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Relationship of Exercise to Quality of Life in Cancer Patients Beginning Chemotherapy

Open AccessPublished:February 18, 2011DOI:https://doi.org/10.1016/j.jpainsymman.2010.07.019

      Abstract

      Context

      Cancer diagnosis and treatment, particularly chemotherapy, has well-established adverse effects on individuals. Exercise has been found to confer benefits to patients, although the current evidence base is limited primarily to patients assessed during or after treatment. Although exercise has been a target of intervention efforts, its relationship to quality of life in patients about to begin chemotherapy has not fully been examined.

      Objectives

      To examine the relationship of pre-treatment exercise rates to patient’s quality of life.

      Methods

      One hundred ninety-two adults diagnosed with Stages I–IV cancer and Eastern Cooperative Oncology Group performance status ≤2, provided data on exercise, distress (anxiety and depression), and health-related quality of life prior to their initial chemotherapy infusion.

      Results

      As predicted, higher rates of exercise activity were associated with lower levels of anxiety and depression, and better overall mental and physical quality of life. These relationships were independent of demographic variables (i.e., body mass index and age) also associated with quality of life in the present analyses.

      Conclusion

      These findings further highlight the importance of assessing exercise before the start of chemotherapy as part of broader efforts to link patients to appropriate interventions aimed at enhancing quality of life. Findings also raise the possibility that assessing exercise rates could be useful in matching patients to the type of intervention most likely to benefit them. Future research should use prospective longitudinal designs to further explore this association.

