Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial

BACKGROUND:

Cancer‐related fatigue afflicts up to 33% of breast cancer survivors, yet there are no empirically validated treatments for this symptom.

METHODS:

The authors conducted a 2‐group randomized controlled trial to determine the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent post‐treatment fatigue. Participants were breast cancer survivors who had completed cancer treatments (other than endocrine therapy) at least 6 months before enrollment, reported significant cancer‐related fatigue, and had no other medical conditions that would account for fatigue symptoms or interfere with yoga practice. Block randomization was used to assign participants to a 12‐week, Iyengar‐based yoga intervention or to 12 weeks of health education (control). The primary outcome was change in fatigue measured at baseline, immediately post‐treatment, and 3 months after treatment completion. Additional outcomes included changes in vigor, depressive symptoms, sleep, perceived stress, and physical performance. Intent‐to‐treat analyses were conducted with all randomized participants using linear mixed models.

RESULTS:

Thirty‐one women were randomly assigned to yoga (n = 16) or health education (n = 15). Fatigue severity declined significantly from baseline to post‐treatment and over a 3‐month follow‐up in the yoga group relative to controls (P = .032). In addition, the yoga group had significant increases in vigor relative to controls (P = .011). Both groups had positive changes in depressive symptoms and perceived stress (P < .05). No significant changes in sleep or physical performance were observed.

CONCLUSIONS:

A targeted yoga intervention led to significant improvements in fatigue and vigor among breast cancer survivors with persistent fatigue symptoms. Cancer 2012. © 2011 American Cancer Society.     

Feasibility of a self‐help treatment for insomnia comorbid with cancer

Objective: Professionally administered cognitive‐behavioral therapy (CBT) is efficacious for treating insomnia in breast cancer survivors. However, given the limited accessibility to CBT for insomnia in cancer clinics, there is a need to develop other delivery formats for this intervention. This feasibility study examined patients' satisfaction with a self‐help CBT for insomnia comorbid with cancer and gathered some preliminary data on its effect on sleep and associated features. Methods: Eleven breast cancer patients reporting insomnia symptoms received a 6‐week intervention composed of a 60‐min video using an animated cartoon format and 6 short booklets developed in French. Patients completed a semi‐structured interview at post‐treatment, a battery of self‐report scales and a daily sleep diary (14 days) at pre‐ and post‐treatment and at a 3‐month follow‐up. Results: At post‐treatment interview, comments about the treatment material were uniformly positive. On a questionnaire, patients also reported to be satisfied with the treatment overall, with the video and the booklets' content, as well as with their sleep improvement at post‐treatment (scores from 2.7 to 3.1; scale from 0 to 4). From pre‐ to post‐treatment, moderate‐to‐large effect sizes and statistically and clinically significant differences were found on most sleep variables, as well as overall quality of life. These therapeutic gains were well sustained at a 3‐month follow‐up. Conclusions: Patients were satisfied with the treatment received. Although it is too early to draw any firm conclusion, treatment outcomes suggest a potential for integration into routine cancer care as a first‐line sleep management intervention. Copyright © 2010 John Wiley & Sons, Ltd.     

Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia

Objective: Insomnia is a common complaint among cancer survivors. Fortunately, cognitive‐behavioral therapy for insomnia (CBT‐I) has been shown to be an effective treatment in this population. However, it is rarely implemented given its limited availability. To address this barrier, we examined the ability of an easily accessible online CBT‐I program to improve insomnia symptoms in cancer survivors. Methods: Twenty‐eight cancer survivors with insomnia were randomly assigned to either an Internet insomnia intervention (n = 14) or to a waitlist control group (n = 14). The online program, Sleep Healthy Using The Internet, delivers the primary components of CBT‐I (sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relapse prevention). Pre‐ and post‐assessment data were collected via online questionnaires and daily sleep diaries. Results: Participants in the Internet group showed significant improvements at post‐assessment compared with those in the control group in overall insomnia severity (F_1,26 = 22.8; p<0.001), sleep efficiency (F_1,24 = 11.45; P = 0.002), sleep onset latency (F_1,24 = 5.18; P = 0.03), soundness of sleep (F_1,24 = 9.34; P = 0.005), restored feeling upon awakening (F_1,24 = 11.95; P = 0.002), and general fatigue (F_1,26 = 13.88; P = 0.001). Although other group × time interactions were not significant, overall adjusted effect sizes for all sleep variables as well as for fatigue, depression, anxiety, and quality of life ranged from small to large. Conclusions: CBT‐I delivered through an interactive, individually tailored Internet intervention may be a viable treatment option for cancer survivors experiencing insomnia. Copyright © 2011 John Wiley & Sons, Ltd.     

