The development of an evidence-based physical self-management

University of Groningen

Cancer rehabilitationWeert, Ellen van

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.

Document VersionPublisher's PDF, also known as Version of record

Publication date:2007

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):Weert, E. V. (2007). Cancer rehabilitation: effects and mechanisms s.n.

CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.

Download date: 13-04-2018

https://www.rug.nl/research/portal/en/publications/cancer-rehabilitation(0c0b5cc4-3d26-44bc-91ce-58c8fc0a89b0).html

CANCER REHABILITATION:

effects and mechanisms

Ellen van Weert

Herstel en Balans.indb 1 25-7-2007 15:05:40

Van Weert, Ellen

Cancer rehabilitation: effects and mechanisms

Thesis University of Groningen, the Netherlands – With ref. – With summary in Dutch

ISBN 978-90-367-3132-4

Financial support for the research in this thesis was obtained from a Dutch Rotary/Dutch Cancer

Society jubilee grant

The publication of this thesis was supported by:

Comprehensive Cancer Centre North-Netherlands

Financial support for this thesis was kindly given by:

University Medical Center Groningen, Center for Rehabilitation

University Medical Center Groningen, discipline Physiotherapy

University Medical Center Groningen, Stichting Werkgroep Interne Oncologie

Stichting Beatrixoord Noord-Nederland

Roche Nederland BV

Cover design: N. Heesterman, www.mantext.nl

Logo design: G. Hoekstra, [email protected]

Lay out/dtp: N. Heesterman, www.mantext.nl

Printed by: Drukkerij C. Regenboog Groningen

© Copyright E. van Weert, 2007

All rights reserved


rijksuniversiteit groningen

CANCER REHABILITATION:

effects and mechanisms

Proefschrift

ter verkrijging van het doctoraat in de Medische Wetenschappen

aan de Rijksuniversiteit Groningen op gezag van de

Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op

woensdag 10 oktober 2007om 14.45 uur

doorEllen van Weert

geboren op 21 maart 1966te Hellendoorn


Promotores: Prof. dr. K. Postema Prof. dr. R. Sanderman

Copromotores: Dr. C.P. van der Schans Dr. J.E.H.M. Hoekstra-Weebers Dr. R. Otter

Beoordelingscommissie: Prof. dr. J.A. Langendijk Prof. dr. J.H.B. Geertzen Prof. dr. H.B.M. van de Wiel


Paranimfen: Boukje Faber-BeukenkampMarrit Tuinman



vii

Contents

Chapter 1 Introduction 1

Chapter 2 Physical functioning and quality of life after cancer rehabilitation 9 Int J Rehabil Res 2004;27:27-35

Chapter 3 A multidimensional cancer rehabilitation program for cancer survivors: 23 effectiveness on health-related quality of life J Psychosom Res 2005;58:485-496

Chapter 4 Perceived social support and self-efficacy and quality of life before 43 and after cancer rehabilitation Submitted

Chapter 5 Cancer-related fatigue: predictors and effects of rehabilitation 63 Oncologist 2006;11:184-196

Chapter 6 The development of an evidence-based physical self-management 83 rehabilitation programme for cancer survivors Submitted Chapter 7 General discussion 121

Chapter 8 Summary 133

Samenvatting 139

Dankwoord 145



�

1 Introduction

Cancer and cancer treatment may have serious effects on patients’ quality of life, not only during treatment but also years after the treatment has been completed. Adaptation to the cancer experience involves adjusting to a loss of functioning and requires patients to refocus on future plans and goals. The majority of cancer patients seem to cope effectively with the diagnosis and the cancer treatment [1]. However, a significant minority (c. 30%) experience so many continuing adjustment problems and a low quality of life [2] after cancer treatment that they may need professional support [3]. Cancer and cancer treatment are often associated with problems that are psychological (anxiety and depression), physical (impaired physical capacity, fatigue) and social (isolation, unemployment) in their nature. For patients with such persisting problems, supportive care interventions such as cancer rehabilitation programmes may be beneficial.

The present thesis deals with the subject: rehabilitation after cancer. This introductory chapter first provides a global description of the cancer problem and its extent [4]. Then the impact of the treatment on the quality of life, the need for rehabilitation, and the development of rehabilitation programmes for cancer patients are described. Finally, the model for the thesis is presented and the consequent goals are formulated.

Cancer,cancertreatmentandrehabilitation

CancerCancer is a general term for the abnormal, uncontrolled cell growth that leads to tissue failure unless the abnormal cells are removed or destroyed. Cancer is a common name for different diseases: tumours are named according to the tissue or organ of origin and the degree of differentiation. Cancer has the potential to spread, and the anatomic extent of the cancer, determined before definitive therapy, is expressed by the tnm staging: t= the local tumour size, n= the spread of the cancer to regional lymph nodes, and m= the presence or absence of distant metastasis. The tnm classification is translated into four stages (I to IV) representing the extent of the cancer. The higher the stage, the further the cancer has progressed and the worse the prognosis.

Cancer in the Netherlands The data from the database of the Dutch Cancer Registry show the magnitude of the cancer problem in the Netherlands (see Box 1). The Dutch Cancer Registry is a population- based cancer registry, and involves a systematic collection of data on malignant neoplasms occurring in a geographically defined population. The data are collected by nine regional comprehensive cancer centres in collaboration with all Dutch hospitals [4].


Introduction

�

Box 1Cancer in the Netherlands

Incidence and prevalence In 2003, 73,000 cases of cancer were diagnosed in the Netherlands, 37,500 in men and 35,500 in women. Of every 1000 men, 4.7 developed some form of cancer, against 4.4 of every 1000 women (crude rates). The total prevalence (= the total number of living cancer patients at a well-defined point in time) in the Netherlands is not known but is rated at 400,000 patients, which is about 2.5 percent of the Dutch population.

Most frequent types of cancer, gender and age In 2003, breast cancer was the most common type (one third of all cases in females), with 11,800 new cases, followed by colorectal cancer (13 per cent of cancer in both sexes), lung cancer (18 per cent of all cases in males and 7 per cent in females), and prostate cancer (19 per cent of all cases in males). Other common types of cancer were cancer of the skin, bladder, lymphatic system, head and neck, uterus, and stomach. Cancer is most common among the elderly; 40 per cent of all new cases were diagnosed in patients between 60 and 75 years old and 30 per cent was 75 years or older. Nine per cent of all new cancer patients were younger than 45 years.

Trends, mortality and survival ratesThe overall number of registered malignant invasive tumours is rising by approximately 1000 tumours a year. This is due to population growth, an increasing number of older people, as well as effects of national cancer-screening procedures for breast and cervical cancer, early detection of prostate cancer, and improved diagnostic techniques and effective treatment. Cancer is responsible for approximately 30% of deaths. Cancer is reported to be the primary cause of death for men and number two for women [5]. The survival rates of cancer patients vary and depend on the type of cancer and stage of disease. Globally, half of the cancer patients survive after cancer. The 5-year survival rate for breast cancer is 70-80%, for colorectal cancer 50-55%, for lung cancer 10-15% and for prostate cancer 50-60%.

Cancer treatment and related side effects Depending on the type and the extent of the cancer, the morbidity and the choice of the patient, most cancer treatment is multidisciplinary and consists of surgery, radiotherapy, chemotherapy, hormonal therapy, or combined treatment modalities. Oncological guidelines are available on the internet (www.oncoline.nl).

Treatment-related side effects and symptoms are often the result of toxicities in multiple systems. Side effects include physical and psychological problems such as fatigue, lymphedema, decreased oxygen uptake, pain, body image problems, sleep disturbances, anxiety and depression, all potentially affecting the functioning of cancer patients.

Impact on the quality of life Physical, psychological and social problems may occur in the short term, but problems are also reported to persist over time, and all have the potential to affect the overall quality of life of cancer patients [6]. Therefore, Health-Related Quality of Life (HRQoL) has become


�

Introduction

an increasingly important and frequently-examined outcome measure in oncology. In addition, HRQoL may be a predictor for mortality and morbidity [7] and improvement of quality of life has therefore become a main goal of supportive care in cancer patients.

HRQoL is a multidimensional construct incorporating at least three broad domains - physical, psychological and social functioning. Physical functioning is usually defined as the performance or the ability to perform a range of daily activities, as well as physical symptoms resulting either from the disease itself or from treatment. Psychological functioning ranges from severe psychological distress to a positive sense of well-being and may also encompass cognitive functioning. Social functioning refers to quantitative and qualitative aspects of social relationships and interactions, and social integration. Beyond these core domains, HRQoL measuring instruments include an overall judgement of patients regarding their health and quality of life [7].

Need for rehabilitation A low quality of life after cancer may be associated with the need for supportive care, such as rehabilitation. The number of cancer patients that may need rehabilitation is expected to grow. An estimation about this target population, i.e., patients who have completed cancer treatment and have a life expectancy >1 year, and who continue to experience quality of life problems, indicates a population of 5000 rehabilitation candidates in the year 2000 and nearly 7000 patients in 2015 [8].

Rehabilitation and the ICF classification The World Health Organisation (who) defines rehabilitation as a wide range of activities in addition to medical care, including physical, psychosocial and occupational therapy. It is a process aimed at enabling people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological and/or social functional levels.

The who promotes the use of the International Classification of Functioning, Disability and Health (icf), because of its help in facilitating the understanding and measurement of health outcomes (Figure 1, bold). The icf describes how people live with their health condition. The icf is a classification of health and health-related domains that describe body functions and structures, activities and participation. The domains are classified from body, individual and societal perspectives. Body functions are the physiological functions of body systems (including psychological functions). Impairments are problems in body functions such as deviation or loss. Activity is the execution of a task or action by an individual. Activity limitations are difficulties an individual may have in executing activaties. Participation is involvement a life situation, and participation restrictions are problems an individual may experience in involvement in life situations. Functioning is an umbrella term encompassing all body functions, activities and participation. The icf acknowledges that the functioning is affected by various factors. These factors include medical factors such as the disease and the consequent treatment, personal factors such as age, gender, personality, and external factors such as an individual physical and social context.

Application of the ICF classification in cancerThe icf describes how people cope with their health status, which may also be helpful in the case of cancer. Figure 1 shows examples that may determine cancer patients’ functioning (Figure 1, italics). After cancer and cancer treatment, a loss of physiological or


Introduction

�

psychological functions may occur, such as an impaired oxygen uptake, or psychological distress. Cancer patients may also experience limitations in the performance of certain activities such as walking, cycling, or making decisions. Cancer patients may further experience participation restrictions in visiting friends or in taking part in sports or in keeping employment. Some sociodemographic variables such as gender and age seem to be risk factors for adjustment. For example, women and younger patients seem to have more difficulty adapting to the disease than male and older patients do [9]. Furthermore, individuals may have internal and external resources that may help or hinder them in coping with cancer. Internal and external resources refer, for example, to self-efficacy [10] and the amount of social support that patients may perceive when confronted with cancer [11].

Figure 1 Interaction of the aspects of health status, functioning, and personal and external factors.Italics: examples with cancer

Health status

Functioning

Medical factors

Function Activities ParticipationReduced abilityto walk, cycle, decision making

Physical andemotional rolefunctioning

Reduced oxygenuptake,mental distress

External factorsSocial support

Personal factorsSelf-efficacy

Cancer (treatment)

Rehabilitation programmes for cancer patients Several interventions have been developed to improve the quality of life of cancer patients. Such interventions include psychological programmes and/or physical training programmes. Psychosocial interventions primarily focus on coping with the disease and reducing psychological symptoms such as anxiety and depression [12,13]. Physical training, i.e., exercise training programmes, are reported to be beneficial for cancer patients because they are aimed at improving functional capacity, muscle strength, and cancer-related fatigue which may, in turn, contribute to a better overall quality of life [14,15].

Multidimensional rehabilitation programmes that include both physical and psychological programmes were developed to overcome the multi-facetted problems facing cancer patients. These combined programmes were developed in the Scandinavian countries in the early 1990-s [16]. Since 1995, the comprehensive cancer centres in the Netherlands have developed and implemented such combined programmes.


�

Introduction

Despite the increasing number of patients and centres that have supplied multidimensional rehabilitation programmes up to the present, little is known about the effectiveness of such programmes. Therefore research is needed. The present dissertation is the first in the Netherlands to focus on the effectiveness of a multidimensional cancer rehabilitation programme on the quality of life.

Modelforthethesisandaims

The model for the thesis is visualized in Figure 2 and represents the following train of thought. Cancer and cancer-treatment can be considered stressors to which an individual has to adapt. These stressors will have a direct effect on the quality of life or on the fatigue experienced by the patient. However, some patients seem to have a greater risk of experiencing problems while others seem to be able to adjust well. The risk or resistance factors may be sociodemographic (such as age, gender) or be related to internal and external resources. Furthermore, the model incorporates an intervention, a multidimensional rehabilitation programme, which will be delivered after the completion of cancer treatment to patients who continue to have quality of life problems [3]. The rehabilitation programme is assumed to have a directly beneficial effect on quality of life, but it may also affect internal and external resources through which a positive effect on outcome may subsequently be realized.

The aim of the present thesis is to examine the effect of a multidimensional rehabilitation programme on physical, psychological and social functioning, and on fatigue. Our second aim was to obtain insight into risk and resistance variables for the quality of life and for fatigue. After all, even up to the present, it is still not clear why some patients benefit from rehabilitation while others do not.