      Key Words

      Introduction

      A large body of evidence has documented the adverse mental impact of a cancer diagnosis for many individuals, and the adverse mental and physical impact of many forms of cancer treatment.
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      nausea/vomiting,
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      Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates.
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      Quality of life and mood in women receiving extensive chemotherapy for gynecologic cancer.
      with associated declines in well-being and functioning. Consequently, it is important to identify ways to prevent or relieve these symptoms and to improve their impact on quality of life. Exercise is an important health behavior that confers numerous positive benefits to those who regularly engage in it.
      U.S. Department of Health and Human Services
      2008 physical activity guidelines for Americans.
      A growing body of observational and interventional research suggests that exercise also has the potential to improve mood and quality of life and reduce fatigue in cancer patients.
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      Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates.
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      Exercise interventions for cancer patients: systematic review of controlled trials.
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      • et al.
      Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis.
      Cancer and its treatment can present significant challenges to participation in exercise regimens.
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      • et al.
      Barriers to supervised exercise training in a randomized controlled trial of breast cancer patients receiving chemotherapy.
      Despite evidence that exercise is beneficial, less than half of patients are engaged in some form of it during cancer treatment, with estimates ranging from 15% to 44% of patients.
      • Pinto B.
      • Maruyama N.
      • Engebretson T.
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      Participation in exercise, mood, and coping in survivors of early stage breast cancer.
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      • Johnson D.
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      Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial.
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      • Stein K.
      Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society’s SCS-II.
      Findings indicate that rates of exercise decrease during the course of active treatment.
      • Andrykowski M.
      • Beacham A.
      • Jacobsen P.B.
      Prospective longitudinal study of leisure-time exercise in women with early stage breast cancer.
      • Courneya K.
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      Relationship between exercise during treatment and current quality of life among survivors of breast cancer.
      • Demark-Wahnefried W.
      • Hars V.
      • Conaway M.
      • et al.
      Reduced rates of metabolism and decreased physical activity in breast cancer patients receiving adjuvant chemotherapy.
      Among breast cancer patients, greater declines have been reported for patients treated with chemotherapy, as compared with surgery alone and surgery combined with radiotherapy.
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      Physical activity levels before and after a diagnosis of breast carcinoma.
      Thus, compared with other forms of cancer treatment (e.g., surgery and radiotherapy), chemotherapy appears to have a greater negative impact on exercise and overall rates of daily activity.
      Although it may be a challenge for patients, evidence from randomized trials suggests that initiating exercise during chemotherapy treatment is both feasible and beneficial.
      • Speck R.
      • Courneya K.
      • Masse L.
      • Duval S.
      • Schmitz K.H.
      An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analyses.
      • Courneya K.
      • Segal R.
      • Gelmon K.
      • et al.
      Six-month follow-up of patient-rated outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy.
      • Courneya K.
      • Friedenreich C.
      • Reid R.
      • et al.
      Predictors of follow-up exercise behavior 6-months after a randomized trial of exercise training during breast cancer chemotherapy.
      Along these lines, studies of exercise during chemotherapy have reported adherence rates ranging from 20% to 98% for supervised exercise training, and 51% to 90% for home-based exercise training.
      • Knols R.
      • Aaronson N.
      • Uebelhart D.
      • Fransen J.
      • Aufdemkampe G.
      Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials.
      • Stevinson C.
      • Lawlor D.A.
      • Fox K.R.
      Exercise interventions for cancer patients: systematic review of controlled trials.
      • McNeely M.
      • Campbell K.
      • Rowe B.
      • et al.
      Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis.
      Moreover, randomized controlled trials (RCTs) have shown that, relative to chemotherapy patients in control conditions, chemotherapy patients participating in exercise programs experience less emotional distress,
      • Segal R.
      • Evans W.
      • Johnson D.
      • et al.
      Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial.
      • Dimeo F.
      • Stieglitz R.
      • Novelli-Fischer U.
      • Fetscher S.
      • Keul J.
      Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy.
      • Mock V.
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      • Sheehan P.
      • et al.
      A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy.
      and better overall mental
      • Mock V.
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      • et al.
      A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy.
      • Mock V.
      • Pickett M.
      • Ropka M.
      • et al.
      Fatigue and quality of life during cancer treatment.
      and physical
      • Segal R.
      • Evans W.
      • Johnson D.
      • et al.
      Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial.
      • Campbell A.
      • Mutrie N.
      • White F.
      • et al.
      Pilot study of supervised group exercise program as rehabilitation treatment for women with breast cancer receiving adjuvant treatment.
      quality of life. Results from RCTs also indicate that patients participating in exercise interventions experience less fatigue post-treatment;
      • Dimeo F.
      • Stieglitz R.
      • Novelli-Fischer U.
      • Fetscher S.
      • Keul J.
      Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy.
      • Pinto B.
      • Frierson G.
      • Rabin C.
      • et al.
      Home-based physical activity intervention for breast cancer patients.
      results regarding benefits on fatigue during treatment have been mixed.
      • Speck R.
      • Courneya K.
      • Masse L.
      • Duval S.
      • Schmitz K.H.
      An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analyses.
      The potential for patients to benefit from exercise during chemotherapy suggests the importance of gaining information about exercise in the period immediately before the start of chemotherapy. Identification of recent exercise patterns and factors associated with pretreatment exercise activity could be used to tailor interventions designed to promote exercise during chemotherapy treatment. For example, interventions to promote adoption of exercise in sedentary patients may differ greatly from those which promote exercise maintenance in patients who routinely engage in physical activity. As such, knowledge of patients’ pre-chemotherapy exercise status is critical. In addition, developing a profile of demographic, clinical, and psychosocial characteristics of patients not regularly exercising before the start of chemotherapy would be extremely helpful for planning exercise interventions targeted to these individuals. Most existing studies have not directly addressed this issue because they rely on retrospective reports of exercise prior to cancer diagnosis
      • Andrykowski M.
      • Beacham A.
      • Jacobsen P.B.
      Prospective longitudinal study of leisure-time exercise in women with early stage breast cancer.
      • Midtgaard J.
      • Baadsgaard M.
      • Moller T.
      • et al.
      Self-reported physical activity behavior: exercise motivation and information among Danish adult cancer patients undergoing chemotherapy.
      or current reports of exercise after the start of chemotherapy.
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      • Hathaway J.
      • et al.
      Physical activity in patients with advanced-stage cancer actively receiving chemotherapy.
      • Harrison S.
      • Hayes S.
      • Newman B.
      Level of physical activity and characteristics associated with change following breast cancer diagnosis and treatment.
      One of few pieces of relevant evidence comes from a study by Demark-Wahnefried et al.
      • Demark-Wahnefried W.
      • Hars V.
      • Conaway M.
      • et al.
      Reduced rates of metabolism and decreased physical activity in breast cancer patients receiving adjuvant chemotherapy.
      in which women provided self-reports of physical activity before and after the start of adjuvant chemotherapy. In addition to reporting an average level of physical activity before the start of treatment (2159 kJ/day±490), the study found that physical activity declined significantly after the start of treatment.
      • Demark-Wahnefried W.
      • Hars V.
      • Conaway M.
      • et al.
      Reduced rates of metabolism and decreased physical activity in breast cancer patients receiving adjuvant chemotherapy.
      The present study sought to address this gap in knowledge by assessing recent exercise activity and examining the links between exercise activity and quality of life in cancer patients scheduled to undergo chemotherapy. On the basis of the findings among cancer survivors and associations between exercise and quality of life for cancer survivors (post-treatment), it was hypothesized that higher rates of pre-treatment exercise would be associated with less depression and anxiety and better health-related quality of life. The study also explored the relationship of recent exercise activity to patients’ demographic (e.g., age, gender) and clinical characteristics (e.g., cancer type and stage).

