Exercise and other non-pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis

Abstract

Aim: To assess the relative effects of different types of exercise and other non-pharmaceutical interventions on cancer-related fatigue (CRF) in patients during and after cancer treatment.

Design: Systematic review and indirect-comparisons meta-analysis.

Data sources: Articles were searched in PubMed, Cochrane CENTRAL and published meta-analyses.

Eligibility criteria for selecting studies: Randomised studies published up to January 2017 evaluating different types of exercise or other non-pharmaceutical interventions to reduce CRF in any cancer type during or after treatment.

Study appraisal and synthesis: Risk of bias assessment with PEDro criteria and random effects Bayesian network meta-analysis.

Results: We included 245 studies. Comparing the treatments with usual care during cancer treatment, relaxation exercise was the highest ranked intervention with a standardisedmean difference (SMD) of -0.77 (95% Credible Interval (CrI) -1.22 to -0.31), while massage (-0.78; -1.55 to -0.01), cognitive-behavioural therapy combined with physical activity (combined CBT, -0.72; -1.34 to -0.09), combined aerobic and resistance training (-0.67; -1.01 to -0.34), resistance training (-0.53; -1.02 to -0.03), aerobic (-0.53; -0.80 to -0.26) and yoga (-0.51; -1.01 to 0.00) all had moderate-to-large SMDs. After cancer treatment, yoga showed the highest effect (-0.68; -0.93 to -0.43). Combined aerobic and resistance training (-0.50; -0.66 to -0.34), combined CBT (-0.45; -0.70 to -0.21), Tai-Chi (-0.45; -0.84 to -0.06), CBT (-0.42; -0.58 to -0.25), resistance training (-0.35; -0.62 to -0.08) and aerobic (-0.33; -0.51 to -0.16) showed all small-to-moderate SMDs.

Conclusions: Patients can choose among different effective types of exercise and non-pharmaceutical interventions to reduce CRF.

Keywords: cancer related fatigue; exercise; indirect comparison meta-analysis.; network meta-analysis; non-pharmaceutical interventions.

Figure 1

Flow chart of the study selection process.

Figure 2

Plots of the two networks (during and after cancer treatment). The size of the circles corresponds to the number of patients within the groups, the width of the lines between the treatment circles indicates the statistical precision of the comparison (ie, inverse of the variance). The numbers on or besides the lines between the treatments indicate the number of trials comparing the two treatments and the numbers in parentheses indicate the number of patients in the given comparison. Red coloured lines indicate that more than 50% of the trials had no allocation concealment or more than 15% drop-outs; green dashed lines indicate that 50% or more of the trials had correct allocation concealment and less than 15% drop-outs. CBT, cognitive–behavioural therapy.

Figure 3

Forest plots for the comparisons between the active interventions and the control intervention (usual care) for the studies performed during cancer treatment. The left side of the panel shows all studies. The right side shows only the studies with more than 25 patients per arm (on average). CBT, cognitive–behavioural therapy; SMD, standardised mean difference; SUCRA, surface under the cumulative ranking curve; 95% Crl, 95% Crl.

Figure 4

Forest plots for the comparisons between the active interventions and the control intervention (usual care) for the studies performed after cancer treatment. The left side of the panel shows all studies. The right side shows only the studies with more than 25 patients per arm (on average). CBT, cognitive–behavioural therapy; SMD, standardised mean difference; SUCRA, surface under the cumulative ranking curve; 95%Crl, 95% Crl.