The effectiveness of a psycho‐educational group after early‐stage breast cancer treatment: results of a randomized French study

Background: Many women with breast cancer need psychological help to cope more effectively after treatment. Cognitive and behavioural techniques are not yet well established in France. A multi‐site randomized study was conducted to evaluate the effects of a psycho‐educational group intervention in this population. Methods: Two hundred and three patients, recruited after primary treatment, were randomly assigned either to a treatment group (psycho‐educational intervention) or to a waiting‐list control group. The 8‐week programme of 2 h sessions comprised of thematic discussions, information and training in stress management techniques. Evaluation at baseline, after 8 sessions, and 1 month after programme completion, included evaluations using the STAI, POMS, MAC, EORTC QLQ‐C30 and EORTC QLQ‐BR23 breast module scales. Results: We observed a significant reduction in anxiety (STAI, POMS) among group participants, a reduction in anger, depression and fatigue (POMS), a significant improvement in vigor and interpersonal relationships (POMS), in emotional and role functioning, in health status and fatigue level (EORTC QLQ‐C30). In contrast, coping strategies (MAC) were not significantly different between groups. No group‐related negative effects were observed and the global satisfaction levels were very high. Conclusion: This study demonstrates the feasibility and effectiveness of a psycho‐educational intervention, which can accelerate the reduction of those negative affects which are present at the end of treatment. It represents an excellent complement or an alternative to individual psycho‐oncologic therapeutic support, widely proposed in France, and should now be tested in groups with other types of cancer and at other disease phases. Copyright © 2008 John Wiley & Sons, Ltd.     

Peer support for physical activity adoption among breast cancer survivors: Do the helped resemble the helpers?

Interventions offering peer mentoring programmes promoting moderate‐to‐vigorous physical activity (MVPA) have shown improvements in MVPA and well‐being from baseline; however, research is limited. The purpose of this study was to compare the physical activity (PA) levels and psychosocial well‐being of coaches and participants at baseline and following a 12‐week intervention. Breast cancer survivors (<5 years) were recruited and randomised into either exercise (Reach‐to‐Recovery (RTR) + PA) or control (RTR Control). Participants in both groups were individually assigned one of the 18 available coaches who delivered either the MVPA intervention or the control condition via telephone. PA (7‐Day PA Recall), psychosocial well‐being, fatigue and mood were assessed at baseline and intervention completion. Seventy‐six breast cancer survivors (average age = 55.62 (±9.55)) were randomised. At baseline, all participants showed significantly lower MVPA (p = .001) and well‐being (p < .05) as compared to coaches. However, post‐intervention showed significant improvement in PA and well‐being in RTR + PA, so that they were no longer significantly different from the coaches. Post‐intervention, MVPA (p < .01), quality of life (p < .05) and fatigue (p < .05) remained significantly lower in RTR Controls compared to coaches. Future interventions should consider the behavioural patterns not only of the participants, but also of those who deliver the interventions.     

The effect of group cohesion on rehabilitation outcome in cancer survivors

Objective: Group‐based physical training interventions have been shown to be effective in increasing quality of life in cancer survivors. Until now, however, the impact of cohesion within the group on intervention outcome has not been investigated. Methods: We examined self‐reported individual group cohesion ratings collected in the first half of a 12‐week rehabilitation programme for cancer survivors (N=132). Four dimensions of group cohesion were measured, i.e. the bond with the group as whole, the bond with other members, cooperation within the group and the instrumental value. Quality of life, physical functioning and fatigue were assessed before and after the intervention using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire‐C30. Linear multiple multivariate regression analysis was conducted to explore the relationship between group cohesion and intervention outcome. Results: The relationship between group cohesion and outcome was significantly modified by gender. Higher ratings of cooperation within the group predicted better post‐intervention quality of life and physical functioning and less fatigue in men, and better quality of life and physical functioning in women. Additionally, women who reported a stronger bond with other members showed a lower quality of life after the intervention. No relationship was found between the instrumental value and the outcome variables. Conclusion: Some dimensions of group cohesion seem to be associated with intervention outcome. The underlying mechanisms need to be unravelled. Copyright © 2007 John Wiley & Sons, Ltd.     