Figure 2 Model for the thesis

Internal + external resources- Social demographics- Self-efficacy- Social support

Stressor- Cancer- Cancer-related treatment

Outcome/Adaptation- Quality of life- Fatigue

Intervention- Rehabilitation programme

Physiological, PhysicalPsychological and Social functioning

Time


Introduction

�

Overviewofthethesis

The first part of the present thesis is based on a project performed by the Comprehensive Cancer Centre North Netherlands (cccn) and Center for Rehabilitation of the University Medical Center Groningen. This project involved the development, implementation and delivery of a multidimensional rehabilitation programme during the period 1998-2001.

The second part of the present thesis is based on a multi-centre randomized controlled trial (rct) that started in 2003 and was financially supported by the Dutch Cancer Society. This rct (Oncorev) aims to examine the effect of a physical training programme on patients’ quality of life and on fatigue in comparison to the effect of a multidimensional rehabilitation programme and to no intervention (a waiting control group). For this rct, a new physical training programme was developed. The development of this evidence-based self-management physical training programme will be presented in Chapter 6 of this thesis.

Chapter 2 reports on the short-term effects of the multidimensional cancer rehabilitation programme on physical functioning, fatigue, and quality of life.

Chapter 3 focuses on differences in the quality of life between cancer patients referred to the rehabilitation programme, a reference group of cancer patients, and the general population. The main goal is to examine the effect of the multidimensional rehabilitation programme on global and disease-specific health-related quality of life. Finally, investigation is performed into the differences between patients who chose to follow the entire rehabilitation programme and patients who chose certain components of the programme.

Chapter 4 deals with the examination of the effect of the cancer rehabilitation programme on social support (an external resource) and on self-efficacy (an internal resource). In addition, the chapter focuses on the effect of these personal resources on the quality of life before and after the programme, and on associations between change in quality of life and change in personal resources. Because fatigue is one of the most frequently-reported complaints of cancer patients and survivors, Chapter 5 focuses on fatigue and rehabilitation. First, the effect of the multi-dimensional rehabilitation programme on five domains of fatigue is examined. Second, the chapter explores several predictors of fatigue in patients referred to cancer rehabilitation. Finally, the chapter explores the association between change in fatigue after the programme and the change in the predictors of fatigue identified at baseline.

Chapter 6 describes the development of a self-management physical training programme, based on the best available evidence regarding the content and the delivery.

A general discussion and concluding remarks concerning the studies are presented in Chapter 7.

Chapter 8 summarizes the results of the studies in English and Dutch, respectively.


�

Introduction

ReferenceList

[1] Petrie KJ, Buick DL, Weinman J, Booth RJ. Positive effects of illness reported by myocardial infarction and breast cancer patients. J Psychosom Res 1999; 47: 537-543.

[2] Fallowfield LJ, Hall A, Maguire GP, Baum M. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 1990; 22: 575-580.

[3] van Harten WH, van Noort O, Warmerdam R, Hendricks H, Seidel E. Assessment of rehabilitation needs in cancer patients. Int J Rehabil Res 1998; 21: 247-257.

[4] VIKC. Kennisnetwerk cijfers, http://www.ikcnet.nl. Cited January 2006.

[5] CBS. http://www.cbs.nl. Cited May 2006.

[6] Schroevers M, Ranchor AV, Sanderman R. The role of social support and self-esteem in the presence and course of depressive symptoms: a comparison of cancer patients and individuals from the general population. Soc Sci Med 2003; 57: 375-385.

[7] Sprangers MAG. Quality of life assessment in oncology. Achievements and challenges. Acta Oncol 2002; 41: 229-237.

[8] Gijssen B, Hellendoorn- van Vreeswijk AJH, Koppejan-Rensebrink AG, Remie ME. Kanker en revalidatie; Herstel en Balans een innovatief programma. Utrecht: 2005.

[9] Parker P, Baile W, De Moor C, Cohen L. Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psychooncology 2003; 12: 183-193.

[10] Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977; 84: 191-215.

[11] Helgeson VS, Cohen S. Social support and adjustment to cancer: reconciling descriptive, correlational, and intervention research. Health Psychol 1996; 15: 135-148.

[12] Zabora JR, Blanchard CG, Smith ED, Roberts CS, Glajchen M, Sharp JW, BrintzenhofeSzoc KM, Locher JW, Carr EW, Best-Castner S, Smith PM, Dozier-Hall D, Polinsky LM, Hedlund SC. Prevalence of psychological distress among cancer patients across the disease continuum. J Psychsocial Oncol 1997; 15: 73-87.

[13] Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 1995; 14: 101-108.

[14] Dimeo F, Fetscher S, Lange W, Mertelsmann R, Keul J. Effects of aerobic exercise on the physical performance and incidence of treatment-related complications after high-dose chemotherapy. Blood 1997; 90: 3390-3394.

[15] Pinto BM, Clark MM, Maruyama NC, Feder SI. Psychological and fitness changes associated with exercise participation among women with breast cancer. Psychooncology 2003; 12: 118-126.

[16] Berglund G, Bolund C, Gustafsson UL, Sjoden PO. One-year follow-up of the ‘Starting Again’ group rehabilitation programme for cancer patients. Eur J Cancer 1994; 30A: 1744-1751.



�

2 Physicalfunctioningandqualityoflife

aftercancerrehabilitation

E. van Weert, J.E.H.M. Hoekstra-Weebers, B.M.F. Grol, R. Otter, J.H. Arendzen, K. Postema, C.P. van der SchansInt Journal of Rehab Res 2004, 27:27-35

AbstractIn order to overcome cancer-related problems and to improve quality of life, an intensive multi-focus rehabilitation programme for cancer patients was developed. We hypothesised that this six-week intensive rehabilitation programme would result in physiological improvements and improvement in quality of life. Thirty-four patients with cancer-related physical and psychosocial problems were the subjects of a prospective observational study. A six-week intensive multi-focus rehabilitation programme consisted of four components: individual exercise, sports, psycho-education, and information. Measurements (symptom-limited bicycle ergometry performance, muscle force and quality of life [rand-36, rscl, mfi]) were performed before (T0) and after six weeks of rehabilitation (T1). After the intensive rehabilitation programme, statistically significant improvements were found in symptom-limited bicycle ergometry performance, muscle force, and several domains of the rand-36, rscl and mfi. The six-week intensive multi-focus rehabilitation programme had immediate beneficial effects on physiological variables, on quality of life and on fatigue.


Physical functioning and quality of life after cancer rehabilitation

�0

Introduction

Cancer and the treatment of cancer are often associated with impaired physical capacity and psychosocial problems and can therefore substantially diminish quality of life [1]. Impaired physical capacity can be explained by several factors, such as tumour toxicity and the treatment of cancer [2] including surgery, chemotherapy and radiotherapy which may induce cardiorespiratory and muscular–skeletal deconditioning. Impaired physical capacity may lead to a greater degree of exertion being required for the performance of everyday activities. Consequently, patients may experience fatigue even when performing normal activities. Patients are usually advised to avoid physical exertion and to minimize their daily activity load in order to reduce fatigue. As a result, a vicious circle of fatigue, reduced activity and further impaired physical capacity may occur. Impaired physical capacity has been postulated as being a substantial contributor to cancer-related fatigue [3] and to diminished quality of life in cancer patients [4].

Cancer patients may also experience psychosocial problems. The psychosocial problems most frequently mentioned are anxiety, depression, mood disturbances, stress, insecurity, grief and decreased self-esteem [5-12]. Additionally, problems in job reintegration and social isolation are reported in cancer patients [13].

Several rehabilitation programmes have been developed, consisting of physical or psychological interventions to overcome the cancer-related physical and psychosocial problems and to improve quality of life in cancer patients. Physical exercise training is thought to be beneficial for cancer patients in promoting health, reducing or preventing cancer-related fatigue and improving quality of life [2-4, 14-20]. However, very little data supporting this hypothesis has been gathered to date.

Psychosocial interventions for cancer patients can be divided into three general categories [21]: (1) coping-skills training based on cognitive– behavioural approaches, (2) patient education and (3) support groups. It has been demonstrated that these psychosocial interventions can facilitate coping with the disease and potentially improve quality of life [11, 13, 22-26].

Physical and psychological interventions may be combined in multi-focus rehabilitation programmes. Berglund et al. [27,28] evaluated a multi-focus rehabilitation programme consisting of low-intensity physical training, and information-and coping-skills training in a selected group of patients with breast cancer. The study revealed perceived physical benefits in addition to psychosocial benefits, although these were only quantified with a questionnaire and not with physiological measures. Berglund’s results were confirmed by another study on 14 selected patients with breast cancer during chemotherapy [29]. These studies suggested that multi-focus rehabilitation programmes are beneficial to breast cancer patients. However, it is unclear whether these programmes are feasible and effective in unselected mixed groups of cancer patients.

For the present study, we developed a cancer rehabilitation programme for a mixed group of cancer patients based on three theoretical assumptions. Firstly, we acknowledged the value of Engel’s bio-psychosocial model [30], which, in our opinion, requires a multi-focus approach. We accordingly developed a multifocus programme including psychosocial, educational and physical interventions. Secondly, the intervention consisted of an intensive rehabilitation period of six weeks with a large number of contact hours.


��


We expected this boost programme to have positive and immediate effects on physical and psychosocial outcomes. Thirdly, with respect to the physical part of the intervention, we theorized that genuine physiological improvements might be key to breaking the vicious circle of impaired physical capacity, fatigue and reduced activity. Consequent to the expectation of the inclusion of cancer patients with low physical capacity and a high level of fatigue, we developed a mild-to-moderate training programme of six weeks that would be both feasible and effective in improving physiological functioning. If a short, boost programme were to produce an improvement in both physiological functioning and quality of life, it might eventually contribute to the further development of cancer rehabilitation programmes. Therefore, it was of the utmost importance to determine both effects at approximately six weeks, i.e., at the end of the intensive rehabilitation programme.

The purpose of this study was to evaluate the immediate effects of the intensive multi-focus rehabilitation programme on physiological variables and on quality of life in cancer patients. We hypothesized (1) that the intensive multi-focus programme would result in physiological training effects, and (2) that the intensive multi-focus programme would result in an improvement of quality of life and a decrease of fatigue.

Patientsandmethods

PatientsThe rehabilitation programme was developed for cancer patients who experienced impaired physical and psychosocial functioning after cancer treatment. The programme was open to patients referred by hospitals and by general practitioners. Participants were included in the programme and study if they met the following inclusion criteria:- Age > 18 years - Last cancer-related treatment > three months ago - Life expectancy C one year - An indication for rehabilitation, e.g., patients were included in the programme if they

met at least three of the following criteria, as judged by a physician: - Physical complaints like sore muscles, pain, headache, etc. - Reduced physical capacity, e.g., impairment in walking, cycling or at work - Psychological problems like increased levels of anxiety, depression or

nervousness - Increased levels of fatigue - Sleep disturbances - Problems with coping with reduced physical and psychosocial functioning due to

cancer.

Patients were not included if they met one of the following exclusion criteria:- A very low level of activity, e.g., less than 50% of their time ambulant, rapid fatigue

appearance after low physical activity performance, and ADL dependency - Inability to travel independently to the rehabilitation centre - Cognitive disturbances that may interfere with participation in the rehabilitation

programme - Emotional disturbances that may interfere with participation in the rehabilitation

programme.



��

The Medical Ethics Committee of University Hospital Groningen approved the study. All patients provided informed written consent to participation in the study and for the procurement of medical information from their hospital charts. Medical data were verified by record linkage with the cancer registry of the Comprehensive Cancer Centre North-Netherlands.

Thirty-seven patients were included, but one patient left the programme for personal reasons and two patients did not finish the programme due to cancer recurrence. Therefore, data from the 34 patients who completed the programme at six weeks were taken for analysis.

Rehabilitation programmeThe rehabilitation programme took place in a rehabilitation centre. The programme took place with groups of 8-12 cancer patients in order to facilitate peer contact. The rehabilitation programme was approached from a multidisciplinary perspective and consisted of an intensive six-week multi-focus programme and a nine-week phase-out programme. During the intensive six-week programme, the sessions took place twice weekly, i.e., the group met 12 times, and the total number of contact hours was 48 hours.

The intensive rehabilitation programme consisted of the following components: (a) Individual Exercise, (b) Sports, (c) Psycho-education, and (d) Information.

Individual exercise (twice a week, 1.5 hours)The exercise programme was divided into bicycle training and a muscle exercise circuit focussed on physical performance and muscle force respectively.- Bicycle training programme Patients exercised twice a week over the six weeks on a bicycle ergometer. Before the

exercise training, a symptom-limited bicycle ergometry test was performed. This test was used as the basis on which an exercise schedule for individual patients was worked out, with two options: (1) in the case of physiological limitations during the ergometry test, for example the achievement of the heart rate predicted, the training programme was to be based on the training heart rate (thr), which was computed using the Karvonen formulae: thr=HRrest +50 to 80% (HRmax–HRrest) [31-33]. During weeks 1-3, exercise training was performed at a thr of HRrest+50 to 60% (HRmax–HRrest) and during weeks 4-6 at a thr of HRrest+70 to 80% (HRmax–HRrest). This aerobic exercise training was performed over 15–20 minutes with a warm-up before and a cool-down after the training. (2) In the case of symptom limitations without reaching physiological limitations due to severe symptoms, or for patients who could not reach a thr, the training was to be based on a protocol according to Alison [34].