      Methods

      Participants

      Participants were recruited as part of a larger study investigating the efficacy of interventions (i.e., stress management and exercise training) designed to improve quality of life during chemotherapy treatment. Eligibility criteria for the study were that participants: 1) have a cancer diagnosis; 2) be 18 years of age or older; 3) have not received intravenous chemotherapy within the past two months; 4) be scheduled to receive cytotoxic chemotherapy as an outpatient at Moffitt Cancer Center (MCC) over a period of at least nine weeks; 5) have no contraindications to participating in moderate intensity exercise or graded exercise testing as determined by their attending oncologist and research staff; 6) be capable of speaking and reading English; 7) provide written informed consent, and 8) have an Eastern Cooperative Oncology Group (ECOG) performance status of ≤2. ECOG score >2 indicates that patients require assistance/support in daily activities (have limited self-care abilities, or confined to bed or chair for more than 50% of waking hours) thus precluding their safely participating in the exercise condition (home-based walking program) in the present study.
      Of the 236 patients who were eligible and approached, 192 (81%) agreed to participate. The 44 patients who declined participation cited lack of time as the reason for study refusal. In preliminary analyses comparing nonparticipants to study participants, no differences were found. That is, participation was not associated with age, gender, marital status, cancer diagnosis, cancer stage, or ECOG status (Ps>0.05).

      Procedure

      At MCC, patients being considered for chemotherapy are seen in consultation by a medical oncologist. Those for whom chemotherapy is indicated are then scheduled to receive their initial infusion at a later date. Patients being seen for consultations were identified through the use of an existing computerized appointment system. Patient eligibility was initially determined via a medical chart review. Final determination was based on the medical oncologist reviewing and signing a clearance form that excluded patients for whom moderate exercise or graded exercise testing was contraindicated. Those patients meeting eligibility criteria were introduced to the study by a research assistant and provided with an opportunity to ask questions before signing an institutional review board-approved informed consent form. Following screening and consent procedures and before randomization to intervention condition, participants completed questionnaires, which are the focus of this report. Participants were asked to complete the paper-and-pencil questionnaires during the appointment immediately prior to beginning chemotherapy treatment.

      Measures

      Demographic and Clinical Characteristics

      Demographic information was obtained through the use of a standardized self-report questionnaire. Variables assessed were age, gender, race/ethnicity, educational attainment, marital status, and body mass index (BMI). Clinical information, comprising cancer type, cancer stage, ECOG performance status, time prior to treatment (lag time in days between completion of baseline questionnaires and chemotherapy initiation), recent cancer surgery, and previous treatment with chemotherapy, was obtained through review of patients’ medical charts.

      Rates of Leisure Exercise

      The Leisure Score Index (LSI) of the Godin Leisure-Time Exercise Questionnaire was used to assess current exercise activity.
      • Godin G.
      • Jobin J.
      • Bouillion J.
      Assessment of leisure time exercise behavior by self-report: a concurrent validity study.
      The LSI consists of questions that assess the average frequency of mild, moderate, and strenuous exercise in the past week.
      • Godin G.
      • Shepard R.
      A simple method to assess exercise behavior in the community.
      The LSI yields a standard score of estimated weekly metabolic equivalent tasks (METS).
      • Godin G.
      • Jobin J.
      • Bouillion J.
      Assessment of leisure time exercise behavior by self-report: a concurrent validity study.
      The reliability and validity of the LSI has been found to compare favorably with other self-report measures of exercise activities in terms of test-retest scores and correlations with objective activity monitors and objective fitness indices.
      • Jacobs D.
      • Ainsworth B.
      • Hartman T.
      • et al.
      A simultaneous evaluation of 10 commonly used physical activity questionnaires.
      In addition to calculating average weekly METS, participants were grouped according to their highest level of exercise intensity in the past week as reported on the LSI to provide another index of exercise activity. Participants who reported engaging in no exercise in the past week constituted the “no exercise group.” Participants who reported engaging in mild intensity exercise only as their highest level of exercise activity in the past week constituted the “mild exercise group.” Participants who reported engaging in any moderate or strenuous exercise in the past week constituted the “moderate or strenuous exercise group.” Both METS and exercise group were included in the descriptive and correlational analyses. METS as a continuous variable was included in the hierarchical analyses.