Prospective assessment of quality of life in long‐term ovarian cancer survivors

The objective of our study was to compare prospectively the QoL in long‐term ovarian cancer survivors with short‐term survivors and to explore discriminating variables between short‐term and long‐term survival. Thirty‐three patients were included, 22 died within 5 years post diagnosis and 11 survived beyond 10 years. QoL data were collected pre‐treatment (baseline), 1‐year post diagnoses and for long‐term survivors 10 years post‐treatment using the EORTC QLQ‐C30. At baseline, there was no difference in terms of FIGO stage, residual tumor and adjuvant chemotherapy. Significantly, more short‐term survivors (96%) had intra operative ascites as compared to long‐term survivors (55%) (p=0.01). Before treatment, short‐term survivors had clinically significantly lower QoL scores on the physical functioning (mean 75.45) and role functioning scale (mean 68.94) compared to long‐term survivors (mean 68.94 and 84.85, respectively). They also reported higher levels of symptoms. One year post‐diagnosis, QoL scores were comparable in most domains. Long‐term survivors had a significantly better global QoL but more insomnia. Emotional functioning and global QoL/health status improved significantly from baseline to 1‐year post‐diagnosis and remained relatively stable at the 10‐year follow‐up. The presence of intra operative ascites and a supporting social network were identified as significant variables that discriminated between short‐term and long‐term survival. Compared to a reference sample, long‐term survivors showed similar QoL scores but more dyspnoea. Although ovarian cancer patients do not belong to the most prevalent survivor populations, we found that long‐term survivors have QoL scores similar to females without a history of cancer.     

A brief self‐administered psychological intervention to improve well‐being in patients with cancer: results from a feasibility study

Background: Patients with cancer have relatively high rates of anxiety and distress, adversely affecting their well‐being and quality of life. Recent studies indicate that addressing these symptoms could result in better response to cancer treatment. Researchers have found that interventions that focus on increasing mental awareness and the frequency of positive experiences may have a greater impact on reducing psychological morbidity and increasing quality of life than interventions that target relief of psychological symptoms. Aim: To develop and test a brief, easy to use intervention that could improve well‐being and quality of life in cancer patients. Methods: We developed a simple well‐being intervention that made few demands on patient time and required little training resource. Participants were randomly assigned to an intervention group or a deferred entry group. Measures of anxiety, depression, well‐being and quality of life were administered at baseline and at follow‐ups. Results: Twenty‐two women with metastatic breast cancer and 24 men with metastatic prostate cancer were recruited from oncology clinics. Thirteen women and 14 men completed the study. Both qualitative and quantitative data showed that the intervention was acceptable to users. There was statistically significant improvement in quality of life scores on WHOQOL‐BREF post‐intervention (p=0.046). Compliance with the intervention was good. Conclusions: This brief well‐being intervention appears to be a promising technique for improving quality of life of cancer patients, without making undue demands on staff resources or patient time. If further studies confirm its effectiveness, it could prove to be a cost‐effective intervention. Copyright © 2009 John Wiley & Sons, Ltd.     

