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Review
. 2023 Mar 13;3(3):CD013448.
doi: 10.1002/14651858.CD013448.pub2.

Exercise interventions for adults with cancer receiving radiation therapy alone

Maike Trommer  1 , Simone Marnitz  1 , Nicole Skoetz  2 , Ronja Rupp  3 , Timo Niels  3 , Janis Morgenthaler  1 , Sebastian Theurich  4 , Michael von Bergwelt-Baildon  4 , Christian Baues  1 , Freerk T Baumann  3
Affiliations
Review

Exercise interventions for adults with cancer receiving radiation therapy alone

Maike Trommer et al. Cochrane Database Syst Rev. .

Abstract

Background: Radiation therapy (RT) is given to about half of all people with cancer. RT alone is used to treat various cancers at different stages. Although it is a local treatment, systemic symptoms may occur. Cancer- or treatment-related side effects can lead to a reduction in physical activity, physical performance, and quality of life (QoL). The literature suggests that physical exercise can reduce the risk of various side effects of cancer and cancer treatments, cancer-specific mortality, recurrence of cancer, and all-cause mortality.

Objectives: To evaluate the benefits and harms of exercise plus standard care compared with standard care alone in adults with cancer receiving RT alone.

Search methods: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid), CINAHL, conference proceedings and trial registries up to 26 October 2022.

Selection criteria: We included randomised controlled trials (RCTs) that enrolled people who were receiving RT without adjuvant systemic treatment for any type or stage of cancer. We considered any type of exercise intervention, defined as a planned, structured, repetitive, objective-oriented physical activity programme in addition to standard care. We excluded exercise interventions that involved physiotherapy alone, relaxation programmes, and multimodal approaches that combined exercise with other non-standard interventions such as nutritional restriction.

Data collection and analysis: We used standard Cochrane methodology and the GRADE approach for assessing the certainty of the evidence. Our primary outcome was fatigue and the secondary outcomes were QoL, physical performance, psychosocial effects, overall survival, return to work, anthropometric measurements, and adverse events.

Main results: Database searching identified 5875 records, of which 430 were duplicates. We excluded 5324 records and the remaining 121 references were assessed for eligibility. We included three two-arm RCTs with 130 participants. Cancer types were breast and prostate cancer. Both treatment groups received the same standard care, but the exercise groups also participated in supervised exercise programmes several times per week while undergoing RT. Exercise interventions included warm-up, treadmill walking (in addition to cycling and stretching and strengthening exercises in one study), and cool-down. In some analysed endpoints (fatigue, physical performance, QoL), there were baseline differences between exercise and control groups. We were unable to pool the results of the different studies owing to substantial clinical heterogeneity. All three studies measured fatigue. Our analyses, presented below, showed that exercise may reduce fatigue (positive SMD values signify less fatigue; low certainty). • Standardised mean difference (SMD) 0.96, 95% confidence interval (CI) 0.27 to 1.64; 37 participants (fatigue measured with Brief Fatigue Inventory (BFI)) • SMD 2.42, 95% CI 1.71 to 3.13; 54 participants (fatigue measured with BFI) • SMD 1.44, 95% CI 0.46 to 2.42; 21 participants (fatigue measured with revised Piper Fatigue Scale) All three studies measured QoL, although one provided insufficient data for analysis. Our analyses, presented below, showed that exercise may have little or no effect on QoL (positive SMD values signify better QoL; low certainty). • SMD 0.40, 95% CI -0.26 to 1.05; 37 participants (QoL measured with Functional Assessment of Cancer Therapy-Prostate) • SMD 0.47, 95% CI -0.40 to 1.34; 21 participants (QoL measured with World Health Organization QoL questionnaire (WHOQOL-BREF)) All three studies measured physical performance. Our analyses of two studies, presented below, showed that exercise may improve physical performance, but we are very unsure about the results (positive SMD values signify better physical performance; very low certainty) • SMD 1.25, 95% CI 0.54 to 1.97; 37 participants (shoulder mobility and pain measured on a visual analogue scale) • SMD⁠⁠⁠⁠⁠⁠ 3.13 (95% CI 2.32 to 3.95; 54 participants (physical performance measured with the six-minute walk test) Our analyses of data from the third study showed that exercise may have little or no effect on physical performance measured with the stand-and-sit test, but we are very unsure about the results (SMD 0.00, 95% CI -0.86 to 0.86, positive SMD values signify better physical performance; 21 participants; very low certainty). Two studies measured psychosocial effects. Our analyses (presented below) showed that exercise may have little or no effect on psychosocial effects, but we are very unsure about the results (positive SMD values signify better psychosocial well-being; very low certainty). • SMD 0.48, 95% CI -0.18 to 1.13; 37 participants (psychosocial effects measured on the WHOQOL-BREF social subscale) • SMD 0.29, 95% CI -0.57 to 1.15; 21 participants (psychosocial effects measured with the Beck Depression Inventory) Two studies recorded adverse events related to the exercise programmes and reported no events. We estimated the certainty of the evidence as very low. No studies reported adverse events unrelated to exercise. No studies reported the other outcomes we intended to analyse (overall survival, anthropometric measurements, return to work).

