Skip to main content

Advertisement

SpringerLink
Log in

Cancer-related fatigue mediates the relationships between physical fitness and attendance and quality of life after participation in a clinical exercise program for survivors of cancer

  • Published:
Quality of Life Research Aims and scope Submit manuscript

Abstract

Purpose

Cancer-related fatigue (CRF) is a common and limiting symptom reported by survivors of cancer, negatively impacting health-related quality of life (HRQoL). Exercise improves CRF, HRQoL, and physical fitness in survivors. Prospective research trials have shown that exercise-associated fitness improvements effects on HRQoL are mediated by CRF; however, this has not been investigated in a pragmatic real-world setting. This study utilizes data from a large heterogenous population of survivors participating in a clinical exercise program to investigate this mediation effect, as well as effects of program attendance.

Methods

Data were collected from 194 survivors completing the BfitBwell Cancer Exercise Program (July 2016–February 2020). Changes in HRQoL, CRF, and fitness were calculated and program attendance collected. Basic correlation analyses were performed. Linear regression analyses were performed to assess mediation by CRF.

Results

All measures of CRF, HRQoL, and physical fitness significantly improved following the exercise program. Improvements in physical fitness were significantly correlated with improvements in HRQoL (r = 0.15–0.18), as was program attendance (r = 0.26) and CRF (r = 0.59). The effects of physical fitness and program attendance on HRQoL were at least partially mediated by the effects of CRF.

Conclusion

This study extends research findings on how exercise programs improve HRQoL in survivors of cancer to a real-world setting. Results indicate that clinical exercise programs should target reductions in CRF in survivors (during or after treatment) through improvements in physical fitness to improve HRQoL and that high attendance should be encouraged regardless of fitness changes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

adapted from Mascha et al. 2013. b shows the mediation of the effects of Δ6MWT on ΔFACT-G by ΔFACIT-Fatigue. All regressions controlled for age and BMI. c shows the mediation of the effects of ΔGS on ΔFACT-G by ΔFACIT-Fatigue. All regressions controlled for cancer diagnosis. *p < 0.05. Δ6MWT change in six-minute walk test, ΔGS change in grip strength, ΔFACT-G change in Functional Assessment of Cancer Therapy – General, ΔFACIT-Fatigue change in Functional Assessment of Chronic Illness Therapy–Fatigue, CI confidence interval, BMI body mass index

Fig. 3

Similar content being viewed by others

References

  1. Harrington, C. B., Hansen, J. A., Moskowitz, M., Todd, B. L., & Feuerstein, M. (2010). It’s not over when it’s over: Long-term symptoms in cancer survivors–a systematic review. International Journal of Psychiatry in Medicine, 40(2), 163–181.

    PubMed  Google Scholar 

  2. Lawrence, D. P., Kupelnick, B., Miller, K., Devine, D., & Lau, J. (2004). Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients. Journal of the National Cancer Institute Monographs, 2004(32), 40–50.

    Google Scholar 

  3. Bower, J. E., Ganz, P. A., Desmond, K. A., Bernaards, C., Rowland, J. H., Meyerowitz, B. E., & Belin, T. R. (2006). Fatigue in long-term breast carcinoma survivors: A longitudinal investigation. Cancer, 106(4), 751–758.

    PubMed  Google Scholar 

  4. Cella, D., Davis, K., Breitbart, W., Curt, G., & Fatigue, C. (2001). Cancer-related fatigue: Prevalence of proposed diagnostic criteria in a United States sample of cancer survivors. Journal of Clinical Oncology, 19(14), 3385–3391.

    CAS  PubMed  Google Scholar 

  5. Hofman, M., Ryan, J. L., Figueroa-Moseley, C. D., Jean-Pierre, P., & Morrow, G. R. (2007). Cancer-related fatigue: The scale of the problem. The Oncologist, 12(Suppl 1), 4–10.