Impact of a meaning‐centered intervention on job satisfaction and on quality of life among palliative care nurses

Objective: Palliative care (PC) nurses experience several recurrent organizational, professional, and individual challenges. To address existential and emotional demands, the meaning‐centered intervention was recently developed. The intervention applied didactic and process‐oriented strategies, including guided reflections, experiential exercises, and education based on themes of Viktor Frankl's logotherapy. The objective of this study was to test its efficiency to improve job satisfaction and quality of life in PC nurses from three regional districts in Quebec Province, Canada. Methods: A randomized waiting‐list group design was conducted, intervention group (n=56) versus waiting‐list group (n=53). Job satisfaction, perception of benefits of working in PC, and spiritual and emotional quality of life were measured at pre‐, posttest, and 3‐month follow‐up. Results: The PC nurses in the experimental group reported more perceived benefits of working in PC after the intervention and at follow‐up. Spiritual and emotional quality of life remained, however, unaffected by the intervention. Conclusions: To explain null findings, theoretical and methodological challenges, related to existential interventions, such as choice of outcomes, and selection bias (participants recruited were healthy workers) are discussed. Future directions and strategies to deal with those issues are proposed. Copyright © 2009 John Wiley & Sons, Ltd.     

Development of CBT for chemotherapy-related cognitive change: results of a waitlist control trial

Objective: To evaluate the efficacy of a brief cognitive‐behavioral therapy (CBT) that is being developed for management of cognitive dysfunction following chemotherapy among breast cancer survivors. Memory and Attention Adaptation Training (MAAT) is a brief CBT designed to improve the quality of life and function among cancer survivors with post‐chemotherapy cognitive complaints. Methods: An initial, two‐group (MAAT versus waitlist, no treatment control), randomized clinical trial (RCT) was conducted. Forty stage I and II female breast cancer survivors (mean age = 50; SD = 6.4) were randomized to conditions and assessed at baseline, post‐treatment (8 weeks) and 2‐month follow‐up assessment points on measures of: (1) self‐reported daily cognitive failures; (2) quality of life; and (3) neuropsychological performance. Participants were also assessed for satisfaction with MAAT. Results: With education and IQ as covariates, MAAT participants made significant improvements relative to controls on the spiritual well‐being subscale of the quality of life measure and on verbal memory, but statistical significance was not achieved on self‐report of daily cognitive complaints. However, moderate‐to‐large effect sizes were observed on these outcomes. Participants gave MAAT high satisfaction ratings. Conclusions: Although this initial RCT is a small study, MAAT participants appear to improve on one measure of quality of life and verbal memory performance relative to no treatment controls and rate MAAT with high satisfaction. These data are encouraging and support the continued development and evaluation of MAAT efficacy.Copyright © 2010 John Wiley & Sons, Ltd.     

Changes in metabolic risk,insulin resistance,leptin and adiponectin following a lifestyle intervention in overweight and obese breast cancer survivors

Adiposity and physical activity are modifiable factors that could be important determinants of breast cancer (BC) prognosis through their effects on endogenous reproductive hormones, chronic inflammation and metabolic changes. Therefore, it is necessary to evaluate whether offering lifestyle interventions to BC survivors could affect the levels of certain biomarkers involved in these mechanisms. We designed a pre–post intervention study offering diet and exercise sessions over 12 weeks to 42 overweight/obese BC survivors. Before and after the intervention, we obtained dietary information, anthropometry and cardiorespiratory fitness (CRF) measurements and blood samples to measure metabolic risk, insulin resistance and adipokines biomarkers. Wilcoxon signed‐rank tests and Spearman partial correlation coefficients were used to compare pre‐ and post‐measurements and assess the correlations between changes in biomarkers and changes in anthropometry and CRF. Breast cancer survivors showed significant improvements in metabolic risk biomarkers and insulin resistance indicators along with a non‐significant leptin decrease and a significant adiponectin decrease. The improvements in metabolic risk biomarkers, insulin resistance indicators and leptin were moderately correlated (0.32 ≤ |r| ≤ 0.55) with the decrease in body mass index and the increase in CRF. Diet and exercise interventions implemented in overweight/obese BC survivors may improve metabolic risk, insulin resistance and leptin biomarkers.     

Inflammation and fatigue dimensions in advanced cancer patients and cancer survivors

BACKGROUND:

Inflammation may underlie cancer‐related fatigue; however, there are no studies that assess the relation between fatigue and cytokines in patients with advanced disease versus patients without disease activity. Furthermore, the relation between cytokines and the separate dimensions of fatigue is unknown. Here, association of plasma levels of inflammatory markers with physical fatigue and mental fatigue was explored in advanced cancer patients and cancer survivors.

