To evaluate the effect of a structured supervised outpatient exercise program on insomnia and depression in patients with cancer.

Patients were referred by their oncologist office to the program. Participants were consented, administered two instruments before and after, and then participated in a 90-minute structured, supervised exercise program two days per week. The exercise consisted of a warm-up, cardiovascular circuit training, strength training, and cool down. The program was for 10 weeks.

• N = 75 
• MEAN AGE: 59 years (SD = 10)
• MALES: 23.1%  
• FEMALES: 59.7%
• CURRENT TREATMENT: Combination of radiation therapy and chemotherapy 
• KEY DISEASE CHARACTERISTICS: Currently on treatment for any type of cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Older than age 18, excluded if within 8 weeks of surgery, within 6 months of treatment, cognitive issues excluded

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: 40-facility Catholic healthcare system in Stockton, California

PHASE OF CARE: Active anti-tumor treatment

• Descriptive observational study
• Patients consented and enrolled

• Insomnia measured with Athens Insomnia scale (AIS)
• Depression measured with Zung Self-Rating Depression Scale (ZSDS)
• Both tests administered on the first and last day of the 10-week program

75 patients were enrolled and 40 completed the 10-week program. The study demonstrated a significant improvement in insomnia. Baseline scores (mean = 9.5; SD = 3.7) compared to final scores (mean = 6.3; SD = 3.5) showed (t = 4.468; p = 0.01). The significance level of 0.05 is over the 90%. The depression scores were also seen as significantly different from baseline (mean = 37.4; SD = 9.7) and final scores (mean = 33; SD = 9.7) (t = 2.427; p = 0.01). The significance of 0.05 is about 80%. The study team also evaluated those who did not complete the program and there was no difference. Depression scores at baseline were higher for those who did not complete the program.

This study showed improvement in depression and insomnia in patients with cancer who participated in a structured, supervised exercise program.

• Small sample (< 100)
• Baseline sample/group differences of import        
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable
• Subject withdrawals ≥ 10%

Nurses should assess patients for insomnia and depression and provide appropriate referrals to structured exercise programs. The cost is low and many cancer centers have existing exercise programs for fatigue which could be combined with the mental health benefits. Nurses could encourage and participate in development of these programs with their healthcare and community fitness centers where none currently exist.

• STUDY PURPOSE: To evaluate the effects of exercises and aerobic on cancer survivors
• TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: Web of Science, Scopus, Cochrane Library, CINAHL, Medline
• YEARS INCLUDED: 1988-2017
• INCLUSION CRITERIA: Adult diagnosed with cancer
• EXCLUSION CRITERIA: Not specified

• TOTAL REFERENCES RETRIEVED: 65 articles for 140 meta-analyses reported
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Umbrella review following PRISMA

• FINAL NUMBER STUDIES INCLUDED: 65 
• TOTAL PATIENTS INCLUDED IN REVIEW: Not specified. Each category (cardiovascular fitness = 8,306 (55-1,310), muscle strength = 10,367 (241-1,244), fatigue = 59,233 (78-5,603), quality of life = 24,893 (78-2,357), depression = 13,538 (78-2,929); some patients are not reported in few articles.
• SAMPLE RANGE ACROSS STUDIES: See above in parenthesis for each category. 
• KEY SAMPLE CHARACTERISTICS: Different type of cancer

PHASE OF CARE: Not specified or not applicable

The effects of exercises on thousands of patients in 140 meta-analyses are reviewed. The beneficial effect is statistically significant in 75% of the meta-analyses. The effect for cardiovascular fitness and muscle strength are classified as moderate, and the effect on fatigue, quality of life, and depression are classified as small. The incidence of exercise-related adverse event is very low (3.5%). The large majority of the studied cancer population are patients with breast cancer.

The study shows how exercises have an important role in the well-being of patients and survivors. It would be interesting to have another meta-analyses on different cancer populations and at different stages of the disease/treatment. It would also be interesting to have the results by gender.

• Low sample sizes
• This study is mostly about patients with breast cancer

Nurses should encourage patients to have a physical activity. Cardiovascular markers and muscular fitness is improved with exercises as well as depression, fatigue, and quality of life to a lesser extent. In addition, it is relatively easy to find information on how to exercise.

To determine the effectiveness of physical activity following surgery for breast cancer in improving depression and quality of life

Participants were randomized between a CBSM (cognitive behavioral stress management) intervention group (which corresponds to a 2 hours per week meeting for 10 consecutive weeks) and a single-day psychoeducational control group. The CBMS intervention consist in a structured intervention with relaxation and cognitive behavioral therapy, coping effectiveness training, assertiveness, and anger management.