    PubMed  Google Scholar 

  6. Scott, K., & Posmontier, B. (2017). Exercise interventions to reduce cancer-related fatigue and improve health-related quality of life in cancer patients. Holistic Nursing Practice, 31(2), 66–79.

    PubMed  Google Scholar 

  7. Bower, J. E. (2014). Cancer-related fatigue–mechanisms, risk factors, and treatments. Nature Reviews Clinical Oncology, 11(10), 597–609.

    CAS  PubMed  PubMed Central  Google Scholar 

  8. Wu, H. S., & Harden, J. K. (2015). Symptom burden and quality of life in survivorship: A review of the literature. Cancer Nursing, 38(1), E29-54.

    PubMed  Google Scholar 

  9. Berger, A. M., Mooney, K., Alvarez-Perez, A., Breitbart, W. S., Carpenter, K. M., Cella, D., Cleeland, C., Dotan, E., Eisenberger, M. A., Escalante, C. P., Jacobsen, P. B., Jankowski, C., LeBlanc, T., Ligibel, J. A., Loggers, E. T., Mandrell, B., Murphy, B. A., Palesh, O., Pirl, W. F., … National comprehensive cancer network. (2015). Cancer-related fatigue, version 2.2015. Journal of the National Comprehensive Cancer Network, 13(8), 1012–1039.

    PubMed  PubMed Central  Google Scholar 

  10. O’Higgins, C. M., Brady, B., O’Connor, B., Walsh, D., & Reilly, R. B. (2018). The pathophysiology of cancer-related fatigue: Current controversies. Supportive Care in Cancer, 26(10), 3353–3364.

    PubMed  Google Scholar 

  11. Ma, Y., He, B., Jiang, M., Yang, Y., Wang, C., Huang, C., & Han, L. (2020). Prevalence and risk factors of cancer-related fatigue: A systematic review and meta-analysis. International Journal of Nursing Studies, 111, 103707.

    PubMed  Google Scholar 

  12. Aaqbali, M., Al Sinani, M., Aaamani, Z., Aadi, K., & Tanash, M. I. (2021). Prevalence of fatigue in patients with cancer: A systematic review and meta-analysis. Journal of Pain and Symptom Management, 61(1), 167-189.e14.

    Google Scholar 

  13. Speck, R. M., Courneya, K. S., Masse, L. C., Duval, S., & Schmitz, K. H. (2010). An update of controlled physical activity trials in cancer survivors: A systematic review and meta-analysis. Journal of Cancer Survivorship, 4(2), 87–100.

    PubMed  Google Scholar 

  14. Loughney, L., West, M. A., Kemp, G. J., Grocott, M. P., & Jack, S. (2015). Exercise intervention in people with cancer undergoing adjuvant cancer treatment following surgery: A systematic review. European Journal of Surgical Oncology, 41(12), 1590–1602.

    CAS  PubMed  Google Scholar 

  15. Mishra, S. I., Scherer, R. W., Geigle, P. M., Berlanstein, D. R., Topaloglu, O., Gotay, C. C., & Snyder, C. (2012). Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database of Systematic Reviews, 2012(8), CD007566.

    PubMed Central  Google Scholar 

  16. Mishra, S. I., Scherer, R. W., Snyder, C., Geigle, P. M., Berlanstein, D. R., & Topaloglu, O. (2012). Exercise interventions on health-related quality of life for people with cancer during active treatment. Cochrane Database of Systematic Reviews, 2012(8), CD008465.

    PubMed Central  Google Scholar 

  17. Campbell, K. L., Winters-Stone, K. M., Wiskemann, J., May, A. M., Schwartz, A. L., Courneya, K. S., Zucker, D. S., Matthews, C. E., Ligibel, J. A., Gerber, L. H., Morris, G. S., Patel, A. V., Hue, T. F., Perna, F. M., & Schmitz, K. H. (2019). Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Medicine and Science in Sports and Exercise, 51(11), 2375–2390.