      Health-Related Quality of Life

      The Acute (past week) Version of the Medical Outcomes Survey 36-Item Short Form (SF-36) was used to assess perceived health and functioning.
      • Ware J.
      SF-36 health survey: Manual and interpretation guide.
      • Ware J.
      SF-36 physical and mental health summary scales: A user’s manual.
      This self-report instrument contains eight multi-item scales: general health (GH) perceptions, physical functioning (PF), role limitations because of physical problems (R-P), bodily pain (BP), general mental health (MH), vitality (VT), role limitations because of emotional problems (R-E), and social functioning (SF). The SF-36 also yields two summary scores that reflect the two-dimensional factor structure underlying the eight subscales: a physical component summary score (PCS) and a mental component summary score (MCS). Three scales, PF, R-P, and BP, load positively only on the physical component summary.
      • Ware J.
      SF-36 physical and mental health summary scales: A user’s manual.
      Three other scales, MH, SF, and R-E, load positively only on the MCS.
      • Ware J.
      SF-36 physical and mental health summary scales: A user’s manual.
      The remaining two scales, VT and GH, load positively on both the MCS and PCS.
      • Ware J.
      SF-36 physical and mental health summary scales: A user’s manual.
      Reliability (alpha) coefficients for the SF-36 scales in the present study ranged from 0.73 (GH) to 0.91 (VT and PF).

      Depression

      The Center for Epidemiological Studies Depression Scale (CES-D) is a self-report measure of depression severity in the past week.
      • Radloff L.
      The CES-D scale: a self-report depression scale for research in the general population.
      The 20 items are scored on a four-point scale (0=<1 day to 3=5–7 days). The reliability and validity of this measure have been demonstrated in a variety of clinical populations, including cancer patients.
      • Hann D.
      • Jacobsen P.B.
      • Martin S.
      • Azarello L.
      • Greenberg H.
      Fatigue and quality of life following radiotherapy for breast cancer: a comparative study.
      Reliability (alpha) of the CES-D for the present study was 0.88.

      Anxiety

      The Beck Anxiety Inventory (BAI) is a self-report measure that assesses the severity of anxiety symptoms in the past week.
      • Beck A.
      • Steer R.
      Beck anxiety inventory manual.
      The reliability and validity of the BAI have been demonstrated in a variety of clinical populations, including cancer patients.
      • Beck A.
      • Steer R.
      Beck anxiety inventory manual.
      Reliability (alpha) of the BAI in the present study was 0.90.

      Statistical Analyses

      Univariate correlational analyses were conducted to examine the relationships of clinical and demographic characteristics with exercise, anxiety, depression, and quality of life as well as relationships of exercise with anxiety, depression, and quality of life. Demographic or clinical characteristics found to be significantly (P<0.05) related to anxiety, depression, and/or quality of life were used as control variables in subsequent hierarchical regression analyses further examining the relationship of exercise (METS score) to anxiety, depression, and quality of life. Additional analyses were conducted that excluded from the sample any participant who had previously received chemotherapy. As the exclusion of these participants (n=33) did not significantly change the direction nor strength of the results, these data are included in the final analyses.