Authors' conclusions: There is little evidence on the effects of exercise interventions in people with cancer who are receiving RT alone. While all included studies reported benefits for the exercise intervention groups in all assessed outcomes, our analyses did not consistently support this evidence. There was low-certainty evidence that exercise improved fatigue in all three studies. Regarding physical performance, our analysis showed very low-certainty evidence of a difference favouring exercise in two studies, and very low-certainty evidence of no difference in one study. We found very low-certainty evidence of little or no difference between the effects of exercise and no exercise on quality of life or psychosocial effects. We downgraded the certainty of the evidence for possible outcome reporting bias, imprecision due to small sample sizes in a small number of studies, and indirectness of outcomes. In summary, exercise may have some beneficial outcomes in people with cancer who are receiving RT alone, but the evidence supporting this statement is of low certainty. There is a need for high-quality research on this topic.

PubMed Disclaimer

Conflict of interest statement

MT: none known SM: none known NS: none known RR: none known TN: none known JM: none known ST: none known MvBB: none known CB: none known FTB: none known

Figures

1
1
PRISMA flow diagram summarising the study selection process.
2
2
Review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Exercise intervention plus standard of care versus standard of care alone, Outcome 1: Fatigue
1.2
1.2. Analysis
Comparison 1: Exercise intervention plus standard of care versus standard of care alone, Outcome 2: Overall Quality of Life (QoL)
1.3
1.3. Analysis
Comparison 1: Exercise intervention plus standard of care versus standard of care alone, Outcome 3: Physical performance
1.4
1.4. Analysis
Comparison 1: Exercise intervention plus standard of care versus standard of care alone, Outcome 4: Psychosocial effects
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD013448

References

References to studies included in this review

Hwang 2008 {published data only}
    1. Hwang JH, Chang HJ, Shim YH, Park WH, Park W, Huh SJ, et al. Effects of supervised exercise therapy in patients receiving radiotherapy for breast cancer. Yonsei Medical Journal 2008;49(3):443-50. [DOI: 10.3349/ymj.2008.49.3.443] - DOI - PMC - PubMed
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Monga 2007 {published data only}
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References to studies excluded from this review