    PubMed  PubMed Central  Google Scholar 

  18. Kalter, J., Kampshoff, C. S., Chinapaw, M. J., Van Mechelen, W., Galindo-Garre, F., Schep, G., & Buffart, L. M. (2016). Mediators of exercise effects on HRQoL in cancer survivors after chemotherapy. Medicine & Science in Sports & Exercise, 48(10), 1859–1865.

    CAS  Google Scholar 

  19. Schwartz, A. L. (1999). Fatigue mediates the effects of exercise on quality of life. Quality of Life Research, 8(6), 529–538.

    CAS  PubMed  Google Scholar 

  20. Buffart, L. M., De Backer, I. C., Schep, G., Vreugdenhil, A., Brug, J., & Chinapaw, M. J. M. (2013). Fatigue mediates the relationship between physical fitness and quality of life in cancer survivors. Journal of Science and Medicine in Sport, 16(2), 99–104.

    PubMed  Google Scholar 

  21. Buffart, L. M., Galvao, D. A., Chinapaw, M. J., Brug, J., Taaffe, D. R., Spry, N., Joseph, D., & Newton, R. U. (2014). Mediators of the resistance and aerobic exercise intervention effect on physical and general health in men undergoing androgen deprivation therapy for prostate cancer. Cancer, 120(2), 294–301.

    PubMed  Google Scholar 

  22. Buffart, L. M., Ros, W. J., Chinapaw, M. J., Brug, J., Knol, D. L., Korstjens, I., van Weert, E., Mesters, I., van den Borne, B., Hoekstra-Weebers, J. E., & May, A. M. (2014). Mediators of physical exercise for improvement in cancer survivors’ quality of life. Psycho-Oncology, 23(3), 330–338.

    CAS  PubMed  Google Scholar 

  23. Marker, R. J., Cox-Martin, E., Jankowski, C. M., Purcell, W. T., & Peters, J. C. (2018). Evaluation of the effects of a clinically implemented exercise program on physical fitness, fatigue, and depression in cancer survivors. Supportive Care in Cancer, 26(6), 1861–1869.

    PubMed  Google Scholar 

  24. Leach, H. J., Marker, R. J., Scorsone, J. J., Peters, J. C., & Purcell, W. T. (2021). Predictors of attendance during an exercise program for cancer survivors. Supportive Care in Cancer, 29(7), 3425–3428.

    PubMed  Google Scholar 

  25. Covington, K. R., Hidde, M. C., Pergolotti, M., & Leach, H. J. (2019). Community-based exercise programs for cancer survivors: A scoping review of practice-based evidence. Supportive Care in Cancer. https://doi.org/10.1007/s00520-019-05022-6

    Article  PubMed  Google Scholar 

  26. Foley, M. P., & Hasson, S. M. (2016). Effects of a community-based multimodal exercise program on health-related physical fitness and physical function in breast cancer survivors: A pilot study. Integrative Cancer Therapies, 15(4), 446–454.

    PubMed  PubMed Central  Google Scholar 

  27. Sweegers, M. G., Buffart, L. M., van Veldhuizen, W. M., Geleijn, E., Verheul, H. M. W., Brug, J., Chinapaw, M. J. M., & Altenburg, T. M. (2019). How Does a supervised exercise program improve quality of life in patients with cancer? A concept mapping study examining patients’ perspectives. The Oncologist, 24(6), e374–e383.

    PubMed  Google Scholar 

  28. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.

    PubMed  Google Scholar 

  29. Denlinger, C. S., Ligibel, J. A., Are, M., Baker, K. S., Demark-Wahnefried, W., Dizon, D., Friedman, D. L., Goldman, M., Jones, L., King, A., Ku, G. H., Kvale, E., Langbaum, T. S., Leonardi-Warren, K., McCabe, M. S., Melisko, M., Montoya, J. G., Mooney, K., Morgan, M. A., … National comprehensive cancer network. (2014). Survivorship: healthy lifestyles, version 22014. Journal of the National Comprehensive Cancer Network, 12(9), 1222–1237.