      Results

      Demographic, Clinical, and Study Variable Characteristics

      The demographic and clinical characteristics of the sample are shown in Table 1. Participants were primarily female (67%), Caucasian (93%), well-educated (40% held a college degree), married (61%), and diagnosed with either breast (40%) or lung cancer (31%). The majority of participants had Stage III (30%) or Stage IV (33%) disease. Of the 63 participants with Stage IV disease, 41 had a diagnosis of lung cancer. Of the remaining 22 participants, the most common disease site was the gastrointestinal tract (n=8 patients with gastric, colon, or rectal cancer). Among the 33 participants who had undergone previous chemotherapy, three patients had received it in the past year, and 30 had received it between one year and 23 years ago. For those who had undergone previous radiotherapy, six patients received it within the past 12 months, and seven had received it from one year to 45 years ago. The means and ranges for exercise, anxiety, depression, and quality of life variables are shown in Table 2.
      Table 1Demographic and Clinical Characteristics
      Characteristicsn (%)
      Demographic Factor
       Age, yrs, n=192 mean (SD)/range56.4 (10.8)/29–81 years
       Body mass index, n=192 mean (SD)26.9 (5.2)
       Gender
      Female130 (67.7)
      Male62 (32.3)
       Ethnicity
      Non-Hispanic175 (91.1)
      Hispanic17 (8.9)
       Race
      Caucasian/White178 (92.7)
      African American/Black5 (2.6)
      >One race4 (2.1)
      Asian3 (1.6)
      Native American2 (1.0)
       Education
      College degree76 (39.5)
      HS diploma106 (55.2)
      <HS diploma10 (5.3)
       Marital status
      Not married75 (39.1)
      Married117 (60.9)
      Clinical Factor
       Cancer diagnosis
      Breast77 (40.2)
      Lung60 (31.3)
      Ovarian12 (6.2)
      Colorectal12 (6.2)
      Bladder6 (3.1)
      Prostate6 (3.1)
      Other sites (n<6)19 (9.9)
       Cancer Stage
      I22 (11.5)
      II50 (26.1)
      III57 (29.6)
      IV63 (32.8)
       ECOG performance status
      0130 (67.7)
      162 (32.3)
      20 (0.0)
       Previous chemotherapy treatment
      No159 (82.8)
      Yes33 (17.2)
       Previous radiotherapy treatment
      No179 (93.2)
      Yes13 (6.8)
       Recent cancer surgery
      No60 (31.3)
      Yes132 (68.7)
       Time prior to treatment, n=192 mean (SD)/range3.1 days (7.4)/0–40 days
      Time prior to treatment=days between completion of baseline measures and chemotherapy infusion. SD=standard deviation; ECOG=Eastern Cooperative Oncology Group; HS=high school.
      Table 2Characteristics of Study Variables
      VariableMinimumMaximumMeanSD
      BAI0448.68.2
      CES-D04812.110.0
      SF-36
       Physical component score176044.110.5
       Mental component score136749.211.1
       Physical functioning510067.626.9
       Role-physical010054.444.0
       Bodily pain1210072.224.8
       Vitality010057.423.5
       General health010068.021.4
       Social functioning010075.326.8
       Role-emotional010070.340.0
       Mental health1210071.820.0
      LSI
       METS0619.812.7
       Exercise groupnPercentage
      None6332.8
      Mild5528.6
      Moderate or strenuous7438.6
      SD=standard deviation; BAI=Beck Anxiety Inventory; CES-D=Center for Epidemiological Studies Depression Scale; SF-36=Medical Outcomes Survey 36-Item Short Form; LSI=Leisure Score Index; METS=weekly metabolic equivalent tasks (exercise activity) from LSI.

      Relationship of Demographic and Clinical Variables to Study Variables

      Correlational analyses were performed to examine the relationship of demographic and clinical variables with anxiety, depression, quality of life, and exercise. As shown in Table 3, several significant (P<0.05) relationships were observed. Younger age and higher BMI scores were associated with higher levels of anxiety. Higher BMI scores, alone among the demographic and clinical variables, were associated with higher levels of depression. Gender (being female) and younger age were associated with better physical quality of life. Additionally, less advanced cancer stage, lower ECOG status (indicating better physical functioning), and being novel to (i.e., not previously treated with) chemotherapy were significantly associated with better physical quality of life. However, mental quality of life was not significantly correlated with any sociodemographic or clinical variables. Greater physical functioning (lower ECOG performance status) and more time prior to treatment were associated with greater rates of exercise (in weekly METS).
      Table 3Pearson Correlations of Demographic and Clinical Characteristics with Psychosocial and Exercise Variables
      VariableExercise GroupMETSBAICES-DSF-36 PCSSF-36 MCS
      Demographic Variable
       Age (in years)−0.040.01−0.18
      P<0.05.
      −0.13−0.17
      P<0.05.
      0.13
       Gender (female/male)0.010.060.10−0.010.32
      P<0.01.
      −0.08
       Education (college degree/no)0.080.10−0.20−0.050.090.03
       Ethnicity (Hispanic/non-Hispanic)0.04−0.010.020.06−0.04−0.11
       Race (White/other)−0.03−0.01−0.030.010.03−0.04
       Marital status (married/unmarried)−0.11−0.12−0.09−0.10−0.060.12
       Body mass index−0.08−0.100.14
      P<0.05.
      0.17
      P<0.05.
      −0.09−0.11
      Clinical Variable
       Cancer Stages (I–IV)−0.12−0.09−0.07−0.00−0.20
      P<0.01.
      −0.02
       ECOG status (0–2)−0.19
      P<0.01.
      −0.18
      P<0.05.
      −0.010.10−0.17
      P<0.05.
      −0.13
       Time prior to treatment (days)0.050.21
      P<0.01.
      −0.03−0.000.020.07
       Previously received chemotherapy (yes/no)0.00−0.030.030.03−0.15
      P<0.05.
      0.02
       Recent cancer surgery (yes/no)0.15
      P<0.05.
      0.09−0.06−0.000.040.04
      LSI=Leisure Score Index; METS=weekly metabolic equivalent tasks (exercise activity) from LSI; BAI=Beck Anxiety Inventory; CES-D=Center for Epidemiological Studies Depression Scale; SF-36 MCS=Short-Form 36 mental component summary score; SF-36 PCS=Short-Form 36 physical component summary score; ECOG=Eastern Cooperative Oncology Group performance status.
      Note: Exercise group: higher scores=participation in higher level of exercise intensity in the past week. Participants designated into three groups based on highest level of exercise intensity endorsed on the LSI (none=no exercise, mild=mild exercise only, or moderate/strenuous=moderate or strenuous exercise).
      a P<0.05.
      b P<0.01.