METHODS:

A total of 45 advanced cancer patients and 47 cancer survivors completed the subscales Physical Fatigue and Mental Fatigue of the Multidimensional Fatigue Inventory. Plasma concentrations of C‐reactive protein (CRP), interleukin‐1 receptor antagonist (IL‐1‐ra), interleukin‐6 (IL‐6), interleukin‐8 (IL‐8), and neopterin were measured. Nonparametric tests were used to assess differences in fatigue intensity and levels of inflammatory markers and to determine correlation coefficients between the fatigue dimensions and inflammatory markers.

RESULTS:

Compared with cancer survivors, patients with advanced cancer had higher levels of physical fatigue (median 16 vs 9, P < .001) and mental fatigue (median 11 vs 6, P = .01). They also had higher levels of all cytokines (P < .01). In advanced cancer, CRP (r = 0.49, P = .001), IL‐6 (r = 0.43, P = .003), IL‐1‐ra (r = 0.32, P = .03), and neopterin (r = 0.25, P = .10) were correlated with physical but not with mental fatigue. In cancer survivors, only IL‐1‐ra was related to both physical fatigue (r = 0.24, P = .10) and mental fatigue (r = 0.35, P = .02).

CONCLUSIONS:

In advanced cancer, inflammation seems to be associated with physical fatigue, but not to mental fatigue. In cancer survivors, there was no convincing evidence that inflammation plays a major role in fatigue. Cancer 2012. © 2012 American Cancer Society.     

The ONE‐MIND Study: Rationale and protocol for assessing the effects of ONlinE MINDfulness‐based cancer recovery for the prevention of fatigue and other common side effects during chemotherapy

Cancer patients often experience poor quality of life (QoL) during chemotherapy (CT) treatments due to side effects including fatigue, insomnia, pain and nausea/vomiting. Mindfulness‐based cancer recovery (MBCR) is an evidence‐based intervention for treating such symptoms, but has not been investigated as an adjunctive treatment during CT. This study aims to determine the efficacy of an online group MBCR programme delivered during CT in 12 real‐time interactive weekly sessions for managing fatigue (primary outcome). Secondary outcomes include sleep disturbance, pain, nausea/vomiting, mood, stress and QoL. Exploratory outcomes include cognitive function, white blood cell counts and return to work. The study is a two‐armed randomised controlled waitlist trial with 2:1 allocation to treatment (online group MBCR during CT) or control (waitlist usual care; online MBCR following CT completion) with a target sample size of N = 178. Participants are breast or colorectal cancer patients undergoing common CT regimens in Calgary, Canada. Online assessments using validated self‐reported instruments will take place at baseline, post‐MBCR, post‐CT and 12 months’ post‐baseline. If online MBCR delivered during CT significantly reduces fatigue in cancer patients’ post‐CT and also impacts secondary symptoms, this would provide evidence for including mindfulness training as an adjunctive symptom management therapy during CT.     

Neuropsychological functioning and quality of life during the first year after completing chemotherapy for breast cancer

Objective: Research has documented modest cognitive difficulties among women treated for breast cancer. The present study was designed to evaluate the effects of these subtle cognitive changes on quality of life after treatment. Methods: Data are presented from women breast cancer patients who completed neuropsychological tests and questionnaires regarding quality of life 6 and 12 months post‐chemotherapy (n's=39 and 33). Neuropsychological test scores were examined for evidence of cognitive difficulties at each time point; repeated measures ANOVAs were used to identify changes over time. Regression analyses assessed relationships of quality of life outcomes with cognitive functioning, social support seeking, and fatigue. Results: Small percentages of participants (<20% across tests) evidenced deficits in delayed memory, processing speed, response inhibition, and verbal fluency (VF) at each time point. Reliable change index analyses suggested statistically reliable improvements in each cognitive domain for a modest portion of participants. Regressions revealed hesitation to seek social support and fatigue as the most consistent predictors of quality of life at 6 and 12 months post‐chemotherapy. Cognitive complaints and VF difficulties were also significantly related to quality of life at 12 months. Conclusions: In addition to confirming the importance of fatigue and social support in quality of life, these data offer preliminary indications that weaker VF skills and self‐reported cognitive complaints may be associated with poorer functional outcomes among cancer survivors. Further research is needed to validate these potential relationships, which suggest that cognitive difficulties among cancer survivors may warrant monitoring and possible intervention. Copyright © 2009 John Wiley & Sons, Ltd.     