- Muscle force training General muscle force training of the trunk and the lower and upper extremities was

performed twice a week. Before training, the individual 1-Repetiton Maximum (1-RM) was defined. Individual intensity of muscle force training started at 50% of the 1-RM during the first week, and was increased by 5-10% over the ensuing weeks with a frequency of 12 repetitions during three series. In the individual exercise programme, patients were also advised to follow a walking programme at home, once a week.


��


Sports (twice a week, one hour)The sports programme consisted of sessions that were directed towards “enjoying sports”, “self-confidence”, and “body knowledge”. In order to increase the chance that patients would continue sports activities in their leisure time after the end of the rehabilitation programme, patients were offered a variety of sports activities, like badminton, soccer, mini-golf, swimming, and so forth. During the performance of certain sports activities, patients were instructed to become aware of their physical sensations or limitations, in such a way that they would recognize and respect them in other sports.

Psycho-education (once a week, two hours)The psycho-educational programme was aimed at reducing negative emotions and at improving coping with the disease. The psycho-educational programme was led by a course leader with several years experience in conducting group sessions with cancer survivors. The course leader brought up the following psychologically oriented topics with respect to cancer: “confrontation with cancer”, “anxiety”, “stress”, “depression”, “asking for professional help”, and “social support”. Over several sessions, expressive-supportive techniques were used in order to explore negative emotions and to provide the opportunity to receive support from other cancer survivors. In addition, breathing exercises, relaxation exercises and exercises from Rational-Emotive Therapy were used in order to provide patients with stress-management techniques. Patients were instructed to practice the exercises and to prepare every session at home. All sessions were described in a course book that was used by course leader and participants.

Information (once a week, one hour)The aim of the information programme was to reduce uncertainty due to lack of knowledge of the disease by providing information with respect to cancer-related subjects. Several professional healthcare providers who had specific knowledge of several subjects conducted the information session. The following subjects, with respect to cancer, were discussed in group sessions: “medical aspects of cancer”, “cancer-related fatigue”, “food”, “sexuality”, “sport”, “body image”, “work and insurance”, “complementary medicine”, “pain”, and “daily activities”. During the session, patients were provided with information and were also given the opportunity to raise questions and to share experiences with other cancer survivors.

Study designThis study followed a prospective cohort study design. Measurements were performed before (T0) and at the end of the intensive six-week rehabilitation programme (T1).

Outcome variablesPhysical variables- Physical capacity performance At T0 and T1 a symptom-limited bicycle ergometry test was performed using a ramp

10-, 15- or 20-protocol, depending on the patient’s condition. This implied that the load was increased every minute by 10, 15 or 20 Watts respectively, in such a way that patients could reach their maximal workload within 10 minutes. The test was terminated on the basis of the patient’s symptoms or at the physician’s discretion [35]. Borg scores [36] for



��

dyspnoea and muscle fatigue were taken before and after the test. Maximal workload, maximal O2 uptake, O2-pulse and Borg scores at maximal workload were taken for analysis.

- Muscle force Maximal voluntary isometric muscle force of the right and left extremity of extension

of the knee, flexion of the knee, flexion of the elbow, extension of the elbow and grip-strength of the hand were measured using a hand-held dynamometer (Force Evaluating & Testing [microFET], Hoggan Health Industries Inc, usa). The “break method” was used for all measurements. To employ this technique, the examiner gradually overcame the force exerted by the patient until the extremity gave way [37]. All measurements were performed at least three times, with recovery intervals of at least 10 seconds. The peak forces (in Newtons) were recorded and mean values of three technically correct measurements were taken for analysis. At that point, a compound value for general muscle force was calculated by computing a sum score of the values obtained for the upper and lower extremities to one sum value for each.

Quality of lifeQuality of life was measured with the rand-36, the Rotterdam Symptom Check List (rscl), and the Multi Fatigue Index (mfi). The rand-36 is a multidimensional self-report questionnaire to assess global health-related quality of life. The questionnaire consists of the following nine domains: physical functioning (10 items), social functioning (two items), role impairment due to physical problems (four items), role impairment due to emotional problems (three items), mental health (five items), vitality (four items), pain (two items), general health appraisal (five items), and overall quality of life (one item). Scores range from 0 to 100 with a higher score representing better health. Psychometric characteristics of the instrument are described as follows: internal consistency ranges from α=0.71–0.92; test–retest is sufficient; the instrument has high convergent validity and low divergent validity [38]. The rscl is a self-report measure for the assessment of quality of life of cancer patients. The instrument is disease-specific and differentiates between disease and treatment state, and treatment processes. It consists of 39 items, which cover the following domains: physical symptom distress (23 items), psychological distress (seven items), activity level (eight items) and an overall valuation of quality of life (one item). Responses are given for most items on four-point Likert-type scale. A high score reflects a higher level of impairment burden. Psychometric characteristics of the instrument are described as follows: internal consistency is good; construct validity and clinical validity are sufficient [39]. The mfi is a self-report questionnaire that measures the following five aspects of fatigue: general fatigue (four items), physical fatigue (four items), reduction in activity (four items), reduction in motivation (four items), and mental fatigue (four items). Responses are given on four-point Likert-type scales. Scores range from 4–100, with a high score reflecting a greater sense of fatigue. Psychometric characteristics of the instrument are described as follows: internal consistency ranges from > 0.70 to > 0.80; construct and convergent validity are classified as good [40,41].

Statistical analysisStatistical analyses were performed using the Statistical Package for the Social Sciences (spss). Non-parametric Wilcoxon tests were used for ordinal data and paired t tests were used for interval and ratio data.


��


Results

Patient characteristicsSixty-seven percent of the patients were women with breast cancer (Table 1) and 70.2% of the patients had a tumour at stage I or II. The most frequently mentioned indications for rehabilitation were reduced physical capacity (94.6%) and fatigue (94.6%). Within a year of their last cancer-related treatment, 61.2% of the patients started the rehabilitation programme. Thirty-four patients completed the intensive six-week programme, implying a dropout rate of 8.1%.

Table 1Patients’ characteristics at time of inclusion (T0) n=��

Age, mean (SD), years Range

52.8 (6.2)(43-67)

Gender, male: female (%) 16.2: 83.8

Indication for rehabilitation (%)Physical complaintsReduced physical capacity Psychological symptomsFatigue Sleep disturbancesCoping/acceptance problems

83.394.678.494.664.951.4

Diagnosis (%)Breast cancerNon-Hodgkin Lymphoma /M.HodgkinGynaecological cancerRest category (< 5.0 %)

67.68.18.1

16.2

Stage (%)Stage IStage IIStage IIIStage IV

24.345.921.6

8.1

Treatment before rehabilitation (%)Surgical treatmentChemotherapyRadiotherapy

64.962.964.9

Time between last treatment and programme start in months (%)< 6 6-12 12-18 > 18 Median

29.732.416.221.6

7.1 months



��

Comparison T0 versus T1, outcome measurements Hypothesis 1: patients would do better physiologically after six weeksThe immediate effects of the intensive rehabilitation programme on physical capacity and muscle force are presented in Table 2. Twenty-nine of the 34 patients performed the bicycle ergometry test and the hand-held dynamometry test at the end of the high-dose rehabilitation period. Two patients were not able to perform the test due to claustrophobia, nausea and absence, and three patients due to cancer-recurrence treatment. Statistically significant improvements were found in all physical outcome variables, including oxygen pulse, muscle force, and muscle fatigue (Tables 2 and 3), except for dyspnoea.

Table 2 Descriptives of aerobic physical capacity and muscle force before (T0) and after six weeks of rehabilitation (T�), and paired t tests

T0, n=34Mean (SD)

T1, n=29Mean (SD) t p

W. Max (W) 112.2 (33.5) 124.8 (30.7) –3.908 0.001

HR rest min-1 87.7 (13.6) 82.2 (10.9) 2.797 0.002

Respiratory quotient 1.1 (0.1) 1.2 (0.1) –3.467 0.002

O2-uptake (ml/min) 1389.5 (266.2) 1498.4 (392.2) –2.681 0.03

O2-pulse (ml/hf ) 10.0 (2.3) 10.7 (2.8) –2.588 0.02

Muscle strength upper extremity (N) 710.0 (150.9) 768.3 (190.1) –3.261 0.005

Muscle strength lower extremity (N) 544.9 (79.6) 620.7 (128.6) –3.430 0.001

Table 3Descriptives of Borg scores of dyspnea and muscle fatigue after bicycle ergometry before (T0) and after six weeks of rehabilitation (T�), and Wilcoxon tests of the difference between scores at T0 and T�

T0Median (range)

T1Median (range) p

Dyspnoea post-test (median, range) 3.0 (0.5-8.0) 3.0 (0.5-9.0) 0.150

Muscle fatigue post-test (median, range) 5.0 (0.0-8.0) 3.0 (0.5-7.0) 0.041

Hypothesis 2: patients would report higher levels of quality of life after six weeksTables 4, 5 and 6 present the prevalence of physical and psychosocial patient problems referred to the programme at time of inclusion, and the immediate effects of the rehabilitation programme on quality of life after six weeks. As expected, patients experienced more physical and psychological problems at the start of the programme than found in the general population (Tables 4, 5 and 6).


��

Table 4RAND-�� scores for general population�8, patients at T0, patients at T�, and Wilcoxon test of the differences between scores at T0 and at T�

General populationn = 1063Mean (SD)

Patients at T0n = 37Mean (SD)

Patients at T1n = 34Mean (SD) p

Physical functioning 81.9 (23.9) 58.2 (20.3) 62.1 (20.0) 0.029

Social functioning 86.9 (20.5) 55.7 (19.7) 60.0 (25.2) 0.196

Role limitation (physical problem) 79.4 (35.5) 20.7 (32.9) 28.0 (32.4) 0.162

Role limitation (emotional problem) 84.1 (32.3) 34.2 (40.0) 51.0 (44.4) 0.036

Mental health 76.8 (18.4) 59.9 (17.8) 63.8 (18.3) 0.126

Vitality 67.4 (19.9) 45.6 (18.9) 49.9 (20.1) 0.049

Pain 79.5 (25.6) 67.5 (20.8) 68.3 (21.2) 0.499

General health appraisal 72.7 (22.7) 52.6 (13.8) 53.2 (15.7) 0.697

Change of health 52.4 (19.4) 43.3 (38.2) 61.8 (38.6) 0.010

Table 5RSCL scores for general population��, patients at T0, patients at T�, and Wilcoxon tests of the differences between scores at T0 and at T�

Generalpopulationn = 201Mean (SD)

Patients at T0n = 37Mean (SD)

Patients at T1n = 34Mean (SD) p

Overall valuation of life 21.1 (83.7) 38.9 (16.9) 40.6 (20.7) 0.599

Psychological distress 17.0 (18.1) 37.3 (21.2) 30.1 (20.7) 0.015

Physical symptom distress 9.9 (9.0) 24.5 (10.2) 22.5 (11.8) 0.031

Activity level Not available 21.5 (22.2) 19.8 (16.9) 0.656

Table 6MFI scores for general population��, patients at T0, patients at T�, and Wilcoxon tests of the differences between scores at T0 and at T�

Generalpopulationn = 139

Patients at T0n = 37

Patients at T1n = 33 p

General fatigue 9.91 (5.2) 15.5 (3.6) 14.4 (4.2) 0.024

Physical fatigue 8.79 (4.9) 15.1 (4.1) 13.1 (4.3) 0.007

Reduction of activity 8.69 (4.6) 12.7 (4.5) 12.0 (4.4) 0.159

Reduction of motivation 8.23 (4.0) 10.4 (3.6) 9.8 (3.9) 0.013

Mental fatigue 8.33 (4.8) 12.8 (4.0) 13.8 (4.7) 0.824



�8

After six weeks of rehabilitation, patients showed a statistically significant improvement in physical functioning, role limitation due to emotional problems and vitality in the rand-36 domains, as compared with baseline values (Table 4). Furthermore, the score on the change of health domain, which reflects a comparison between the present situation and the situation a year ago, was increased and reached a value which was greater than the mean score of the general population. In addition, patients in the study perceived a statistically significant reduction in physical symptom distress and psychological distress after six weeks following the rehabilitation programme (Table 5). Finally, patients experienced less general fatigue, physical fatigue and reduction in motivation after six weeks of the rehabilitation programme in comparison with baseline values on the mfi (Table 6). Change was not significant for the remaining rand-36, rscl and mfi domains.

Discussion

The results of this study indicate that this intensive multi-focus rehabilitation programme for cancer patients is well tolerated and feasible. During the programme, three patients dropped out, two of them because of cancer recurrence, which is a dropout rate of only 8.1%.

Furthermore, the results of the study indicate that this intensive multi-focus rehabilitation programme had immediate short-term beneficial effects in cancer patients on physiological variables and on quality of life.

