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Aerobic Exercise For Treatment Related Fatigue in Men Receiving Radiotherapy For Localizes Prostate Carcinoma.

< Exercise as it related to Disease

This is an analysis o f the journal article “A randomized, controlled trial of aerobic exercise for treatment-related fatigue in men receiving radical external beam radiotherapy for localized prostate carcinoma,” by Windsor et al (2004).

CONTENTS BOX

What is the background to this research?

Prostate cancer, caused by abnormal cells growing more quickly than a normal prostate, is an age dependent disease that affects the male population across the world. The prostate is a walnut-sized glad, situated in the internal reproductive and urinary organs of a male. Localised prostate carcinoma refers to the stage in which the cancer has not spread beyond the prostate (1).

Facts about prostate cancer: • Is third most common cancer diagnosed in Australia • Is the third most common cause of cancer death • In 2013, 19233 new cases were diagnosed in Australia. (2). • Rates are projected to rise by 12% in the UK between 2014 and 2035 (6)

External beam radical therapy (EBRT) is a non-surgical treatment for prostate cancer, using high-energy x-rays. It remains one of the primary treatment methods for patients with localized prostate cancer (3).). It aims to treat all cancer cells, and the treatment is painless, but can cause side effects, commonly fatigue, up to some months following treatment (4) (5).

Fatigue in cancer patients is a common disease related problem that is associated with psychological and physiological complications. During radiotherapy, fatigue affects up to 80% of patients, and becomes chronic in 30%. Inactivity is known to increase fatigue; where as physical activity may be beneficial. (5) Windsor et al have conducted a study to examine potential benefits of regular walking with patients receiving radiotherapy.

Where is the research from? - Is the location or group, in which this research was conducted important to share? - Do the authors of the research have a track-record/ reputation in the field - Are there organisations/ sponsorship links that may be of conflict of interest/ bias the findings?

This study was performed in the UK by three health professionals based in Dundee, Scotland, from different departments, including: • Phyllis Windsor- Department of Radiotherapy and Oncology, Ninewells Hospital and Medical School • Kathleen F. Nicol- Physiotherapy Department, Ninewells Hospital and Medical School • Joan Potter- Community Perth and Kinross Tayside Primary Care Trust

The completed study was published in the American Cancer Society, 2004.

What kind of research was this? - Does the level of evidence from these, and other types of studies differ?

This study was an unblinded, randomised controlled trial that investigated the effects of aerobic exercise on fatigue related to radiotherapy. It was conducted over a 4-week period, in which patients underwent 20 fractions of radiotherapy, with a follow up 4 weeks post completion of treatment. Ethical approval was granted by the Tayside Local Research Ethics Commiteee, and patients were randomised to the trial by telephone calling the Scottish Cancer Therapy Network randomization line, avoiding selection bias. A randomised controlled trial is considered the most appropriate design for clinical trails, and was chosen for increased comparability of the control and exercise intervention groups.

What did the research involve? - Provide a lay summary of what the participants did in the study - Was the methodology the best approach? - What limitation exist related to the important measures taken, or other aspect of the methodology (participant recruitment for instance?)

The trial involved 66 male subjects aged 52-82 years (M=68.8yrs), recruited between Dec 2001-2002 via an outpatient waiting list for radiotherapy. Exclusion Criteria included: - Physical frailty due to age and comorbidity, such as unstable or severe angina - Recent myocardinal infaraction - Dementia.

Each participant was treated prone, with the bladder empty, using a three field, beam-directed radiotherapy technique with 6 megavolt photons to maintain consistency. A control and an exercise intervention group were utilized to obtain results. The exercise group participants were required to complete continuous walking for 30 minutes, on at least 3 days of each week of radiotherapy with a target heart rate (HR) 60-70% of max. Duration of activity and HR were recorded with wristband HR monitor.

Information gathering included:

Fatigue - The Brief Fatigue Inventory was self- completed by all participants at baseline, after 5, 10 , 15, 20 fraction and follow up after 4 weeks

Physical Function - At baseline and end of radiotherapy the resting HR was recorded and a modified shuttle test was performed - Scottish Physical Activity Questionnaire (SPAQ) was administered at baseline to assess participants attitude towards activity and usual activity levels

Exercise Adherence - All participants kept a patient-activity diary over the duration of receiving radiotherapy. Exercise group recorded frequency, duration of walking and HR achieved. Control group recorded frequency and duration of everyday aerobic activity - Patients were contacted weekly. Control group by a nurse about general health, and exercise group by a physiotherapist who encouraged adherence to exercise

Statistical Analyses - Various tests were used to assess the significance of group differences and variables.

• Participant randomization flow chart

What were the basic results? - What were the important findings?

Main findings included:

FATIGUE • Significant increase in fatigue scores at the end of radiotherapy compared with the baseline for the control group, and no significant difference in fatigue scores for the exercise group • Mean BFI scores for the control group and exercise group did not differ significantly at baseline, after 4 weeks of radiotherapy or 4 week follow up

PHYSICAL FUNCTIONING • No differences were observed with regard to resting or exercise heart-rate values over the course of the trial. • The mean shuttle-test distance for the control group at baseline was 479.1 (+- 19.8 meters) compared with 467.6 (+- 23.2) meters at the end of radiotherapy; for the exercise group it was 511.6 (+- 31.2 metres), compared with 579.1 (+- 27) meters respectively. • Therefore the shuttle test distance did not differ significantly between groups at baseline, but did differ a the end of radiotherapy

ADHERENCE - Control group showed a small, non significant decline in hours of reported aerobic activity per week - All patients in the exercise group recorded at least 1.5 hours of aerobic exercise at the recommended percentage maximum heart rate per week throughout radiotherapy

How did the researchers interpret the results? - Do they over-emphasis the implications of their findings?

The researchers determined that adhering to regular walking or aerobic exercise whilst receiving radiotherapy showed no significant change in fatigue over time, where as little involvement in aerobic activity lead to a significant increase in fatigue from baseline to end of radiotherapy. In a similar study, walking exercise intervention for radiation fatigue in women who received 6 weeks of radiotherapy for early stage breast carcinoma, it was demonstrated that women who exercise show a trend toward improved physical and psychosocial function, where as those who don’t showed a decline in physical function over time. The researchers therefore believe that aerobic exercise can have a positive effect on radiotherapy related fatigue, however identify that more research is required increase accuracy and reliability.

What conclusions can we take from this research? - Provide your own insights on the conclusion (may be different to the authors) - How do the findings align with other research in the area? (in particular more recent publications that wont be mentioned in the paper?)

• An overall strong association between aerobic exercise and fatigue • Participants who don’t participate in aerobic exercise during treatment can expect a decline in physical function • Effectiveness of the intervention is dependent on the compliancy rate of the participants • Area is promising, but needs further research

Limitations • There is no “gold-standard” instrument for the measurement of fatigue and it should be noted the BFI doesn’t capture cognitive, affective and somatic components of fatigue • Small sample size • Self reporting questionnaires can be bias

Practical Advice - What real-world implications does this research have? - Are there other considerations readers should know about before taking on this practical advice? I.e. health/safety comments

- The protocols employed by author should be replicated, with much larger sample size to ensure results are valid and reliable. - If successful, the intervention should significantly improve fatigue in patients receiving radiotherapy - This study may stimulate further research because author identified there is currently lack of knowledge, yet potential to make a difference.

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