      Relationship of Exercise to Anxiety, Depression, and Quality of Life

      Correlations between exercise and anxiety, depression, and quality of life are shown in Table 4. As expected, findings indicated that a higher METS score was related to a lower score on the BAI (P<0.01) and the CES-D (P<0.05). That is, higher rates of exercise activity were associated with lower levels of anxiety and depression. A similar pattern of results was observed between METS scores and the SF-36 (both the component summary scales and individual scales). Again, as expected, higher rates of exercise activity were significantly (P<0.01) related to better overall mental and physical quality of life, better general health, better physical role (fewer role limitations) and social functioning, greater vitality, and less body pain. With the exception of anxiety, the exercise group displayed a similar pattern of significant relationships. Additionally, given the similarity of results for both exercise variables, only METS scores (as a continuous variable) were used in hierarchical regression analyses. Given that all subscales of the SF-36 were significantly correlated to METS, the component scores (MCS, PCS) were used in hierarchical regression analyses.
      Table 4Correlations of Exercise (METS and Three Groups) and Psychosocial Variables
      VariableExercise GroupMETS
      Anxiety (BAI)−0.13−0.19
      P<0.01.
      Depressive symptoms (CES-D)−0.15
      P<0.05.
      −0.18
      P<0.05.
      Quality of life (SF-36)
       MCS0.18
      P<0.05.
      0.22
      P<0.01.
       PCS0.31
      P<0.01.
      0.35
      P<0.01.
       Physical functioning0.30
      P<0.01.
      0.31
      P<0.01.
       Role-physical0.28
      P<0.01.
      0.33
      P<0.01.
       Bodily pain0.18
      P<0.05.
      0.29
      P<0.01.
       Vitality0.34
      P<0.01.
      0.36
      P<0.01.
       General health0.18
      P<0.05.
      0.22
      P<0.01.
       Social functioning0.30
      P<0.01.
      0.31
      P<0.01.
       Role-emotional0.15
      P<0.05.
      0.21
      P<0.01.
       Mental health0.15
      P<0.05.
      0.22
      P<0.01.
      METS=LSI weekly metabolic equivalent tasks (exercise activity); BAI=Beck Anxiety Inventory; CES-D=Center for Epidemiological Studies Depression Scale; For Medical Outcomes Survey Short-Form (SF-36) scales: MCS=mental component summary; PCS=physical component summary.
      Note: Exercise group: higher scores=participation in higher level of exercise intensity in the past week. Participants designated into three groups based on highest level of exercise intensity endorsed on the LSI (none=no exercise, mild=mild exercise only, or moderate/strenuous=moderate or strenuous exercise).
      a P<0.01.
      b P<0.05.