• N = 240   
• AVERAGE AGE: 50.3 years
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer; surgery for primary breast cancer in the 2-10 weeks prior to enrollment.
• OTHER KEY SAMPLE CHARACTERISTICS: More than 50 % have completed a college degree; more than 75% are married or partnered. Exclusion: Diagnosis of stage IV breast cancer or other cancer, except skin cancer

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Miami, Florida

PHASE OF CARE: Active anti-tumor treatment

Randomized control trial

7-item Perceived Interference Subscale of the 12-item Fatigue Symptom Inventory, IBS for depression, 7-Item Functional Well-Being Subscale of the Functional Assessment of Cancer Therapy (FACT-B)

Both the control and the intervention arm saw significant changes in clinician-rated depression and depressed mood (control: standardized B = 0.15; B = 0.29, p = 0.049; p < 0.001) (intervention: standardized B = 0.14; B = 0.29, p < 0.001;p < 0.001) with regard to FRDI; however, there were no significant changes in functional QOL with either arms with regard to FRDI.

The study shows that a moderate physical activity improves fatigue, depression, and quality of life for patients with breast cancer , and nurses should make a point of encouraging this. Future replications are needed, the sample chosen may already have the awareness of the health benefits of physical activity before the study was enacted.

• Key sample group differences that could influence results
• Findings not generalizable
• Other limitations/explanation: The limitation can be seen in the fact that the data have been collected in a group of White, highly motivated, well-educated women. Those results should not be generalized to an entire population.

Nurses should encourage physical activity in patients with breast cancer.

To examine the long-term changes of anxiety, depression, and fatigue in patients with cancer six months after a yoga intervention

Gentle hatha yoga provided to the participants in small groups under supervision and guidance. 60 minutes once a week for 8 weeks total. Participants also received a CD and a printed manual to motivate training at home.

• N = 58   
• AVERAGE AGE: 58 years 
• MALES: 10%  
• FEMALES: 90% 
• KEY DISEASE CHARACTERISTICS: 55% breast cancer, remaining other cancers (lymphoma, leukemia, colorectal cancer, ovarian cancer, and endometrial cancer)

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Germany

PHASE OF CARE: Active anti-tumor treatment

Prospective observational one group pre-/post-test design

Self-reported Generalized Anxiety Disorder Scale (GAD-7) to measure anxiety, Patient Health Questionnaire (PHQ-2) to measure depression, European Organization for Research and Treatment of Cancer QOL (EORTC) Questionnaire-Fatigue scale to measure fatigue

There was a statistically significant reduction in the anxiety, depression, and fatigue levels after six months from the baseline. A small time effect on anxiety (SES = 0.22, CI [-0.3, 0.47]) and fatigue (SES = 0.27, CI [-0.11, 0.13]) indicating slight nonsignificant increase of symptoms. No time effect found in terms of depression (SES = 0.01, CI = [-0.11, 0.13]).

Although the study shows reduction in outcomes, studies with larger sample sizes with better study designs (i.e., RCT) are needed to confirm the findings.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Questionable protocol fidelity

Yoga appears to have some benefit in reducing the symptoms of anxiety, depression, and fatigue, and the benefits may be lasting. Additional research with randomized studies will be important to confirm these results.

To examine the effect of two psilocybin doses on symptoms of anxiety and depression among patients with advanced cancer

Participants were assigned to two groups: one received low-dose psyilocybin in the first session and high-dose psyilocybin in a second session. The other group received psilocybin doses in reverse order. The first session was done about one month after study entry, and the second session was five weeks later. Study measures were obtained at baseline, during, and at the end of each session, and approximately six months later. Session monitors met with patients prior to sessions to establish rapport and prepare the patient for the sessions. Drug session were done in a living room-like environment with two monitors present.

• N: 56 (46 at 6 months)   
• MEAN AGE: 56.3 years (SD = 1.4)
• MALES: 51%  
• FEMALES: 49%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: All had life-threatening cancer diagnoses and DSM-IV diagnoses of anxiety or mood symptoms  Various tumor types
• OTHER KEY SAMPLE CHARACTERISTICS: 69% married, 47% used cannabinoids, 51% had prior medication for anxiety or depression.  Almost all had at least a college education

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Johns Hopkins, Maryland

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Crossover, double blind, randomized study

• Cardiovascular monitoring during sessions
• Session monitor ratings of participant behaviors and mood throughout session
• Hallucinogen Rating Scale
• 5 Dimension Altered States of Consciousness
• Mysticism Scale
• States of Consciousness Questionnaire
• Mystical Experience Questionnaire
• GRID-HAM-D-17 (for depression)
• HAM_A (for anxiety)
• Beck Depression Inventory
• Hospital Anxiety and Depression Scale 
• POMS 
• Spiritual Religious Outcomes Scale
• STAI State trait anxiety

There were no serious adverse effects of the intervention. There were transient moderate increases in blood pressure after psilocybin. Transient psychological distress was seen in some patients with high-dose psilocybin. All measures of depression, anxiety, and total mood disturbance showed significant improvement with high dose (p < 0.001). Death acceptance and optimism also were increased with high-dose intervention (p < 0.01). These changes were maintained at 6 months.

High-dose psilocybin under supportive conditions was shown to decrease symptoms of depression and anxiety, and improve mood, optimism, acceptance of death and spirituality. These effects were generally maintained for months after drug use.