ACTRN12618000225213 2018 {published data only}
    1. ACTRN12618000225213. Exercise for men with prostate cancer on active surveillance. www.who.int/trialsearch/Trial2.aspx?TrialID=ACTRN12618000225213 2018.
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Banerjee 2007 {published data only}
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Ben‐Josef 2017 {published data only}
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Berglund 2007 {published data only}
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Bertram 2011 {published data only}
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Cantarero Villanueva 2011 {published data only}
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Chen 2016 {published data only}
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Cheville 2010 {published data only}
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Cho 2006 {published data only}
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Cho 2016 {published data only}
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Chock 2013 {published data only}
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Cinar 2008 {published data only}
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Clark 2013 {published data only}
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Cormie 2013 {published data only}
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Danhauer 2009 {published data only}
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Desbiens 2017 {published data only}
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DiBlasio 2016 {published data only}
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Dieli‐Conwright 2018 {published data only}
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Dieperink 2013 {published data only}
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Dimeo 2008 {published data only}
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Dong 2019 {published data only}
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Douglass 2012 {published data only}
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Drouin 2002 {published data only}
    1. Drouin J. Aerobic exercise training effects on physical function, fatigue and mood, immune status, and oxidative stress in subjects undergoing radiation treatment for breast cancer. Wayne State University ProQuest Dissertations Publishing 2002;3047549:1-148.
Drouin 2005 {published data only}
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Ehlers 2018 {published data only}
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Emslie 2007 {published data only}
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Galvao 2013 {published data only}
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Grote 2018 {published data only}
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Guerreiro Godoy 2010 {published data only}
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Haddad 2011 {published data only}
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Haines 2010 {published data only}
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Hajdu 2017 {published data only}
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Hayes 2017 {published data only}
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Ho 2014 {published data only}
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Ho 2018 {published data only}
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Ibrahim 2017 {published data only}
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Ibrahim 2018 {published data only}
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Irdesel 2007 {published data only}
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Janelsins 2016 {published data only}
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Jazi 2017 {published data only}
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Kapur 2010 {published data only}
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Kim 2006 {published data only}
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Kneis 2018 {published data only}
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Kyungjin 2014 {published data only}
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Lauridsen 2005 {published data only}
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Leal 2016 {published data only}
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Mustian 2009 {published data only}
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Oldervoll 2011 {published data only}
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Penttinen 2014 {published data only}
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Pernar 2017 {published data only}
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Pruthi 2012 {published data only}
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Raghavendra 2009 {published data only}
    1. Raghavendra RM, Vadiraja HS, Nagarathna R, Nagendra HR, Rekha M, Vanitha N, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integrative Cancer Therapies 2009;8(1):37-46. - PubMed
Rahnama 2010 {published data only}
    1. Rahnama N, Nouri R, Rahmaninia F, Damirchi A, Emami H. The effects of exercise training on maximum aerobic capacity, resting heart rate, blood pressure and anthropometric variables of postmenopausal women with breast cancer. Journal of Research in Medical Sciences 2010;15(2):78-83. - PMC - PubMed
Ratcliff 2016 {published data only}
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Reis 2013 {published data only}
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Rief 2014a {published data only}
    1. Rief H, Omlor G, Akbar M, Welzel T, Bruckner T, Rieken S, et al. Feasibility of isometric spinal muscle training in patients with bone metastases under radiation therapy – first results of a randomized pilot trial. BMC Cancer 2014;14:67. [DOI: ] - PMC - PubMed
Rief 2014b {published data only}
    1. Rief H, Akbar M, Keller M, Omlor G, Welzel T, Bruckner T, et al. Quality of life and fatigue of patients with spinal bone metastases under combined treatment with resistance training and radiation therapy- a randomized pilot trial. Radiation Oncology 2014;9:151. [DOI: ] - PMC - PubMed
Rief 2014c {published data only}
    1. Rief H, Welzel T, Omlor G, Akbar M, Bruckner T, Rieken S, et al. Pain response of resistance training of the paravertebral musculature under radiotherapy in patients with spinal bone metastases – a randomized trial. BMC Cancer 2014;14:485. [DOI: ] - PMC - PubMed
Rief 2016 {published data only}
    1. Rief H, Bruckner T, Schlampp I, Bostel T, Welzel T, Debus J, et al. Resistance training concomitant to radiotherapy of spinal bone metastases – survival and prognostic factors of a randomized trial. Radiation Oncology (London, England) 2016;11:97. [DOI: 10.1186/s13014-016-0675-x] - DOI - PMC - PubMed
Rogers 2013 {published data only}
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Rosenberger 2020 {published data only}
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Rummans 2006 {published data only}
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Sagen 2009 {published data only}
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Segal 2009 {published data only}
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Siedentopf 2013 {published data only}
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Speck 2010 {published data only}
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Sprave 2019 {published data only}
    1. Sprave T, Rosenberger F, Verma V, Forster R, Bruckner T, Schlampp I, et al. Paravertebral muscle training in patients with unstable spinal metastases receiving palliative radiotherapy: an exploratory randomized feasibility trial. Cancers 2019;11(11):1771. [DOI: 10.3390/cancers11111771] - DOI - PMC - PubMed
Sprod 2010 {published data only}
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Taaffe 2018 {published data only}
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Tome Boisan 2010 {published data only}
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Vadiraja 2009 {published data only}
    1. Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR, Rekha M, Vanitha N et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial [Erratum appears in Integr Cancer Ther. 2009 Jun;8(2):195]. Integrative Cancer Therapies 2009;8(1):37-46. [DOI: 10.1177/1534735409331456] - DOI - PubMed
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van der Horst 1985 {published data only}
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VanderWalde 2018 {published data only}
    1. VanderWalde NA, Martin MY, Kocak M, Morningstar C, Deal AM, Nyrop KA, et al. Phase 2 randomized study of a walking intervention for radiation-related fatigue among older breast cancer patients receiving radiation. In: Journal of Clinical Oncology. Vol. 36. 2018. [DOI: 10.1200/JCO.2018.36.15-suppl.10037] - DOI - PubMed
Windsor 2004 {published data only}
    1. Windsor PM, Nicol KF, Potter J. A randomized, controlled trial of aerobic exercise for treatment-related fatigue in men receiving radical external beam radiotherapy for localized prostate carcinoma. Cancer 2004;101(3):550-7. [DOI: 10.1002/cncr.20378] - DOI - PubMed
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    1. Wong WW. Supervised exercise to reduce cardiovascular morbidity of androgen deprivation therapy for prostate cancer. Polish Archives of Internal Medicine 2017;127(1):5-7. - PubMed
Yang 2015 {published data only}
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Yennu 2017 {published data only}
    1. Yennu S, Basen-Engquist K, Reed VK, Carmack CL, Lee A, Mahmood U, et al. Multimodal therapy for cancer related fatigue in patients with prostate cancer receiving radiotherapy and androgen deprivation therapy. In: Journal of Clinical Oncology. Vol. 35. 2017.
Zissiadis 2015 {published data only}
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References to studies awaiting assessment

ISRCTN26140710 {unpublished data only}
    1. ISRCTN26140710. A pilot study to investigate the effects on fitness and quality of life of an individualised exercise programme for breast cancer patients undergoing radiotherapy. www.isrctn.com/ISRCTN26140710 (first received 30 September 2004).
Milecki 2013 {published data only}
    1. Milecki P, Hojan K, Ozga-Majchrzak O, Molińska-Glura M. Exercise tolerance in breast cancer patients during radiotherapy after aerobic training. Wspolczesna Onkologia 2013;17(2):205-9. - PMC - PubMed

References to ongoing studies

NCT04506476 {published data only}
    1. NCT04506476. Trial evaluating the benefit of a fitness tracker based workout during adjuvant radiotherapy of breast cancer (OnkoFit I). www.clinicaltrials.gov/ct2/show/NCT04506476.
NCT04507789 {published data only}
    1. NCT04507789. Exercise therapy during radiotherapy. clinicaltrials.gov/ct2/show/NCT04507789.

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