Although physical and emotional fatigue is the most common side effect of cancer treatment, it remains underreported, underdiagnosed, and undertreated. Yet the exhaustion patients experience can significantly interfere with their daily functioning, and fatigue can persist for months or even years after treatment ends.

Of the non-pharmacologic interventions for cancer-related fatigue, researchers have found exercise to have the strongest potential to produce a therapeutic benefit. Exercise improves a wide range of biopsychosocial outcomes in patients with cancer. Studies have demonstrated that patients who exercise are less tired, less depressed, and sleep better.

Of course, this can be counterintuitive for patients, who often reduce or stop exercising when undergoing fatigue-inducing treatments such as radiation. To counteract this impulse, oncology social workers at Mount Sinai Downtown Cancer Centers in New York City developed a quality improvement initiative to teach patients about the positive effects of exercise during treatment.

The cancer centers—which include three outpatient oncology practices within one hospital system—used the PDSA (plan, do, study, act) quality improvement tool to gauge behavioral change in patients during the study. This tool works by testing a change (plan), carrying out the test (do), observing and learning from the consequences (study), and then determining what modifications should be made to the test (act).

Exercise during treatment

At the start of the initiative, oncology social workers at Mount Sinai met with patients within their first 10 days of radiation treatment. The social workers gave the patients aerobics DVDs tailored for people with cancer, educational information about fatigue, and information on free exercise programs offered onsite and in the community. During this initial meeting, the social workers asked the patients if they exercised.

When the social workers met with the same patients a second time one week after they completed their radiation treatment, they asked several questions about the patients’ exercise routines while being treated. The social workers used the Brief Fatigue Inventory (BFI) to measure patients’ self-reported fatigue. The BFI assesses the severity of fatigue and its impact on daily functioning in patients with cancer. Patients were asked to rate their level of fatigue from 0, which indicates no fatigue, to 10, which indicates the worst fatigue imaginable. A global fatigue score is obtained by averaging all items on the BFI.

Measuring fatigue

Social workers gathered complete data for 38 patients. Patients who reported exercising during treatment had an average initial BFI score of 2.0 and an average post-treatment score of 2.5. Patients who reported not exercising during treatment had an average initial BFI score of 3.1 and an average post-treatment BFI score of 2.9.

The results indicate that patients who exercised while receiving radiation treatment had lower average BFI scores than patients who did not exercise during treatment. This is consistent with the findings of other cancer-related fatigue studies, although it is not statistically significant.

The data also indicates that patients who exercised during treatment had an increase in fatigue post-treatment, whereas people who did not exercise had a decrease in fatigue post-treatment. One could infer that having a lower baseline BFI score might make patients more susceptible to experiencing fatigue during treatment and that exercise may prevent them from becoming as fatigued as they would have had they not exercised.

Looking ahead

At many cancer programs, exercise and wellness programs are offered free of charge, and patients should be made aware of the availability of these and other community resources. Oncology social workers, patient navigators, and advanced practice nurses often have access to information about these programs and should share it with patients. Oncologists should explain to patients the role of exercise in cancer prevention, treatment, and survivorship and emphasize the health benefits associated with exercise during treatment.

A future direction for this initiative may include collaboration with additional providers, such as nurses, to increase the dissemination of information to patients and provide important clinical perspectives. Although this pilot project was limited by its small sample size, it has yielded enough encouraging information to recommend a larger study.

This post is adapted from “Providing Psycho-Education to Combat Fatigue,” an article by Shannon Morton, LMSW, MA; Alison Snow, PhD, LCSW, OSW-C; Anthony H. Bui, MS3; and Manjeet Chadha, MD. It first appeared in the January/February 2019 issue of Oncology Issues.