      Hierarchical Analyses Controlling for Relevant Demographic and Clinical Variables

      Additional analyses were undertaken to determine if the observed relationships of exercise activity with anxiety, depression, and health-related quality of life were independent of any associations of demographic or clinical factors with these outcomes. Toward that end, a series of hierarchical regression analyses of these outcomes were conducted in which clinical or demographic variables significantly associated with anxiety, depression, and/or mental or physical quality of life were entered first into regression equations followed by exercise activity (i.e., METS scores). As the two component scores and all eight subscales of the SF-36 were significantly correlated with exercise and METS (displayed in Table 4), the MCS and PCS were included as outcomes in the analyses.
      Table 5 summarizes the results for anxiety. In Step 1, age and BMI accounted for 5% of the variance in anxiety (P=0.01). After controlling for age and BMI, exercise activity accounted for an additional 3% of the variance in anxiety (P=0.01).
      Table 5Hierarchical Regression Analysis of METS to Anxiety
      VariableβΔR2Cumulative R2P
      P-value for ΔR2.
      Step 10.050.050.01
       Age−0.18
       BMI0.12
      Step 20.030.080.01
       METS−0.18
      METS=LSI weekly metabolic equivalent tasks (continuous); BMI=body mass index.
      a P-value for ΔR2.
      Table 6 illustrates the results for depression. In Step 1, BMI accounted for 3% of the variance (P=0.02). After controlling for BMI, exercise activity accounted for an additional 3% of the variance in depression (P=0.02).
      Table 6Hierarchical Regression Analysis of METS and CES-D Depression Scores
      VariableβΔR2Cumulative R2P
      P-value for ΔR2.
      Step 10.030.030.02
       BMI0.17
      Step 20.030.060.02
       METS−0.16
      METS=LSI weekly metabolic equivalent tasks (continuous); BMI=body mass index; CES-D=Center for Epidemiological Studies Depression Scale.
      a P-value for ΔR2.
      Table 7 summarizes the results for physical quality of life. In Step 1, age, gender, cancer stage, ECOG score, and previous chemotherapy treatment accounted for 13% of the variance (P<0.001). After controlling for covariates, exercise activity accounted for an additional 10% of the variance in physical quality of life (P<0.001).
      Table 7Hierarchical Regression Analysis of SF-36 Physical Component Summary Score and METS
      VariableβΔR2Cumulative R2P
      P-value for ΔR2.
      Step 10.130.13<0.001
       Gender0.02
       Age−0.04
       ECOG−0.08
       Stage−0.06
       Chemo−0.10
      Step 20.100.23<0.001
       METS0.33
      METS=LSI weekly metabolic equivalent tasks (continuous); ECOG=Eastern Cooperative Oncology Group performance status; Chemo=previously received chemotherapy; SF-36=Medical Outcomes Survey 36-Item Short Form.
      a P-value for ΔR2.
      A regression equation was not performed for mental quality of life because no clinical or demographic variable was significantly associated with this outcome. Correlations presented previously in Table 4 indicate that exercise activity accounted for 5% of the variance in mental quality of life.