Our hypothesis that the intensive rehabilitation programme would result in physiological improvements within six weeks was confirmed. The most interesting finding of this study is that rehabilitation may lead to an increase in O

2-pulse, which reflects genuine physiological

training effects. Furthermore, the results of our study suggest that a six-week period is sufficient to achieve improvements in physical capacity variables, e.g., O

2- pulse, O

2-uptake

and workload (Wmax). Very low values for maximal O2-uptake, which were far below

the norm values of maximal O2-uptake of 1600–2200 ml/min for untrained women [43],

were found at intake. After six weeks of rehabilitation we found an increase in O2-uptake,

although normal values for healthy untrained women were not attained. These results are in agreement with the Schulz study [43]. An improvement in physical performance after an exercise program was also found by Dimeo in several small groups of patients [4,16,44]. However, in those studies, physical performance was indirectly assessed by calculating metabolic equivalents (mets), which is less accurate [4] and may lead to misinterpretations [35]. Additionally, in this study, lower Borg scores for muscle fatigue posttest were obtained, which reflect a reduction in fatigue experienced after the bicycle test. In general, based on the physical improvements, it can be concluded that patients achieved a higher workload with less subjective and objective effort after six weeks of intensive rehabilitation.

The hypothesis concerning improvement in quality of life following the intensive multi-focus high-dose rehabilitation programme was confirmed in several of the global and disease-specific quality of life domains, and in fatigue. Patients experienced an improvement in physical functioning and vitality after six weeks of rehabilitation. These improvements may have been due to a positive transfer effect of increased physical capacity. This is in agreement with earlier studies reporting an increased physical capacity (VO

2max)

and an improvement in the same rand-36 domain in women with breast cancer who participated in an exercise programme [43,45].



��

The scores in the physical functioning and physical symptom distress (rscl) domains were statistically significantly improved after the intensive programme, while for the scores in the role limitation due to physical problems in the rand-36 domain, only a trend of improvement was found. This may indicate that role limitation is affected in the long term.

Another interesting finding in this study was the significant reduction in psychological distress. This finding is in agreement with another study [46] that concluded that aerobic exercise might improve psychological distress. In the present study, the decrease in psychological distress may be explained by the following. Firstly, the decrease may be the result of the psychosocial or educational components of the intervention. Secondly, a transfer effect from improved physical to improved psychological functioning may have occurred, i.e., improvement in physical performance may have increased the patients’ sense of control, independence, self-esteem and self-efficacy [46]. Thirdly, the decrease may have been a result of nonspecific effects of attention.

Fatigue is the most frequently reported side effect in cancer patients, but its determinants and consequences are still largely unexplored [47]. In this study, several improvements were found in fatigue experienced after six weeks of rehabilitation, especially in ‘general’ and ‘physical’ fatigue. This decrease in fatigue may have been due to improved physical capacity and muscle force. Furthermore, patients demonstrated less reduction in motivation, which may have resulted from their lower levels of reported psychological distress. The ‘reduction of activity’ and ‘mental fatigue’ domains remained unchanged. These results could suggest that improvement in physical capacity may at first have resulted in improvement of general and physical fatigue and less reduction in motivation, and that in order to obtain less reduction in activity and mental fatigue, a further increase of VO

2max, or some other factors, is necessary.

Our hypothesis that the intensive multi-focus programme would result in positive effects on quality of life (including fatigue) was confirmed in nine of 18 domains. However, it remains unclear which components of the programme were responsible for the improvements achieved in physical, psychological and social quality of life. With respect to the physiological improvements, it may be assumed that these may have been due to the physical component of the programme, since physiological improvements only occur due to certain training principles [32] and not as a result of ‘social support’ by peers or psychosocial or educational interventions.

The results of this study may contribute to the knowledge of cancer rehabilitation. Although further research is necessary, the effects obtained, both on physiological functioning and on quality of life within six weeks, can be used for further development of cancer rehabilitation programmes.

Study limitations and future recommendationsAlthough the programme was open to a mixed group of cancer patients, more than half of the participants were women with breast cancer, which may limit the generalisability of the results of our study. Most patients had a cancer at stage I or II, which may reflect the relatively good prognosis of the patients who were referred to the programme. Although this may indicate the correct use of the inclusion criterion of a life expectancy of more than a year, it shows that the results of this study may not be generalisable to the whole population of cancer patients. At the same time, however, these patients form exactly the target population for cancer rehabilitation programmes that focus on improvement and recovery.



�0

Based on the high level of physical and psychological problems encountered, it should be noted that the group of patients in this study might not be representative of cancer patients in general. This is supported by an earlier study showing that programme participants perceive more physical and psychological symptoms than patients who choose not to participate into a rehabilitation programme [48,49]. Therefore, the poor quality of life found in our group of patients may also be the result of the inclusion criteria used for the study.

A final limitation to our study is that we did not include a control group. Therefore, the results of our study should be interpreted with care. Future research should use a randomised controlled trial design in order to determine the effects of the various components of the programme.

AcknowledgementsThis study was supported by a grant from the Dutch Rotary and Dutch Cancer Society.



��


References

[1] Bjordal K, Mastekaasa A, Kaasa S. Self-reported satisfaction with life and physical health in long-term cancer survivors and a matched control group. Eur J Cancer B Oral Oncol 1995; 31B: 340-345.

[2] Seifert E, Ewert S, Werle J. [Exercise and sports therapy for patients with head and neck tumors]. Rehabilitation (Stuttg) 1992; 31: 33-37.

[3] Winningham ML. Walking program for people with cancer. Getting started. Cancer Nurs 1991; 14: 270-276.

[4] Dimeo FC, Tilmann MH, Bertz H, Kanz L, Mertelsmann R, Keul J. Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. Cancer 1997; 79: 1717-1722.

[5] Argerakis GP. Psychosocial considerations of the post-treatment of head and neck cancer patients. Dent Clin North Am 1990; 34: 285-305.

[6] Body JJ, Lossignol D, Ronson A. The concept of rehabilitation of cancer patients. Curr Opin Oncol 1997; 9: 332-340.

[7] de Boer MF, McCormick LK, Pruyn JF, Ryckman RM, van den Borne BW. Physical and psychosocial correlates of head and neck cancer: a review of the literature. Otolaryngol Head Neck Surg 1999; 120: 427-436.

[8] Delbruck H, Aghabi E. [Subjective discomfort of stomach cancer and esophageal cancer patients in after-care]. Rehabilitation (Stuttg) 1993; 32: 232-235.

[9] Fallowfield LJ. Quality of life measurement in breast cancer. J R Soc Med 1993; 86: 10-12.

[10] Ganz PA, Schag AC, Lee JJ, Polinsky ML, Tan SJ. Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer 1992; 69: 1729-1738.

[11] Hill DR, Kelleher K, Shumaker SA. Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review. Gen Hosp Psychiatry 1992; 14: 28S-42S.

[12] Schwibbe G. [Changes in quality of life in oncological patients in the course of an inpatient after-care program]. Rehabilitation (Stuttg) 1991; 30: 55-62.

[13] Andersen BL. Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 2002; 70: 590-610.

[14] Courneya KS, Friedenreich CM. Relationship between exercise during treatment and current quality of life among survivors of breast cancer. J Psychosoc Oncol 2000; 15: 35-57.

[15] Courneya KS, Mackey M, Jones LW. Coping with Cancer: can exercise help? Physician Sportsmed 2000; 28: 49-51.

[16] Dimeo F, Bertz H, Finke J, Fetscher S, Mertelsmann R, Keul J. An aerobic exercise program for patients with haematological malignancies after bone marrow transplantation. Bone Marrow Transplant 1996; 18: 1157-1160.

[17] MacVicar MG, Winningham ML, Nickel JL. Effects of aerobic interval training on cancer patients’ functional capacity. Nurs Res 1989; 38: 348-351.

[18] Pinto BM, Maruyama NC. Exercise in the rehabilitation of breast cancer survivors. Psychooncology 1999; 8: 191-206.

[19] Schwartz AL. Patterns of exercise and fatigue in physically active cancer survivors. Oncol Nurs Forum 1998; 25: 485-491.

[20] Young McCaughan S, Sexton DL. A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. Oncol Nurs Forum 1991; 18: 751-757.

[21] Bloom JR, Kessler L. Risk and timing of counseling and support interventions for younger women with breast cancer. J Natl Cancer Inst Monogr 1994; 199-206.

[22] Cunningham AJ, Edmonds CV. Group Psychological Therapy for cancer patients; a point of view, and discussion of the hierarchy of options. Int J Psychiatry Med 1996; 28: 51-82.

[23] Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, Guthrie D, Fahey JL, Morton DL. Malignant melanoma: Effects of an early structured psychiatric intervention, coping, and affective state on recurrence and survival 6 years later. Arch Gen Psychiatry 1993; 50: 681-689.

[24] Greer S, Moorey S, Baruch JD, Watson M, Robertson BM, Mason A, Rowden L, Law MG, Bliss JM. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 1992; 304: 675-680.



��

[25] Hitch PJ, Fielding RG, Llewlyn SP. Effectiveness of a self-help and support groups for cancer patients: a review. Psychol Health 1994; 9: 437-448.

[26] Trijsburg RW, van Knippenberg FC, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. Psychosom Med 1992; 54: 489-517.

[27] Berglund G, Bolund C, Gustafsson UL, Sjoden PO. A randomized study of a rehabilitation program for cancer patients: The ‘Starting Again’ group. Psychooncology 1994; 3: 109-120.


[29] Mock V, Burke MB, Sheehan P, Creaton EM, Winningham ML, Kenney-Tedder S, Schwager LP, Liebman M. A nursing rehabilitation program for women with breast cancer receiving adjuvant chemotherapy. Oncol Nurs Forum 1994; 21: 899-907.

[30] Engel GL. From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics 1997; 38: 521-528.

[31] Amundsen LR. Establishing activity and training levels for patients with ischemic heart disease. Phys Ther 1979; 59: 754-758.

[32] Goldberg L, Elliot DL, Kuehl KS. Assessment of exercise intensity formulas by use of ventilatory threshold. Chest 1988; 94: 95-98.

[33] Karvonen J, Vuorimaa T. Heart rate and exercise intensity during sports activities. Practical application. Sports Med 1988; 5: 303-311.

[34] Alison JA, Anderson SD. Comparison of two methods of assessing physical performance in patients with chronic airway obstruction. Phys Ther 1981; 61: 1278-1280.

[35] Wasserman K, Hansen JE, Sue DY, Whipp BJ. Principles of exercise training and interpretation, 5 ed. Philadelphia: Lea & Febiger; 1987.

[36] Borg G. A category scale with ratio properties for intermodal and inter-individual comparisons. In: Geissler HG, Petzold PE (eds.), Psychophysical judgment and the process of perception. Berlin: Veb Deutscher Verlag der wissenschaften.; 1982: 25-34.

[37] van der Ploeg RJ, Oosterhuis HJ. The “make/break test” as a diagnostic tool in functional weakness. J Neurol Neurosurg Psychiatry 1991; 54: 248-251.

[38] van der Zee K, Sanderman R. RAND-36. Groningen: Northern Centre for Health Care Research, University of Groningen, the Netherlands; 1993.

[39] de Haes JC, Olschewski M, Fayers PM, Visser MRM, Cull A, Hopwood R, Sanderman R. The Rotterdam Symptom Checklist. Groningen: Northern Centre for Health Care Research, University of Groningen, the Netherlands; 1996.

[40] Smets EM, Garssen B, Bonke B, de Haes JC. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 1995; 39: 315-325.

[41] Smets EM, Garssen B, Cull A, de Haes JC. Application of the multidimensional fatigue inventory (MFI-20) in cancer patients receiving radiotherapy. Br J Cancer 1996; 73: 241-245.

[42] Smets EM, Visser MR, Willems-Groot AF, Garssen B, Schuster-Uitterhoeve AL, de Haes JC. Fatigue and radiotherapy: (B) experience in patients 9 months following treatment. Br J Cancer 1998; 78: 907-912.

[43] Schulz KH, Szlovak C, Schulz H, Gold S, Brechtel L, Braumann M, Koch U. [Implementation and evaluation of an ambulatory exercise therapy based rehabilitation program for breast cancer patients]. Psychother Psychosom Med Psychol 1998; 48: 398-407.

[44] Dimeo F, Rumberger BG, Keul J. Aerobic exercise as therapy for cancer fatigue. Med Sci Sports Exerc 1998; 30: 475-478.

[45] Segal R, Evans W, Johnson D, Smith J, Colletta S, Gayton J, Woodard S, Wells G, Reid R. Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial. J Clin Oncol 2001; 19: 657-665.

[46] Dimeo FC, Stieglitz RD, Novelli-Fischer U, Fetscher S, Keul J. Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer 1999; 85: 2273-2277.

[47] Visser MR, Smets EM. Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer 1998; 6: 101-108.

[48] Berglund G, Bolund C, Gustavsson UL, Sjoden PO. Starting again -a comparison study of a group rehabilitation program for cancer patients. Acta Oncol 1993; 32: 15-21.