• Small sample (< 100)
• Risk of bias (no control group)
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Subjects took a large battery of tests repeatedly raising the question of possible testing affect and subject fatigue. The intervention was provided in a controlled supportive environment

Administration of psilocybin under controlled supportive conditions was shown to have multiple benefits for patients with terminal cancers. Further confirmatory research is warranted, and research comparing outcomes with psilocybin to other appropriate interventions would be helpful.

To determine the long-term (nine months) effectiveness of three different group interventions compared to usual care for patients with breast cancer 

Participants were allowed to select one of three groups to receive either cognitive behavioral therapy, yoga, and self-hypnosis. People who declined to participate were in a control group. Measurements were taken T0 through T3 to include before and after the short-term interventions, at month 3, and at month 9 follow-up.

• N =123 total; 21 yoga, 67 self-hypnosis (after dropouts and one who died), 10 CBT, 24 control group 
• AGE: 27-73 across all groups 
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable; mixed numbers of patients who had surgery, chemotherapy, radiation therapy, and hormonal therapy
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer; 18 months postdiagnosis 
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria were at least 18 years old and can read, speak, and write French

• SITE: Not stated/unknown   
• SETTING TYPE: Not specified    
• LOCATION: Belgium

PHASE OF CARE: Multiple phases of care

Three group intervention self-selection; testing at T0, T1, T2 (month 3), T3 (month 9)

Demographics; medical history; Hospital Anxiety Depression Scale (anxiety and depression emotional distress); Quality of Life 30-item questionnaire (fatigue); Insomnia Severity Index (sleep quality)

Only results from baseline (T0) and the month 9 follow-up (T3) were reported using MANOVA with repeated analysis and post-hoc analysis. 

Post-hoc comparisons of time T0-T1: hypnosis group showed significant decreases in anxiety (p = 0.000), depression (p = 0.004), and fatigue (p = 0.045). Yoga group showed significant decrease in anxiety (p = 0.01). 

Post-hoc comparisons of time at T3: hypnosis group showed decreases in anxiety (p = 0.000), depression (p = 0.000), and fatigue (p = 0.002); yoga group showed decrease in anxiety (p = 0.024).

Self-hypnosis led to improvements in anxiety, depression, and fatigue. Anxiety improved in the yoga group. There were no improvements in the CBT or control groups.

• Small sample (< 100)
• Risk of bias (no random assignment)
• Other limitations/explanation: Control group included some of the non-consenters

Two of the three interventions may be helpful in reducing anxiety, depression, or fatigue when measured at nine months. Self-hypnosis may help patients improve emotional distress such as depression and anxiety, and may also reduce fatigue; yoga may also help improve anxiety. Larger samples and longer follow-up studies are needed.

To determine the effectiveness of a three-month intervention which includes a multicomponent physical activity change intervention on the symptoms of fatigue, depressive symptoms, and anxiety

Better Exercise Adherence after Treatment for Cancer (BEAT Cancer). Twelve supervised exercise sessions with an exercise specialist that were tapered over the first six weeks to an exclusively unsupervised home-based program. Face-to-face update counseling session with exercise specialist every two weeks during the final six weeks. Exercise and heart rate monitor sheets were provided to those who were randomized to the intervention. Group sessions for the participants. Those randomized to control received care as usual, which included handouts and publicly available printed materials.

• N = 222   
• MEAN AGE: 54.4 years
• FEMALES: 100%
• CURRENT TREATMENT:  Radiation, Other
• KEY DISEASE CHARACTERISTICS: Breast cancer, finished with adjuvant therapy except for adjuvant hormonal therapy
• OTHER KEY SAMPLE CHARACTERISTICS: 98% non-Hispanic, 84% White, 11% DCIS, 42% stage I, 35% stage II, 12% stage III, 54 mean months since cancer diagnosis, 58% had chemotherapy, 68% had radiation therapy, 50% were on adjuvant hormonal therapy.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Two midwestern and one southeastern academic institutions

PHASE OF CARE: Late effects and survivorship

Randomized control trial

Measurements happened at baseline, immediately postintervention, month 3, 3 months after intervention completion, and month 6. Instruments used were the Fatigue Symptom Inventory and the 14-item Hospital Anxiety and Depression Scale

Adjusted linear mixed‐model analyses demonstrated significant effects of BEAT Cancer versus usual care on fatigue intensity (month 3 mean between group difference [M] = −0.6; 95% confidence interval [CI] [−1, −0.2]; effect size [d] = −0.32; p = 0.004), fatigue interference (month 3 M = −0.8; CI [−1.3, −0.4]; d = −0.4; p < 0.001), depressive symptomatology (month 3 M = −1.3; CI [−2, −0.6]; d = −0.38; p < 0.001), and anxiety (month 3 M = −1.3; CI [−2, −0.5]; d = −0.33; p < 0.001). BEAT Cancer effects remained significant at month 6 for all outcomes.

This intervention reduced fatigue, depressive symptomatology, and anxiety up to three months postintervention compared to treatment as usual.

Intervention expensive, impractical, or training needs

Nurses can safely recommend exercise as tolerated to breast cancer survivors who have completed adjuvant treatment. There are several exercise programs widely available, including Livestrong and STARS Cancer rehabilitation programs.