Long‐term cancer survivors experience work changes after diagnosis: results of a population‐based study

Background: Although cancer survivorship is increasing with improved diagnosis and treatments, few studies have explored employment changes and the factors related to this change among cancer survivors. Therefore, we aim to explore the prevalence of employment problems in long‐term cancer survivors. In addition, we explored what patient or tumour characteristics predicted employment changes. Methods: All 1893 long‐term survivors of prostate cancer, endometrial cancer, non‐Hodgkin's lymphoma, and Hodgkin's lymphoma diagnosed between 1989 and 1998 in the area of the Comprehensive Cancer Centre South, The Netherlands were included in a population‐based cross‐sectional survey. Results: Response rate was 80% (n=1511). After excluding survivors without a job before diagnosis, 403 survivors remained; 197 (49%) experienced no changes in their work situation following cancer diagnosis, 69 (17%) were working fewer hours, and 137 (34%) stopped working or retired. A medium educational level was significant in reducing the risk of work changes. Being older, having more than one comorbid condition, being treated with chemotherapy, and disease progression were significant independent predictors of work changes after cancer. Experiencing work changes was associated with lower physical functioning but positively associated with social well‐being. Discussion: Long‐term cancer survivors experience work changes after diagnosis and treatment, and clinical factors significantly predicted work change after cancer. As such, our study underscores the importance of rehabilitation programs in improving the return to work after cancer. Copyright © 2009 John Wiley & Sons, Ltd.     

Post‐traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults

Objective: We examined whether post‐traumatic growth would moderate the impact of intrusive thoughts on a range of dimensions of well‐being in a sample of younger adult survivors of various types of cancer. Methods: 167 participants completed questionnaires regarding intrusive thoughts, post‐traumatic growth, mental and physical health‐related quality of life, positive and negative affect, life satisfaction, and spiritual well‐being. Multiple regression analyses controlling for relevant background and cancer‐related variables tested the interaction effects of post‐traumatic growth and intrusive thoughts. Results: Intrusive thoughts were related to poorer adjustment on all indices except physical health‐related quality of life. However, post‐traumatic growth moderated the effects of intrusive thoughts on positive and negative affect, life satisfaction, and spiritual well‐being in a protective fashion. That is, for those higher in post‐traumatic growth, higher levels of intrusive thoughts were related to better adjustment. Conclusions: The positive meaning that individuals assign to their cancer experience as reflected in their reports of post‐traumatic growth appears to be important in determining the impact of intrusive thoughts on post‐cancer adjustment. Copyright © 2009 John Wiley & Sons, Ltd.     

Efficacy of a web‐based cognitive rehabilitation intervention for adult cancer survivors: A pilot study

The purpose of this study was to evaluate the efficacy of a web‐based cognitive rehabilitation intervention in survivors of adult‐onset cancer and a sample of non‐cancer community dwelling adults. Fifty‐one participants were recruited and allocated to a cancer intervention group, a non‐cancer intervention group, or a non‐cancer waitlist group. Intervention groups completed a 4‐week online program and all participants were assessed at baseline, post‐intervention and 3‐month follow‐up. The primary outcome measure was subjective cognitive functioning. Secondary outcome measures included objective cognitive functioning, distress, quality of life (QoL), illness perception and program satisfaction. Results from the study found significant improvements on self‐report measures of cognitive functioning in both treatment groups, as well as improvements on objective measures assessing attention and executive functioning. No intervention effects were observed for distress, QoL or illness perception. High participant satisfaction was observed with 75% of participants in the cancer group reporting being either “satisfied” or “very satisfied” with the program compared to 87% in the non‐cancer treatment group. Initial evaluation of the program suggests that the web‐based cognitive rehabilitation intervention shows potential for improving subjective and objective cognitive functioning in cancer survivors and community dwelling adults.