��

3 Amultidimensionalcancerrehabilitation

programforcancersurvivors

Effectiveness on health-related quality of life

Ellen van Weert, Josette Hoekstra-Weebers, Brigit Grol, Renée Otter, Hans J. Arendzen, Klaas Postema, Robbert Sanderman, Cees van der SchansJ Psychosom Res 2005; 58:495-496

AbstractObjective: A multidimensional rehabilitation program for cancer survivors was developed to overcome cancer-related problems and to improve quality of life. The two purposes of the study were to describe the effectiveness of the program and to obtain information about patient preferences for multi or mono dimensional rehabilitation programs. Methods: Subjects: cancer survivors with different diagnoses, and cancer-related physical and psychosocial problems. Intervention: a 15-week rehabilitation program including individual exercise, sports, psycho-education, and information. Group-wise randomization was implemented by assigning one half of the patients to the complete program while the other half were allowed to choose which program components they considered relevant. Measures: Health-Related Quality of Life [rand-36 and Rotterdam Symptom Check List (rscl)], exercise capacity (symptom limited bicycle ergometry), muscle force (hand-held dynamometry), and patient preferences. Measurements were performed before (T0) and after the rehabilitation program (T1), and at a 3-month follow-up (T2). Results: After the rehabilitation program, cancer survivors (n=63) displayed statistically significant improvements on health-related quality of life with effect sizes (es) varying from 0.38 to 0.99 (rand-36) and from –0.34 to –0.57 (rscl), most persistent at 3-month follow-up. Furthermore, statistically significant improvements in exercise capacity and muscle force of upper and lower extremities were displayed after rehabilitation. If offered a choice, 80% of the patients prior to start and 58% of the patients after completion of the program indicated that they preferred the entire multidimensional program. Conclusion: A multidimensional rehabilitation program has statistically and clinically relevant beneficial effects on health-related quality of life, exercise capacity, and muscle force in cancer patients with different diagnoses. Furthermore, if offered the choice, the majority of cancer survivors seem to prefer multidimensional programs to programs with only one component.


A multidimensional cancer rehabilitation program for cancer survivors

��

Introduction

Cancer patients can suffer from serious physical and psychosocial side effects due to cancer and cancer treatment [1–5]. Both physical and psychosocial side effects can occur in the short term but have also been described as persisting over the years after completion of treatment [6] and have the potential to diminish quality of life in cancer survivors.

Physical side effects like fatigue, reduced muscle strength, and impaired physical capacity [7] can be explained by cancer-related, such as tumor activity and anemia, and treatment-related factors. The treatment of cancer, including surgery, chemotherapy, and radiation, may induce initial cardio-respiratory and muscular skeletal deconditioning. After these initial physical impairments, a vicious cycle of fatigue, reduced activity, and an even further impaired physical capacity may appear and contribute to the persistence of physical problems, even years after the completion of cancer treatment.

A major psychological side effect is the elevated level of depressive feelings reported by patients during the first months after diagnosis. Approximately one quarter of cancer patients report depressive symptoms during the initial period after diagnosis. A significant percentage of cancer patients, ranging from 15% to 30%, seem to continue to experience depressive symptoms 1 year after diagnosis [8,9]. Moreover, cancer patients report other psychosocial problems such as anxiety, mood disturbances, stress, insecurity, grief, low self-esteem, social isolation, and problems with job reintegration [1,2,10–16].

Several mono- or multidimensional rehabilitation programs have been developed to overcome cancer-related physical and psychosocial side effects and to improve the quality of life of cancer survivors. Monodimensional rehabilitation programs consist of either psychosocial or physical interventions. The focus of psychosocial interventions [17–19] is primarily on improving psychological functioning. They are therefore described as less likely to address the physical and functional problems that survivors may encounter [20]. Nevertheless, several different psychosocial interventions have been described to facilitate coping with the disease and to improve quality of life [21,22].

The effectiveness of physical training, i.e., exercise training, has recently been described in several publications [23–27]. Exercise training is reported to be beneficial for cancer patients because it is aimed at improving functional capacity, muscle strength, and cancer-related fatigue which may, in turn, contribute to a better overall quality of life [7,16,27–35].

A multidimensional approach including both physical and psychological interventions is recognized as an effective intervention for patients with heart or lung disease to improve quality of life. There are indications that a multidimensional rehabilitation program is also beneficial to breast cancer patients [36,37]. However, it is, as yet, unclear whether multidimensional rehabilitation programs are feasible and effective for cancer survivors irrespective of their diagnosis type.

Rehabilitation participants appear to have more physical and psychological problems at entry than do patients who chose not to participate in a rehabilitation program [38]. Furthermore, it has been demonstrated that 26% of cancer survivors expressed a need for rehabilitation [39]. These survivors showed a significantly lower quality of life when compared with those expressing no need for professional help. Because healthcare providers now recognize patients as experts with unique knowledge of their own health and treatment preferences, health states, and outcomes, it might be of considerable interest to obtain information about cancer patients’ preferences for mono or multidimensional rehabilitation programs.


��


For the present, we developed a multidimensional rehabilitation program based on Engel’s bio-psychosocial model [40]. This model acknowledges that physical problems may induce psychological and social problems and vice versa. Furthermore, the model implies that physical interventions might influence physical problems as well as psychological and social problems, and that psychosocial interventions have the potential to influence physical problems. A further implication of the model may be that well-matched interventions may enhance the effects of the entire intervention program. Therefore, we developed a multidimensional rehabilitation program including four types of interventions to reduce a wide range of problems in cancer survivors.

The purpose of this study was twofold. First, we were interested in the effects of the multidimensional rehabilitation programfor cancer survivors with different types of cancer on (1) health-related quality of life including physical, psychological, and social functioning, (2) exercise capacity, and (3) patient appreciation. We hypothesized that the multidimensional program would result in immediate beneficial and clinically relevant effects on health-related quality of life that would be sustained at a 3-month follow-up. Second, we were interested in obtaining information about patient preferences for mono- or multidimensional rehabilitation programs by offering half of the patients the entire multidimensional rehabilitation program and the other half of the patients a choice.We expected the majority of cancer patients to choose a multidimensional rehabilitation program due to the wide range of problems that they might experience.

Methods

PatientsPatients were eligible for the study if they met the following criteria: age C18 years; referred by hospital specialists or general practitioners; last cancer-related treatment >3 months ago; estimated life expectancy C1 year; and an indication for rehabilitation. The latter meant a minimum of three positive findings on the following questions, as judged by a physician:1. Physical complaints like aching muscles, problems with coordination, headache,

nausea, heart palpitations, shortness of breath2. Reduced physical capacity compared with before the illness, e.g., less able to walk or

cycle3. Psychological problems like increased anxiety level, depression, uncertainty, lack of

energy or nervousness4. Increased levels of fatigue5. Sleep disturbances6. Problems in coping with reduced physical and psychosocial functioning due to cancer

Patients were not included if they met one of the following criteria:- A very low level of activity, e.g., less than 50% of their daytime ambulant, rapid fatigue

appearance on performance of low physical activity, and activity of daily living (adl) dependency

- Inability to travel independently to the rehabilitation centre- Cognitive disturbances that may interfere with participation in the rehabilitation

program (e.g., participants who are unable to be instructed, to think three-dimensionally, to complete questionnaires)



��

- Serious psychopathology and emotional instability that may impede participation in the rehabilitation program (e.g., being in the process of a divorce or the death of a loved one).

ProceduresAfter being referred to the study, patients were consecutively enrolled in groups of 8-12 patients. Then, an information session including a video session was organized to inform patients about the content of the four components (individual exercise, sports, information, and psycho-education) of the multidimensional rehabilitation program. During the information session, patients were informed about the group-wise randomization. Groups were randomly assigned the entire rehabilitation program condition or the choice-rehabilitation program condition. The entire rehabilitation program condition implied that patients would receive all four components, and the choice condition meant that patients could compose their own program from the four components, as judged beneficial to them. Randomization took place subsequent to patient intake by a physician and cancer nurse. If randomized into the choice condition, patients had 1 week to compose their own program. During the period of the study (1999–2001), 81 patients were referred to and appeared eligible for the program. The randomization procedure resulted in the provision of the entire rehabilitation program to 41 patients, while 40 patients were offered the choice to compose a program of the components they considered relevant.

All patients gave informed written consent to participating in the study and for the acquisition of medical information from their hospital charts. Medical data were verified by record linkage with the population-based cancer registry of the Comprehensive Cancer Centre North-Netherlands (cccn). The Medical Ethics Committee of University Hospital Groningen approved the study. Measurements were performed before (T0) and after the rehabilitation program (T1) and at a 3-month follow-up (T2).

Rehabilitation programThe 15-week program consisted of four components and took place in a rehabilitation centre in groups of 8-12 cancer patients. The choice of a group-oriented program was based on studies that showed that peer contact may facilitate processes of social support, social comparison, and modeling in the participants of rehabilitation programs [41]. The entire rehabilitation program consisted of the following components: (a) individual exercise, (b) sports, (c) psycho-education, and (d) information (Fig. 1).

Figure 1 The content and frequency of the program components

Week � � � � � � � 8 � ��

Day 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5

I.E. (1.5 hours) + + + + + + + + + + + + + + +

Sp (1 hour) + + + + + + + + + + + + + + + + +

PE (2 hours) + + + + + + + + +

Inf (1 hour) + + + + + + + + + + +

Abbreviation: I.E, Individual Exercise; Sp, Sports; PE, Psycho-education; Inf, Information.


��


Individual exerciseThe exercise program consisted of 15 sessions of 1.5 h each and was supervised by a physical therapist. It was aimed at improving exercise capacity and muscle force. Accordingly, the exercise program was divided into a bicycle training and a muscle force training program.Bicycle training program. Prior to the start of the exercise training, a symptom limited bicycle ergometry test was performed. This test was used as the basis for the development of an individual exercise training schedule. This training schedule was based on the training heart rate (thr), computed by using the Karvonen formulae [42,43]. The exercise training was performed at a thr of HRrest+50 to 60% (HRmax–HRrest), during Weeks 1-3 and at a thr of HRrest+70 to 80% (HRmax–HRrest) during Weeks 4-9. This aerobic exercise training was performed over 15–20 min, with a warm-up before and a cooling down after the training.Muscle force training. General muscle force training of trunk and lower and upper extremities was performed and based on the individual 1-Repetiton Maximum (1-rm), which was defined before the training. Individual intensity of muscle force training started at 50% of the 1-rm during the first week and was increased by 5-10% during the following weeks, with a frequency of 12 repetitions over three series.In the individual exercise program, patients were also advised to perform walking exercise at home, lasting 10-20 min once a week.

SportsThe sports program consisted of 17 sessions of 1 h each. The sessions were supervised by a physical therapist and were directed towards “enjoying sports”, “self-confidence”, and “body knowledge”. To increase the chance that patients would continue sport activities in their leisure time after the end of the rehabilitation program, patients were provided with and encouraged to perform a variety of sports and games activities such as badminton, soccer, mini-golf, swimming, curling, and balancing games. During the performance of certain sport activities, the patients were instructed to become aware of physical sensations or limitations, so that they would recognize and respect limitations when performing sports or recreational activities at home.

Psycho-educationThe psycho-educational program consisted of nine sessions of 2 h each. The aims of the psycho-educational program were to reduce negative emotions and to improve coping with the disease. A psychosocial specialist with several years of experience in conducting group sessions with cancer survivors led the psycho-educational program. This course leader discussed the following psychologically oriented topics with respect to cancer: “confrontation with cancer”, “anxiety”, “stress”, “depression”, “asking professional help”, and social support”. Over several sessions, expressive-supportive techniques were used to explore negative emotions and to provide the opportunity to receive support from other cancer survivors. In addition, breathing exercises, relaxation exercises, and exercises from the Rational-Emotive Therapy were used to provide patients with stress-management techniques. Patients were instructed to practice the exercises and to prepare every session at home. All sessions were described in a course book that was used by the course leader and participants.



�8

InformationThe information program consisted of 10 sessions of 1 h each. The aim of this program was to reduce uncertainty due to lack of knowledge of the disease by providing information with respect to cancer-related subjects. The information sessions were conducted in group sessions by several professional healthcare providers who had specific knowledge of the following cancer-related subjects: “medical aspects of cancer”, “cancer-related fatigue”, “food”, “sexuality”, “sport”, “body image”, “work and insurance”, “complementary medicine”, “pain” and “daily activities”. During the sessions, patients were provided with information but also had the opportunity to raise questions and to share experiences with other cancer survivors.

Outcome measures Quality of life General health-related quality of life was measured using the rand-36, a multidimensional self-report questionnaire assessing the following nine domains of global health-related quality of life: physical functioning (10 items), social functioning (2 items), role impairment due to physical problems (4 items), role impairment due to emotional problems (3 items), mental health (5 items), vitality (4 items), pain (2 items), general health appraisal (5 items), and overall quality of life (1 item). After recoding and transformation, scores range from 0 to 100, and a higher score represents better health. The psychometric characteristics of the instrument are described as follows: internal consistency ranges from α=.71 to .92; test–retest is sufficient; the instrument has high convergent validity and low divergent validity [44]. The rand-36 manual provides the scores of a normative group of the Dutch population, which was a randomly selected community group of a midsize town in the north of the Netherlands. The mean age of this population was 44.1 years, with range 18-89, and 65% were women. Furthermore, the rehabilitation program participants’ rand-36 scores were compared with a reference group of cancer patients not referred to a rehabilitation program. The reference group consisted of a sample of 2783 cancer patients entered into the registry of the cccn during the same period as the rehabilitation program took place. Three references were matched based on gender, age, diagnosis, and time since diagnosis for every patient in the rehabilitation group (n=81). This match was successful for 73 patients, and for the remaining eight patients, we found seven matches, resulting in a total of 226 reference patients.