    PubMed  PubMed Central  Google Scholar 

  30. Marker, R. J., Kittelson, A. J., Jankowski, C. M., Scorsone, J. J., Peters, J. C., & Purcell, W. T. (2022). Development of a reference chart for monitoring cancer-related fatigue throughout a supervised exercise program. Rehabilitation Oncology, 40, 82–88.

    PubMed  Google Scholar 

  31. Brucker, P. S., Yost, K., Cashy, J., Webster, K., & Cella, D. (2005). General population and cancer patient norms for the Functional Assessment of Cancer Therapy-General (FACT-G). Evaluation and the Health Professions, 28(2), 192–211.

    PubMed  Google Scholar 

  32. Cella, D. F., Tulsky, D. S., Gray, G., Sarafian, B., Linn, E., Bonomi, A., Silberman, M., Yellen, S. B., Winicour, P., Brannon, J., & Eckberg, K. (1993). The functional assessment of cancer therapy scale: Development and validation of the general measure. Journal of Clinical Oncology, 11(3), 570–579.

    CAS  PubMed  Google Scholar 

  33. Cella, D., Lai, J. S., & Stone, A. (2011). Self-reported fatigue: One dimension or more? Lessons from the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Supportive Care in Cancer, 19(9), 1441–1450.

    PubMed  Google Scholar 

  34. Yellen, S. B., Cella, D. F., Webster, K., Blendowski, C., & Kaplan, E. (1997). Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. Journal of Pain and Symptom Management, 13(2), 63–74.

    CAS  PubMed  Google Scholar 

  35. Montan, I., Löwe, B., Cella, D., Mehnert, A., & Hinz, A. (2018). General Population Norms for the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale. Value in Health, 21(11), 1313–1321.

    PubMed  Google Scholar 

  36. Laboratories, A. T. S. C., & o. P. S. f. C. P. F. (2002). ATS statement: Guidelines for the six-minute walk test. American Journal of Respiratory and Critical Care Medicine, 166(1), 111–117.

    Google Scholar 

  37. Mascha, E. J., Dalton, J. E., Kurz, A., & Saager, L. (2013). Statistical grand rounds: Understanding the mechanism: Mediation analysis in randomized and nonrandomized studies. Anesthesia and Analgesia, 117(4), 980–994.

    PubMed  Google Scholar 

  38. Textor, J., van der Zander, B., Gilthorpe, M. S., Liskiewicz, M., & Ellison, G. T. (2016). Robust causal inference using directed acyclic graphs: The R package “dagitty.” International Journal of Epidemiology, 45(6), 1887–1894.

    PubMed  Google Scholar 

  39. Tofighi, D., & Mackinnon, D. P. (2011). RMediation: An R package for mediation analysis confidence intervals. Behavior Research Methods, 43(3), 692–700.

    PubMed  PubMed Central  Google Scholar 

  40. Meneses-Echavez, J. F., Gonzalez-Jimenez, E., & Ramirez-Velez, R. (2015). Effects of supervised multimodal exercise interventions on cancer-related fatigue: Systematic review and meta-analysis of randomized controlled trials. BioMed Research International, 2015, 328636.

    PubMed  PubMed Central  Google Scholar 

  41. Cramp, F., & Byron-Daniel, J. (2012). Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, 11, CD006145.

    PubMed  Google Scholar 

  42. Crosswell, A. D., Lockwood, K. G., Ganz, P. A., & Bower, J. E. (2014). Low heart rate variability and cancer-related fatigue in breast cancer survivors. Psychoneuroendocrinology, 45, 58–66.

    PubMed  PubMed Central  Google Scholar 

  43. Fagundes, C. P., Murray, D. M., Hwang, B. S., Gouin, J. P., Thayer, J. F., Sollers, J. J., 3rd., Shapiro, C. L., Malarkey, W. B., & Kiecolt-Glaser, J. K. (2011). Sympathetic and parasympathetic activity in cancer-related fatigue: More evidence for a physiological substrate in cancer survivors. Psychoneuroendocrinology, 36(8), 1137–1147.

