in patients with gynecologic cancers.
In their study published in the January 2019 issue (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review) of the Oncology Nursing Forum, Al Maqbali, Hughes, Dunwoody, Rankin, Hacker, and Gracey reported on the results of their systematic review of the currently published evidence for exercise interventions in reducing fatigue in women with gynecologic cancers.
Exercise and CRF
Studies have shown that most patients with cancer identify fatigue as the most distressing symptom affecting their quality of life during the cancer journey, Al Maqbali et al. said (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review).
CRF is attributed to two separate underlying mechanisms: peripheral (muscular) and central (neural). In peripheral fatigue, metabolic changes in the muscle affect excitation and contraction mechanisms, causing muscular decline and reductions in physical performance. With central fatigue, the central nervous system progressively fails to transmit motor neuron impulses. Increasing physical activity improves both mechanisms, Al Maqubali et al. reported (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review).
What the Evidence Says About Exercise and Gynecologic CRF
After narrowing the literature search, Al Maqubali et al. identified (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review) five studies that met the inclusion criteria: two randomized, controlled trials (RCTs) and three single-arm trials. The studies included women diagnosed with ovarian, vulva, vaginal, cervical, uterine, tubal, or placental cancers at different stages and treatment phases. Most of the studies used home-based interval exercise and behavior interventions (e.g., nutrition changes) to meet the minimal required 30 minutes of physical activity for five days for a total of 150 minutes of physical activity per week.
Three studies demonstrated significant improvements in fatigue over time. The first was a single-arm study of a six-month, home-based exercise intervention in endometrial cancer survivors measured with activity-monitoring watches. Participants received printed instructions to complete 30 minutes of exercise for five days per week and were reminded through phone calls. At six months, fatigue scores improved significantly (p = 0.017).
Researchers for the second study evaluated the effect of 90 minutes of exercise per week in patients with ovarian cancer. Participants in the single-arm study completed aerobic (e.g., walking, swimming, cycling), core stability, resistance, and balance exercises. At 12 weeks, the researchers found significant improvements in fatigue scores (p = 0.004); however, the improvement was not sustained at 24 weeks. Other factors that showed significant improvement were physical activity volume; upper and lower body strength; balance; sleep quality; mental function; functional, emotional, and physical well-being; and global quality of life.
In the third study, researchers used an RCT to evaluate a walking and strengthening exercise program in women with gynecologic cancers. The women were reminded with phone calls to complete 30 minutes of exercise for five days per week, and fatigue scores were measured at baseline, 12 weeks, and 6 months. Fatigue improved significantly at both time points (p = 0.046 and p = 0.01, respectively).
The last two of the five studies did not demonstrate that exercise significantly improved fatigue scores, but in both of those studies, other physical indicators improved (e.g., weight loss amounts, depression scores, aerobic fitness).
What This Means for Oncology Nurses
In their discussion, Al Maqbali et al. hypothesized (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review) that because gynecologic cancers have many different subtypes, fatigue severity may differ by specific diagnoses. Other studies have shown that women with cervical cancers experience the greatest amounts of CRF, followed by those with ovarian cancer. Another confounding factor could be type of cancer treatment, Al Maqbali et al. said (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review), where studies have shown that radiation therapy is associated with the highest degree of CRF.
Still, the authors said that the results of their systematic review support the positive effect of exercise on CRF levels in women with gynecologic cancers, although additional, more robustly designed studies are needed. Oncology nurses can provide this information in patient education and instill confidence in patients that the recommendations are supported in published studies.
ONS has tools that oncology nurses can use to discuss physical activity recommendations with their patients—and resources to provide staff education about incorporating physical activity into cancer care. Learn more in the sidebar or at ONS.org (https://www.ons.org/make-a-difference/quality-improvement/get-up-get-moving).
To get more information about Al Maqbali et al.’s literature review (https://onf.ons.org/onf/46/1/exercise-interventions-manage-fatigue-women-gynecologic-cancer-systematic-review), such as the inclusion criteria and more details about the reviewed studies, refer to the full Oncology Nursing Forum article.
This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing or Oncology Nursing Forum (ONF). This edition summarizes “Exercise Interventions to Manage Fatigue in Women With Gynecologic Cancer: A Systematic Review,” by Mohammed Al Maqbali, RN, Dip. Admin., BSc(Hons), MSc, Ciara Hughes, PhD, Lynn Dunwoody, PhD, AFBPsS, C.Psychol, FHEA, Jane P. Rankin, BSc(Hons), MSc, Eileen D. Hacker, PhD, APN, AOCN®, FAAN, and Jackie Gracey, PhD, which was published in the January 2019 issue of ONF. Questions regarding the information presented in this article should be directed to the ONF editor at ONFEditor@ons.org. Photocopying of this article for educational purposes and group discussion is permitted.