Disease specific health-related quality of life was measured with the Rotterdam Symptom Check List (rscl). This self-report measure contains 39 items that differentiate between disease and treatment states, and treatment processes. It consists of the following domains: physical symptom distress (23 items), psychological distress (7 items), activity level (8 items), and overall valuation of quality of life (1 item). Responses are presented on fourpoint Likert-type scale for most items. A higher score reflects a greater level of burden of impairment. Norm scores for the general population are available in the manual. The psychometric characteristics of the instrument are described as follows: internal consistency is good; construct validity and clinical validity are sufficient [45]. A cut-off score of 15 for the psychological distress scale can be used to indicate the presence of “disease” [45,46].

Physical variablesExercise capacityA symptom-limited bicycle ergometry test was performed using a ramp 10, 15, or 20 protocol, depending on the patient’s fitness. This implied that the load was increased every minute by


��


10, 15, or 20 W, respectively, in such a way that patients could reach their maximal workload within 10 min. The test was terminated on the basis of patient’s symptoms or at the physician’s discretion [47]. Maximal workload in Watts at maximal performance was taken for analysis.

Muscle forceThe maximal voluntary isometric muscle force of the right and left extremities of the following muscle groups was measured: extension of the knee, flexion of the elbow, and extension of the elbow using a hand-held dynamometer [Force Evaluating & Testing (microFET), Hoggan Health Industries, usa]. The “break method” was used for all measurements. To employ this technique, the examiner gradually overcomes the force produced by the patient until the extremity gives way [48]. All measurements were performed at least three times, with recovery intervals of at least 10 s. Peak forces (in Newtons) were recorded, and the mean values of three technically correct measurements were taken for analysis and expressed as percentages of predicted normal muscle strength accounting for age and gender.

Patient appreciationA program evaluation form was used to obtain information about patient satisfaction with the various components of the program and the program as a whole. Patients were asked to express their satisfaction with each component and the entire program on a scale from 0 (no satisfaction) to 10 (high satisfaction) immediately after the completion of the program. They were also asked if they would recommend the program to others (yes or no).

Patient preferencesBefore the rehabilitation program, patients randomized into the choice condition were asked to indicate which components of the program they wished to participate in. Furthermore, after completing the rehabilitation program, all patients were asked to indicate the components considered relevant to themselves and those that would be chosen if the choice were offered.

Statistical analysesStatistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, version 11.0). Confidence interval analyses (cia) were performed for comparison of the reference group and patients at T0. Chisquare tests, Mann–Whitney tests, and independent t tests were used to compare participants who completed the program (stay-ins) with those who did not (dropouts). Repeated measures anova performed for time were used to assess change over time. Nonparametric Wilcoxon tests were used to examine differences before and after the program and at 3-month follow-up. Mann–Whitney tests were used to examine differences in outcome between those who participated in all four components of the program and those who followed the program of fewer components. Effect sizes (es) and thresholds at the 5% level were calculated according to Cohen [49] as indices measuring the magnitude of a treatment effect. Middel et al. [50] showed that es also reflects clinical relevance. An es <0.20 indicates “no change”, es C0.20, <0.50 as “a small change”, es C0.50, <0.80 as “a moderate change”, and es C0.80 as “a considerable change”. Frequencies and mean scores were used to examine patient preferences and their subjective evaluation of the program.



�0

Results

Patient characteristicsSixteen percent of the 81 participants were male. The mean (sd) age of the participants was 51.6 (9.3) years.

Table 1Patient characteristics at time of inclusion (T0), n=8�

Mean age (SD), yearsGender, male : female (n ( %))

51.6 (9.3)13 (16): 68 (84)

n %

Physician reported indication criteria for rehabilitation (yes)Physical complaints Reduced physical capacityPsychological problemsFatigueSleep disturbancesCoping/acceptance problems

536456684936

65.479.069.184.060.544.4

Diagnosis Breast cancerNon Hodgkin Lymphoma /M.HodgkinGynaecological cancerHead and neck cancerRest category < 5%

48765

15

59.3 8.6 7.3 6.218.6

Stage of disease In situStage IStage IIStage IIIStage IVNot applicableMissing

1144016

451

1.217.349.919.8 4.9 6.2 1.2

Cancer treatment before rehabilitation Surgical treatmentChemotherapyRadiotherapy

625154

76.563.368.4

Time between treatment and rehabilitation program B 6 months>6-12 months>12-18 months>18 monthsMissing Mean (SD) in months: 11.3 (13.2)

31221412

2

38.327.217.314.8 2.5


��

Fifty-nine percent of the patients were women with breast cancer and 41% had other cancer diagnoses. Two-thirds of the patients had Stage I or II disease. Two-thirds of the participants had completed treatment during the preceding year (Table 1). The most frequently-reported indication for rehabilitation was fatigue, followed by reduced physical capacity and psychological problems (Table 1).

Preliminary analysesDropouts versus stay-insEighteen patients did not complete the program: 12 patients developed a cancer recurrence and dropped out of the program of their own volition. A further six patients left the program for personal reasons (two), because of claustrophobia (one), severe nausea (one), and for unknown reasons (one). The remaining 63 patients completed the rehabilitation program and the questionnaires at T0, T1, and T2. Dropout was therefore 22.2%.

The χ2 and t tests revealed no significant differences between dropouts and stay-ins with respect to gender, age, cancer diagnosis, time since completion of treatment, and time since diagnosis. χ2 tests revealed significantly more cancer recurrences in the dropout than in the stay-in group (p<.001).

At baseline, no significant differences were found between dropouts and stay-ins with respect to the rand-36 domains, except for the general health appraisal domain. The dropout group (mean=43.3, sd=12.2) appraised their health lower than did the stay-ins (mean=55.4, sd=15.1; p =.002). Furthermore, with respect to the rscl, dropouts (mean=44.7, sd=12.2) displayed statistically significant greater psychological distress than did the stay-ins (mean=32.7, sd=21.2; p=.025). Dropouts (mean=51.6, sd=19.7) had a lower overall valuation of quality of life (rscl) when compared with the stay-ins (mean=35.5, sd=15.5; p<.001).

Fisher’s Exact Test showed that the percentage of those who dropped out of the study was similar in the entire program condition (7/41=17.1%) and in the choice condition (11/40=27.5%; p=.30).

Participants versus reference groupsBaseline scores on the questionnaires of the referred patients were compared with the normative Dutch population group [44] and to the matched sample of cancer patients from the cccn (Table 2). At time of inclusion (T0), the referred group of patients had lower mean scores on every rand-36 domain compared with the general population. The referred patients also showed significantly lower scores on all rand-36 domains than did the matched sample of cancer patients. A striking result was the extremely low score of the referred patients on the role limitations due to physical problems domain. Furthermore, at baseline, the referred patients reported higher mean scores on the rscl domains of physical symptom distress, psychological distress, and overall valuation of quality of life compared with the general population (Table 3).



��

Tab

le 2

RAND

-�� s

core

s for

a Du

tch

norm

ativ

e pop

ulat

ion

[��]

, a re

fere

nce g

roup

of c

ance

r pat

ient

s, an

d pa

tient

s at T

0, T

� and

T�

Gene

ral p

opul

atio

nn=

1063

Mea

n (S

D)

Refe

renc

e gro

up of

ca

ncer

pat

ients

n=

226

Mea

n (S

D)

Patie

nts a

t T0

n=81

Mea

n (S

D)

Patie

nts a

t T1

n=63

Mea

n (S

D)Ef

fect

size

s T0

-T1

95%

Con

fiden

ce

Inte

rval

(ES)

Patie

nts a

t T2

n=63

Mea

n (S

D)

Repe

ated

mea

sure

s an

alys

es

F- ti

me

Phys

ical f

unct

ioni

ng81

.9 (2

3.9)

74.3

(22.

2)62

.4 (2

0.3)

†††

70.3

(21.

1) *

**

.38

.05 t

o .71

73.2

(18.

8) ‡

‡‡ §

15.1

###

Socia

l fun

ctio

ning

86.9

(20.

5)79

.0 (2

2.4)

59.0

(23.

3) ††

†70

.4 (2

1.5)

***

.50

.17 t

o .84

67.7

(24.

6) ‡

‡ 7

.7##

#

Role

limita

tion

(p

hysic

al p

robl

em)

79.4

(35.

5)57

.2 (4

2.1)

21.5

(34.

1) ††

†50

.0 (4

2.0)

***

.75

.41 t

o 1.1

40.6

(40.

2) ‡

‡14

.8##

#

Role

limita

tion

(em

otio

nal p

robl

em)

84.1

(32.

3)74

.0 (3

9.6)

39.3

(42.

9) ††

†62

.9 (4

3.6)

**

.54

.21 t

o .88

65.1

(42.

6) ‡

‡ 5

.6##

Men

tal h

ealth

76.8

(18.

4)74

.8 (1

5.1)

61.7

(17.

1) ††

†69

.1 (1

6.5)

**

.44

.10 t

o .77

69.4

(16.

9) ‡

‡‡ 4.

8##

Vita

lity

67.4

(19.

9)62

.9 (1

9.8)

46.1

(20.

3) ††

†56

.7 (1

9.7)

***

.53

.19 t

o .86

56.7

(20.

8) ‡

‡‡13

.3##

#

Pain

79.5

(25.

6)80

.4 (2

4.4)

68.7

(21.

8) ††

†77

.5 (2

1.2)

*.4

1.0

7 to .

7471

.0 (2

3.0)

3.6 #

Gene

ral h

ealth

appr

aisa

l72

.7 (2

2.7)

66.9

(23.

2)52

.6 (1

5.4)

†††

59.9

(16.

7) *

*.4

5.1

2 to .

7956

.0 (1

7.0)

2.4##

#

Chan

ge in

hea

lth52

.4 (1

9.4)

59.3

(30.

4)45

.1 (3

6.7)

††77

.8 (2

6.8)

***

.99

.64 t

o 1.3

76.2

(26.

7) ‡

‡‡20

.4##

#

CIA

for c

ompa

rison

s bet

ween

a re

fere

nce g

roup

and

pat

ient

s at T

0 (†

). W

ilcox

on te

sts b

etwe

en p

atie

nts a

t T0

and

T1 (*

), ca

lcula

ted

ES (T

0-T1

) with

95%

Con

fiden

ce In

terv

al (C

I).

Wilc

oxon

test

s bet

ween

pat

ient

s at T

0 an

d T2

(‡),

and

bet

ween

pat

ient

s at T

1 an

d T2

(§).

Repe

ated

mea

sure

s ANO

VA f

or ch

ange

ove

r tim

e (#)

. A h

ighe

r sco

re re

flect

s bet

ter h

ealth

.*

pB.0

5, §

pB.

05, #

pB.

05,

** pB.

01, †

† pB

.01,

‡ ‡

pB.

01, #

# pB

0.01

, ***

pB.

001,

†††

pB.

001,

‡ ‡

‡ pB.

001,

###

pB.

001.



��

Table 3RSCL scores for general population [��], patients at T0, T� and T�

General population n=102

Mean (SD)

Patients at T0n=81

Mean (SD)

Patients at T1n=63

Mean (SD)

Effect sizesT0-T1

95 % Confidence Interval (ES)

Patients at T2n=63

Mean (SD)

Repeated measures analyses

F-time

Overall valuation of life 21.1 (83.7) 39.2 (17.5) 30.7 (22.0) *** –.43 –.76 to –.10 30.5 (17.1)‡ 1.7###

Psychological distress 17.0 (18.1) 35.4 (20.1) 24.2 (18.8) *** –.57 –.91 to –.23 23.8 (19.8)‡ ‡ ‡ 7.1###

Physical symptom distress 9.9 (9.0) 25.2 (12.1) 18.5 (11.5) *** –.56 –.90 to –.23 18.7 (10.7)‡ ‡ ‡ 17.7###

Activity level Not available 15.9 (12.9) 10.5 (11.3) *** –.44 –.77 to –.11 14.8 (31.3)‡ ‡ 1.9###

Wilcoxon test of comparisons of (a) patients at T0 and at T1(*) and calculated ES with 95% Confidence Interval, (b) patients at T0 and T2(‡), and (c) patients at T1 and T2. Repeated measures ANOVA for change over time (#). A higher score represents more burden of distress. ‡ pB.05, ‡ ‡ pB.01, *** pB.001, ‡ ‡ ‡ pB.001, ### pB.001.

Seventy-nine percent of the patients had scores on the domain of psychological distress of the rscl above the cut-off score of 15. The baseline scores of muscle force as a percentage of predicted normal (Table 4) showed that the muscle force of the upper extremities was slightly diminished whereas the muscle force of the lower extremities was severely diminished.

Table 4Physical capacity before and after the rehabilitation program, based on paired t tests on �� patients, and mean values of hand-held dynamometry based on paired t tests on �� patients, comparisons of patients at a) T0 and T�(*), and at b) T0 and T� (‡)

T0 Mean (SD)

T1 Mean (SD)

T2 Mean (SD)

Wmax (W) 128.7 (44.8) 141.1 (36.4) *** Not available

Muscle strength biceps Brachii (% pred ) 93.5 (23.4) 106.2 (27.7) *** 106.8 (25.0)‡ ‡ ‡

Muscle strength triceps Brachii (% pred) 98.7 (47.3) 106.1 (33.1) ** 110.3 (34.0)‡ ‡ ‡

Muscle strength Quadriceps Femoris (% pred) 70.8 (22.0) 80.9 (25.1)*** 84.8 (24.0)‡ ‡ ‡

Muscle strength is expressed as a percentage of predicted normal considering gender and age. ** pB.01, *** pB.001, ‡ ‡ ‡ pB.001.