    PubMed  PubMed Central  Google Scholar 

  44. Niederer, D., Vogt, L., Thiel, C., Schmidt, K., Bernhorster, M., Lungwitz, A., Jager, E., & Banzer, W. (2013). Exercise effects on HRV in cancer patients. International Journal of Sports Medicine, 34(1), 68–73.

    CAS  PubMed  Google Scholar 

  45. LaVoy, E. C., Fagundes, C. P., & Dantzer, R. (2016). Exercise, inflammation, and fatigue in cancer survivors. Exercise Immunology Review, 22, 82–93.

    PubMed  PubMed Central  Google Scholar 

  46. Vulpen, J. K. V. A. N., Sweegers, M. G., Peeters, P. H. M., Courneya, K. S., Newton, R. U., Aaronson, N. K., Jacobsen, P. B., Galvão, D. A., Chinapaw, M. J., Steindorf, K., Irwin, M. L., Stuiver, M. M., Hayes, S., Griffith, K. A., Mesters, I., Knoop, H., Goedendorp, M. M., Mutrie, N., Daley, A. J., … Buffart, L. M. (2020). Moderators of exercise effects on cancer-related fatigue: A meta-analysis of individual patient data. Medicine and science in sports and exercise, 52(2), 303–314.

    PubMed Central  Google Scholar 

  47. Morimoto, A., Suga, T., Tottori, N., Wachi, M., Misaki, J., Tsuchikane, R., & Isaka, T. (2017). Association between hand muscle thickness and whole-body skeletal muscle mass in healthy adults: A pilot study. Journal of Physical Therapy Science, 29(9), 1644–1648.

    PubMed  PubMed Central  Google Scholar 

  48. Bohannon, R. W. (2015). Muscle strength: Clinical and prognostic value of hand-grip dynamometry. Current Opinion in Clinical Nutrition and Metabolic Care, 18(5), 465–470.

    PubMed  Google Scholar 

  49. Bohannon, R. W. (2015). Association of grip and knee extension strength with walking speed of older women receiving home-care physical therapy. The Journal of Frailty & Aging, 4(4), 181–183.

    CAS  Google Scholar 

Download references

Acknowledgements

The authors acknowledge Nicole Gleason, Rebecca Kienitz, Jared Scorsone, and Ian Moran for assistance with recruitment, scheduling, and exercise delivery

Funding

REDCap use is supported by NIH/NCRR Colorado CTSI Grant Number UL1 TR002535. DMO was supported by F32DK122652.

Author information

Authors and Affiliations

  1. University of Colorado Anschutz Medical Campus, 12348 E Montview Blvd, MS C263, Aurora, CO, 80045, USA

    Ryan J. Marker, Danielle M. Ostendorf & John C. Peters

  2. Colorado State University, Fort Collins, CO, USA

    Heather J. Leach

Authors
  1. Ryan J. Marker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Danielle M. Ostendorf
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Heather J. Leach
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. John C. Peters
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to study conception and design. Material preparation and data collection and analysis were performed by RJM and DMO. The first draft of the manuscript was written by RJM and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ryan J. Marker.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

Collection and use of clinical program data was approved by the Colorado Multiple Institutional Review Board (COMIRB).

Consent to participate

Data used in this study were collected only from individuals who provided written informed consent for their clinical program data to be used in future research.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 812 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marker, R.J., Ostendorf, D.M., Leach, H.J. et al. Cancer-related fatigue mediates the relationships between physical fitness and attendance and quality of life after participation in a clinical exercise program for survivors of cancer. Qual Life Res 31, 3201–3210 (2022). https://doi.org/10.1007/s11136-022-03173-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11136-022-03173-4

Keywords

Search

Navigation