      Discussion

      The present study was designed to fill the general gap in knowledge about exercise activity before the start of chemotherapy treatment. In a sample of patients about to start chemotherapy, we found that 33% reported engaging in no exercise in the past week. Among the 67% who reported exercising in the past week, 43% had engaged in mild exercise and 57% had engaged in moderate or strenuous exercise. As hypothesized, higher rates of exercise were associated with lower levels of anxiety and depression, and better overall physical and mental quality of life. Furthermore, exercise rates were associated with pre-chemotherapy levels of anxiety, depression, and overall mental and physical quality of life, over and above the effects of demographic variables also found to be related to these outcomes (i.e., age and BMI).
      In prior research, exercise has been associated with better quality of life and psychological well-being for patients undergoing treatment and during the survivorship period.
      U.S. Department of Health and Human Services
      2008 physical activity guidelines for Americans.
      • Speck R.
      • Courneya K.
      • Masse L.
      • Duval S.
      • Schmitz K.H.
      An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analyses.
      Findings from the present study suggest that the benefits from exercise may extend to the prechemotherapy treatment period. Current findings are also consistent with research on the benefits of exercise for individuals with other medical conditions, such as Type 2 diabetes
      • Thomas D.
      • Elliott E.
      • Naughton G.
      Exercise for type 2 diabetes mellitus.
      and cardiovascular disease.
      • Jolliffe J.
      • Rees K.
      • Taylor R.
      • et al.
      Exercise-based rehabilitation for coronary heart disease.
      In the present study, exercise activity was not related to demographic variables (e.g., age) nor to clinical variables such as BMI or previous chemotherapy exposure. These findings are contrary to previous findings based primarily on early stage breast cancer patients assessed during and after treatment.
      • Pinto B.
      • Maruyama N.
      • Engebretson T.
      • Thebarge R.
      Participation in exercise, mood, and coping in survivors of early stage breast cancer.
      • Pinto B.
      • Trunzo J.
      Body esteem and mood among sedentary and active breast cancer survivors.
      • Pinto B.
      • Trunzo J.
      • Reiss P.
      • Shiu S.
      Exercise participation after diagnosis of breast cancer: trends and effects on mood and quality of life.
      The inclusion of patients with later stage disease in the present study may have attenuated the association between exercise activity and BMI. That is, patients with advanced disease and a high BMI pre-diagnosis may have lost significant weight as a result of their disease. Additionally, most of the patients (30 of 33) with prior exposure to chemotherapy had received it more than one year ago, and in many of these instances, several years (up to 24 years) previously. The considerable lag-time since previous treatment may have masked potential links between prior chemotherapy exposure and exercise. Among clinical variables, exercise activity was related to ECOG performance status, although not to cancer stage or recent cancer surgery. As ECOG status is a proxy for physical functioning, this likely reflects an overlap in conceptualization. Specifically, if one is more physically able, one would be more likely to exercise.
      • Mock V.
      • Frangakis C.
      • Davidson N.
      • et al.
      Exercise manages fatigue during breast cancer treatment: a randomized controlled trial.
      The strengths of the present study include a sample of patients heterogeneous with regard to both cancer diagnoses and cancer stage. As noted earlier, most previous studies have focused on women with breast cancer and on patients with early stage disease. In addition, the present study is one of the few to examine exercise and its correlates in the important period just before the start of the chemotherapy treatment. Nevertheless, the present study is not without its limitations. Despite heterogeneity in clinical factors such as cancer stage and diagnosis, the sample was relatively homogeneous in that a large majority of participants were white, female, married, and not living in poverty. Secondly, average ECOG performance status was relatively high in this sample because it was drawn from a larger study investigating the efficacy of exercise and stress management interventions for chemotherapy patients. Thirdly, given the lack of longitudinal data, no firm conclusions can be drawn regarding the direction of causality. Although it is likely that greater rates of exercise resulted in better quality of life and less anxiety and depression, we cannot rule out the possibility that less pre-chemotherapy distress and better quality of life resulted in higher exercise rates. Fourth, it is possible that there are factors affecting pre-chemotherapy exercise rates that were not assessed, such as prior advice given by their medical team about whether or not to exercise after cancer diagnosis.
      Several future directions are suggested by the results of the present study. Explication of factors associated with pre-chemotherapy exercise participation (why patients are/are not exercising) is needed, which may include barriers to exercise and motivation or knowledge deficits. For example, are patients not exercising before initiating chemotherapy because they believe their oncologist either does not recommend it or feels they are not physically able to exercise (i.e., that exercise might incur deleterious consequences for their health)? Studies also should be conducted examining changes in exercise rates from diagnosis through the beginning of the treatment. Intentions to exercise during the course of treatment also should be assessed. Additional research is needed to identify the optimal frequency, intensity, and duration of exercise for improving quality of life in cancer patients undergoing chemotherapy. Knowledge of these factors, in conjunction with the correlates of pre-chemotherapy exercise identified in the present study, will be useful in planning intervention efforts aimed at increasing exercise participation among cancer patients beginning treatment and ultimately, improving quality of life for this population.
      In summary, the ability to identify factors that amplify or attenuate risk of distress and dysfunction is important, especially factors that are modifiable and can be targeted for intervention. The present study examined these relationships just before the start of chemotherapy, a period that has received little attention in exercise research. Findings indicate that there was considerable variability in exercise activity among patients about to start chemotherapy and consistently indicated that greater exercise activity was associated with better physical and mental well-being and less psychological distress. Overall, these findings lend support to efforts to promote exercise activity among patients about to start chemotherapy and can serve those efforts by identifying patients’ recent exercise activity.

      Disclosures and Acknowledgments

      This research was supported by funding from the American Cancer Society , grant no. RSGPB-05-243-01 CPPB (P. B. J.). This work was supported in part by the Survey Methods Core Facility at MCC. The authors have no personal or financial conflicts of interest to disclose in relation to this work.
      The data presented in this article were collected through a protocol monitored by the Institutional Review Boards at the University of South Florida and MCC (Protocol #IRB 102390-MCC 13872).

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