Hypothesis 1: Effects of the multidimensional rehabilitation programQuality of life questionnairesRepeated measures anova of those patients who completed all three measurements (n=63), performed for time, indicated a significant effect for time in every domain of the Rand-36 and rscl (Tables 2 and 3), except in the domain of general health appraisal, activity level, and overall valuation.

Wilcoxon tests revealed significant short-term (T0–T1) improvements in every domain of the Rand-36 (Table 2) and in the rscl domains, except for overall valuation of quality of life (Table 3). Wilcoxon tests showed that most improvements in general health-related quality of life were sustained at the 3-month follow-up (T0–T2), except for the domains of



��

pain and general health appraisal (Table 2). Wilcoxon tests (T0–T2) showed improvements in all domains of the rscl at the 3-month follow-up, including in the domain of overall valuation of life (Table 3). Although a slightly lower score was found at T2 than at T1 on some of the subscales, the only significant difference found (Wilcoxon test) was a positive one, namely, a further improvement of physical functioning (p=.03). es (T0–T1), expressing the magnitude of the changes, varied from 0.38 to 0.99 (rand-36) and from –0.57 to –0.43 (rscl), as is shown in Tables 2 and 3. es showed clinical relevant changes in all domains of the questionnaires, varying from “small” changes (six domains), to “moderate” changes (six domains) and “large” changes (one domain; Fig. 2).

Post hoc, we performed power analyses for the es (5% level, two tailed), based on the smallest and largest es, according to the tables of Kreamer [51]. The smallest es (.38, n=63) revealed a power between 80% and 90%; the largest es (.99, n=63) revealed a power >90%.Gender differences. Mann–Whitney tests revealed no differences in outcome between men and women.Disease related variables. Mann–Whitney tests revealed no differences between patients having Stages I–II disease and patients having Stages III–IV disease, except in the domain change of health (Z=–2.8, p<.01), indicating more positive change in patients having Stages I+II disease. Of the patients, 59.3% suffered from breast cancer. The percentages of patients with a different diagnosis were very small. It was therefore decided to make a dichotomous variable of having breast cancer (1) or having a different cancer diagnosis (0). Mann–Whitney tests revealed no differences between patients treated for breast cancer or for another type of cancer, except in the domain change of health (Z=–2.2, p=.03), indicating more positive change in patients treated for breast cancer. Pearson correlational analyses revealed no association of time since completion of treatment with quality of life after the program, except in the domain of change of health (r =-.38, p<.01) and pain (r =.26, p=.43).

Figure 2ES of RAND-�� and RSCL after the program (T0-T�, n=��)

Phys

ical F

.

Socia

l F.

Role

Lim. P

hys.

Role

Lim. E

m.

Men

tal F

.

Vita

lity

Pain

GHA

Chan

ge of

H.

Ovol

Psyc

h. D

istr.

Phys

. Dist

r.

Act.

Leve

l

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1

Large changes

Moderate changes

Small changes

No change



��


Choice versus entire program. Mann–Whitney tests to compare the patients who followed the entire rehabilitation program with the eight patients who followed a program of less components at T1 revealed no significant differences in outcome between the two groups.

Physical variablesThe measurement of W

max and muscle force was not possible in all cases, due to mechanical

breakdown of the apparatus and some patients experiencing claustrophobia and nausea. In addition, a few patients did not want the test because they thought it was irrelevant, painful, uncomfortable, or too strenuous. Paired t tests revealed statistically significant short-term improvements of maximal workload. Furthermore, statistically significant improvements in muscle force were found immediately after the rehabilitation program, which were sustained at the 3-month follow-up (Table 4).

Patient appreciationThe mean program evaluation scores given to the different components of the program were individual exercise: 8.1 (0.5); sports: 8.1 (0.9); psycho-education 8.0 (0.9); and information: 7.2 (1.1). The mean evaluation score of the entire program was 8.2 (0.9). Eighty-one and a half percent of the patients would recommend the program to others.

Hypothesis 2: Patient preferencesOf the 40 patients who were offered a choice condition, 32 (80%) chose the entire multidimensional rehabilitation program with four components. Eight (20%) patients preferred a program with fewer than four components. One patient rejected the individual exercise component, two patients rejected the sports component, two patients rejected the psycho-education component, and two patients rejected the information component. These seven patients still followed a multidimensional program, including physical and psychological components. The eighth patient rejected two psychosocial components, namely, psycho-education and information. All patients who completed the program were asked at T1 what kind of program they would have composed themselves based on their experiences with the program they were following. Thirty (48%) patients chose a multidimensional program with all four components, 23 (36%) patients chose a three-component program, 5 (8%) patients chose two components, and 5 (8%) patients choose only one component. Fisher’s Exact Test showed that 58% (n=19/33) of the patients who were offered a choice at the start of the program and 37% (n=11/30) of the patients who did not have the opportunity to choose indicated that they would have chosen all four components of the program ( p=.13).

Discussion

One of the two aims of this study was to describe the effects of a multidimensional rehabilitation program on (1) health-related quality of life, (2) exercise capacity, and (3) patient appreciation. The hypothesis that the multidimensional rehabilitation program would result in beneficial and clinically relevant improvements in health-related quality of life, including physical, psychological, and social functioning, was confirmed by the study. Furthermore, most improvements found in the short term were sustained in the longer term.



��

The study results are in line with earlier studies showing that multidimensional oncology rehabilitation programs have beneficial effects on psychological distress, general physical complaints, physical capacity, and the quality of life of breast cancer patients [36,37,52,53]. This study also revealed that dropout was low and unrelated to diagnosis. Furthermore, no effects of gender or type of cancer were found, nor of stage of disease or time since completion of treatment with the exception of change of health. These results suggest that the program is feasible and equally effective for men and women and for patients diagnosed with different types or stages of disease, and that it is effective regardless of time since completion of treatment.

This study not only showed that there were statistically significant improvements in health-related quality of life after the multidimensional rehabilitation program, but, moreover, es showed that changes appeared to be also clinically relevant. A meta-analysis of psychological interventions showed weighted es for quality of life measures varying from 0.17 to 0.28 [54]. In another study in which a combined intervention of group psychotherapy and home-based, unsupervised physical exercise was evaluated, es were reported ranging from 0.16 to 0.34 [55]. The es of this multidimensional rehabilitation program, ranging from 0.38 to 0.99, are considerably higher than those of the studies mentioned above. This underlines the clinical effectiveness of this multidimensional program, including supervised individual exercise, sports, psycho-education, and information.

In addition to the results described above, physiological improvements in physical functioning were found, i.e., improvement in maximal exercise capacity and improvement in muscle force of the upper and lower extremities. These results are in keeping with the findings of other researchers [20,27,28,35,56-59]. The results may indicate that the individual exercise and sports components account for the reduction of physical problems found, because genuine physiological improvements only occur due to the presence of physical training principles.

Patient appreciation scores indicated that patients were satisfied with the components of the program and with the program as a whole. Patients were least satisfied with the information component. This accords with the literature over the past three decades, which has consistently identified that many patients and family members are dissatisfied with cancer education [60]. Therefore, future research should pay serious attention to this component.

The second aim of this study was to obtain information about patient preferences for mono- or multidimensional rehabilitation programs, as healthcare professionals are now increasingly encouraged to consider patient preferences for treatments. An interesting finding of this study was that, if offered the choice before the start of the rehabilitation program, most cancer survivors preferred to follow the entire program rather than a program with fewer components. After the completion of the program, the majority of the participants would again have chosen multidimensional programs, although the percentage of participants that chose multidimensional programs after the completion of the program was lower than the percentage found prior to the start of the program. These results may indicate that cancer survivors have an a priori general preference for multidimensional programs, possibly based on the presence of complaints that are physical, psychological, and/or social in nature. Patients possibly consider multidimensional programs most appropriate and effective for their wide range


��


of problems. Participants who were given the choice were more likely to choose the entire program again after the completion of their program than were the participants who did not receive this choice. No additional pattern in choice preference was found in these groups. However, it was obvious that most participants preferred a program that combined a physical and psychological component, and that only a small percentage of the participants chose only one component.

This study confirms that cancer patients perceive themselves as having poor health-related quality of life persisting after the completion of initial treatment. This is also reported in other studies of patients with gastric, esophageal [11], breast [61], head and neck [10], lung, colon, and prostate cancer [62]. However, the patients participating in our study might not be representative of cancer patients in general, as they displayed lower quality of life than did the matched control group of cancer patients not referred to a cancer rehabilitation program. As expected, the latter had a lower quality of life than did the general population but a higher quality of life than did the referred cancer patients. The poor quality of life in our group of patients may be the result of selection, because only patients who met three of the six rehabilitation criteria were referred to our program. Simultaneously, these patients form exactly the target population for cancer rehabilitation programs that focus on improvement and recovery, indicating that the referral procedure was appropriate.

Due to the design of the study and the small number of patients who chose a program of fewer components, it was not possible to determine the effects of the various components. Nevertheless, the Engel Bio-Psychosocial model states that physical interventions support the effects of psychosocial interventions and vice versa. For example, a reduction of psychological distress may be due to psycho-educational intervention or to the “attention” patients receive from healthcare providers and/or the social support of peers. It may also be that improvements due to physical exercise lead to an improvement in quality of life. These “transfer effects” have been described by other researchers [24,25,27,63].

The measurement of muscle force in cancer patients brings to light an additional finding. Muscle force of the upper extremities appeared not to be extremely low at baseline, although a large number of breast cancer patients who have a potential risk of lymphoedema participated. However, the muscle force of the lower extremities showed considerable reduction. This latter phenomenon has also been described in other studies with chronic disease patients, e.g., copd patients [64]. This finding can be explained by the fact that under conditions of disuse, such as hospitalization and during treatment, most patients tend to receive bed rest and adopt a prolonged sedentary lifestyle [7] that seems to mainly affect the muscles of the lower extremities. Under conditions of disuse, a rapid breakdown and excretion of muscle enzymes that normally produce energy for activity occur, leading to decreased energetic potential. Because physical activity or exercise is the normal mechanism for stimulating or maintaining the biochemical basis for energy, this study may offer the therapeutic implication that muscle exercise training is most appropriate for muscles of the lower extremities. Another implication may be that, during hospitalization, patients should be encouraged to perform physical exercises to prevent muscular problems due to disuse.



�8

Study limitationsA limitation of our study was the lack of a control group, implying that improvements as a result of natural recovery could not entirely be excluded. However, the majority of patients had received their last cancer treatment more than 6 months prior to study entry – the mean time between completion of treatment and rehabilitation program was 11.3 months and the median time since diagnoses was 16.1 months. Therefore, on the basis of this timeline, it may be assumed that most natural recovery had already occurred before the commencement of the program. The finding that rehabilitation participants in the study experienced more problems than did the cancer controls not referred to a rehabilitation program suggests that natural recovery was unsuccessful. As a result, the changes described in our study concerning health-related quality of life probably reflect the genuine effects of the multidimensional program.

ConclusionCancer patients referred to a multidimensional rehabilitation program experienced serious physical and psychosocial problems and perceived themselves to have decreased quality of life in comparison with the general population and matched cancer controls not referred to a rehabilitation program. The multidimensional rehabilitation program under study here has beneficial clinically relevant short- and long-term effects on health-related quality of life, including physical, psychological, and social functioning. In addition, the results indicated that a multidimensional program is feasible for cancer survivors with different cancer diagnoses. Finally, if offered the choice, the majority of cancer survivors seem to prefer multidimensional programs to monodimensional programs.

AcknowledgmentsThis study was supported by a Dutch Rotary/kwf jubilee grant.


��


References

[1] Hill DR, Kelleher K, Shumaker SA. Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review. Gen Hosp Psychiatry 1992; 14: 28S-42S.

[2] Fallowfield LJ. Quality of life measurement in breast cancer. J R Soc Med 1993; 86: 10-12.

[3] Langius A, Bjorvell H, Lind MG. Functional status and coping in patients with oral and pharyngeal cancer before and after surgery. Head Neck 1994; 16: 559-568.

[4] Knobf MT. Symptoms and rehabilitation needs of patients with early stage breast cancer during primary therapy. Cancer 1990; 66: 1392-1401.

[5] Bjordal K, Mastekaasa A, Kaasa S. Self-reported satisfaction with life and physical health in long-term cancer survivors and a matched control group. Eur J Cancer B Oral Oncol 1995; 31B: 340-345.





[10] de Boer MF, McCormick LK, Pruyn JF, Ryckman RM, van den Borne BW. Physical and psychosocial correlates of head and neck cancer: a review of the literature. Otolaryngol Head Neck Surg 1999; 120: 427-436.

[11] Delbruck H, Aghabi E. [Subjective discomfort of stomach cancer and esophageal cancer patients in after-care]. Rehabilitation (Stuttg) 1993; 32: 232-235.

[12] Schwibbe G. [Changes in quality of life in oncological patients in the course of an inpatient after-care program]. Rehabilitation (Stuttg) 1991; 30: 55-62.

[13] Ganz PA, Schag AC, Lee JJ, Polinsky ML, Tan SJ. Breast conservation versus mastectomy. Is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer 1992; 69: 1729-1738.

[14] Argerakis GP. Psychosocial considerations of the post-treatment of head and neck cancer patients. Dent Clin North Am 1990; 34: 285-305.

[15] Passik S, Newman M, Brennan M, Holland J. Psychiatric consultation for women undergoing rehabilitation for upper-extremity lymphedema following breast cancer treatment. J Pain Symptom Manage 1993; 8: 226-233.

[16] Body JJ, Lossignol D, Ronson A. The concept of rehabilitation of cancer patients. Curr Opin Oncol 1997; 9: 332-340.

[17] Greer S, Moorey S, Baruch JD, Watson M, Robertson BM, Mason A, Rowden L, Law MG, Bliss JM. Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 1992; 304: 675-680.

[18] Trijsburg RW, van Knippenberg FC, Rijpma SE. Effects of psychological treatment on cancer patients: a critical review. Psychosom Med 1992; 54: 489-517.

[19] Zabora JR, Loscalzo M, Brintzenhofezoc K, Fawzy FI, Fawzy NW, Sourkes BM, Massie MJ, Holland JC, Spira JL, Jacobsen PB, Hann DM, Classen C, Sephton SE, Diamond S, Spiegel D, Luzzatto P, Gabriel B, Bucher JA, Houts PS, Glajchen M, Blum D, Kabat-Zinn J, Massion AO, Hebert JR, Rosenbaum E, Musick MA, Koenig HG, Larson DB, Matthews D, Fitchett G, Handzo G, Pasacreta JV, McCorkle R, Doan BD, Tunkel R, Passik SD. Part X: Interventions. In: Holland JC (ed.), Psycho-oncology. NY,USA: Oxford University Press. xxiv,1189 pp.: New York; 1998: 653-836.

[20] Courneya KS, Friedenreich CM. Relationship between exercise during treatment and current quality of life among survivors of breast cancer. J Psychosoc Oncol 2000; 15: 35-57.




�0


[23] Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS. Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. J Clin Oncol 2003; 21: 1660-1668.

[24] Kolden GG, Strauman TJ, Ward A, Kuta J, Woods TE, Schneider KL, Heerey E, Sanborn L, Burt C, Millbrandt L, Kalin NH, Stewart JA, Mullen B. A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits. Psychooncology 2002; 11: 447-456.

[25] Burnham TR, Wilcox A. Effects of exercise on physiological and psychological variables in cancer survivors. Med Sci Sports Exerc 2002; 34: 1863-1867.

[26] Pinto BM, Trunzo JJ, Reiss P, Shiu SY. Exercise participation after diagnosis of breast cancer: trends and effects on mood and quality of life. Psychooncology 2002; 11: 389-400.

[27] Courneya KS, Mackey M, Jones LW. Coping with cancer: can exercise help? Physician Sportsmed 2000; 28: 49-51.


[29] Leddy SK. Incentives and barriers to exercise in women with a history of breast cancer. Oncol Nurs Forum 1997; 24: 885-890.


[31] Schwartz AL. Patterns of exercise and fatigue in physically active cancer survivors. Oncol Nurs Forum 1998; 25: 485-491.

[32] Seifert E, Ewert S, Werle J. [Exercise and sports therapy for patients with head and neck tumors]. Rehabilitation (Stuttg) 1992; 31: 33-37.

[33] Young McCaughan S, Sexton DL. A retrospective investigation of the relationship between aerobic exercise and quality of life in women with breast cancer. Oncol Nurs Forum 1991; 18: 751-757.


[35] Schwartz AL. Exercise and weight gain in breast cancer patients receiving chemotherapy. Cancer Pract 2000; 8: 231-237.

[36] Berglund G, Bolund C, Gustafsson UL, Sjoden PO. A randomized study of a rehabilitation program for cancer patients: The ‘Starting again’ group. Psychooncology 1994; 3: 109-120.


[38] Berglund G, Bolund C, Gustavsson UL, Sjoden PO. Starting again-a comparison study of a group rehabilitation program for cancer patients. Acta Oncol 1993; 32: 15-21.


[40] Engel GL. From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics 1997; Nov-Dec;38: 521-528.

[41] Helgeson VS, Cohen S, Schulz R, Yasko J. Group support interventions for women with breast cancer: who benefits from what? Health Psychol 2000; 19: 107-114.

[42] Amundsen LR. Establishing activity and training levels for patients with ischemic heart disease. Phys Ther 1979; 59: 754-758.





��


[46] Ibbotson T, Maguire P, Selby P, Priestman T, Wallace L. Screening for anxiety and depression in cancer patients: the effects of disease and treatment. Eur J Cancer 1994; 30A: 37-40.



[49] Cohen J. Statistical power analysis for the behavior sciences. New York: Academic Press; 1977.

[50] Middel B, Stewart R, Bouma J, Van Sonderen E, van den Heuvel WJ. How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating? J Eval Clin Pract 2001; 7: 399-410.

[51] Kreamer HC. How many subjects? Statistical power analyses in research. In. Newbury Park, CA, USA: Sage Publications; 1987: 106.

[52] Johnson JB, Kelly AW. A multifaceted rehabilitation program for women with cancer. Oncol Nurs Forum 1990; 17: 691-695.



[55] Courneya KS, Friedenreich CM, Sela RA, Quinney HA, Rhodes RE, Handman M. The group psychotherapy and home-based physical exercise (group-hope) trial in cancer survivors: physical fitness and quality of life outcomes. Psychooncology 2003; 12: 357-374.




[59] Schulz KH, Szlovak C, Schulz H, Gold S, Brechtel L, Braumann M, Koch U. [Implementation and evaluation of an ambulatory exercise therapy based rehabilitation program for breast cancer patients]. Psychother Psychosom Med Psychol 1998; 48: 398-407.

[60] Champman K, Rush K. Patient and family satisfaction with cancer-related information: a review of the literature. Can Oncol Nurs J 2003; 13: 107-116.

[61] Ferrell BR, Grant MM, Funk BM, Otis-Green S, Garcia NJ. Quality of life in breast cancer survivors: implications for developing support services. Oncol Nurs Forum 1998; 25: 887-895.

[62] Schag CA, Ganz PA, Wing DS, Sim MS, Lee JJ. Quality of life in adult survivors of lung, colon and prostate cancer. Qual Life Res 1994; 3: 127-141.

[63] Friendenreich CM, Courneya KS. Exercise as rehabilitation for cancer patients. Clin J Sport Med 1996; 6: 237-244.

[64] Van Der Woude BT, Kropmans TJ, Douma KW, Van der Bij W, Ouwens JP, Koeter GH, Van Der Schans CP. Peripheral muscle force and exercise capacity in lung transplant candidates. Int J Rehabil Res 2002; 25: 351-355.



��

4 Perceivedsocialsupportandself-efficacy

andqualityoflifebeforeandaftercancer

rehabilitation

E. van Weert, C.P. van der Schans, R. Otter, K. Postema, R. Sanderman, J.E.H.M. Hoekstra-Weebers.Submitted

AbstractBackground: Rehabilitation programs are offered to cancer patients to improve their quality of life. The reasons why some patients benefit more from rehabilitation than others do, however, are unclear. This study examines the effect of a cancer rehabilitation program on social support and self-efficacy, and the effects of these personal resources on quality of life. Methods: Sixty-three cancer patients with various diagnoses, all of whom had undergone cancer treatment, completed questionnaires before (T0) and after (T1) a 15-week multidimensional rehabilitation program. Measures: positive and negative social support experiences (Social Experiences Checklist), self-efficacy (General Efficacy Scale) and quality of life in terms of physical, social and mental functioning (rand-36). Results: Negative social support experiences and self-efficacy were unchanged at T1, and positive social support experiences had decreased. Positive and negative social support and self-efficacy explained between 17% and 47% of the variance in quality of life at T0 and T1. Negative social support had unique negative effects on social functioning at T0 and on all quality-of-life domains at T1, along with a slight prospective effect on mental functioning. Self-efficacy had independent positive effects on mental functioning at T0 and on physical and mental functioning at T1. Positive support had a negative effect only on physical functioning at T1. The explained variance of change in quality of life varied from 52% to 63%, with pre-existing quality of life as the most powerful predictor. Decreased negative support and increased self-efficacy were uniquely associated with improved quality of life. Conclusion: Cancer rehabilitation had little effect on the personal resources of the patients. Negative social support and self-efficacy appeared to be more consistent predictors of quality of life than was positive social support. Although the program neither increased self-efficacy nor decreased experiences of negative social support for the group as a whole, improvements in quality of life were associated with increased self-efficacy and reductions in negative social support experiences.


Perceived social support and self-efficacy

��

Introduction

Cancer and cancer treatment have serious effects on patients’ quality of life, not only during treatment, but also years after treatment has been completed [1]. Adaptation to the cancer experience involves adjusting to a loss of functioning in the physical, social, and mental domains of quality of life [2], and it requires patients to refocus on future plans and goals [3]. Although the majority of cancer patients and their family members seem to cope effectively with the disease, a significant minority (± 30%) experience continuing adjustment problems and low quality of life [4,5].

Patients whose quality of life remains low may need and benefit from professional support. Psychological interventions [6-9], physical exercise training [10,11] and multi-dimensional rehabilitation programs [12,13] that include both physical and psychosocial components have been shown to have beneficial effects on quality of life. We recently reported on the beneficial and clinically relevant effect of a multidimensional rehabilitation program on quality of life and [12,14] and cancer-related fatigue [15], with effect sizes ranging from .38 to .99.

Although statistically significant improvements after multidimensional cancer rehabilitation were shown, little is known about the mechanisms that are associated with improved quality of life after rehabilitation. The reasons why some patients benefit more from rehabilitation than others do are unclear. The present study was performed to obtain more insight into variables associated with improvement in quality of life, based on the following. It has been suggested that the ability to adjust to cancer involves possessing and utilizing external and internal personal resources to meet the demands of the disease and its treatment [16]. An external resource would be perceived social support [17] and an internal resource one’s perception of self-efficacy [16,18]. Both have been described as secondary appraisals and seem to have a positive direct or buffering effect on the adjustment to cancer [19,20].

Social support may strengthen or maintain feelings of social identity, self-evaluation, and social integration, and it may counteract feelings of loneliness. Receiving positive social support may have beneficial effects on patients’ quality of life, while a lack of support (particularly, a lack of emotional support) seems to hinder the adjustment of cancer patients [21]. Negative aspects of social relationships are apparently independent of the positive aspects of social support, and they appear to be strongly negatively related to psychological functioning [22,23].

Self-efficacy involves people’s subjective estimation of their capacity for engaging in particular actions in particular situations [24]. According to self-efficacy theory, those who have greater confidence in their ability to execute courses of action tend to be more likely to attain goals such as maintaining a desired state of quality of life. Numerous and varied experiences of failure and success in various domains of functioning may generate generalized beliefs of self-efficacy that have explanatory values with regard to behavior in general [25]. Self-efficacy may have a positive effect on both physical [26] and mental health [27]. A cancer experience apparently has negative effects on self-efficacy, which may tend to increase psychological distress and decrease quality of life [16,18,28]. In contrast, those who are more self-efficacious are more likely to display such healthy behaviors as physical activity [29], which can positively affect physical functioning and quality of life after cancer.


��


Little information is available concerning the extent to which (multidimensional) cancer rehabilitation affects personal resources. It has been reported that psychosocial interventions that provide a supportive forum in which patients can actively contemplate and discuss difficult thoughts may facilitate cognitive processing, alleviate distress and increase well-being [30]. Furthermore, psychosocial interventions that include self-efficacy as an important therapeutic ingredient were reported to have a greater effect on quality of life than did interventions that involved fewer or no self-efficacy components [31]. Physical interventions (e.g., exercise) have also been reported to have beneficial effects on self-efficacy [32,33]. To our knowledge, no studies have examined the effects of multidimensional rehabilitation programs on perceived social support and self-efficacy. The association of improvements in quality of life after a multidimensional program with changes in perceived personal resources have also not been examined.

In the present study, therefore, we explore the effect of the abovementioned multidimensional rehabilitation program on social support and self-efficacy. Although the primary goal of the intervention was to improve physical, mental and social functioning [14], we theorized that the program had also the potential to affect perceived personal resources. For example, the group approach and mastery experiences may enhance perceived positive social support and self-efficacy, respectively. Because we expected that the program would affect personal resources and quality of life, we will examine the effect of perceived social support and self-efficacy on quality of life before and after cancer rehabilitation. We will also investigate associations between changes in quality of life and changes in perceived personal resources. Earlier studies reported that changes in perceived social support was associated with changes in quality of life [34] and that change in self-efficacy was associated with change in physical activity [35].

Our first hypothesis was that positive changes in perceived personal resources (i.e., social support and self-efficacy) would be evident after the program. The second hypothesis was that perceived social support and self-efficacy would have a positive effect on physical, social, and mental functioning, both before and after the rehabilitation program. Finally, we hypothesized that improved quality of life after the program would be associated with positive changes in personal resources.

PatientsandMethods

Patients Patients who met the following criteria were eligible for the study: age C 18 years, last cancer-related treatment > 3 months before the study, estimated life expectancy C 1 year, referred by hospital specialists or general practitioners, and an indication for rehabilitation. The latter criterion referred to positive findings for at least three of the following conditions, as judged by the physician who referred the patient: a) physical complaints (e.g., aching muscles, problems with co-ordination, headache, nausea, heart palpitations, shortness of breath); b) reduced physical capacity compared to before the illness (e.g., decreased ability to walk or cycle); c) psychological problems (e.g., increased anxiety, depression, uncertainty, lack of energy, or nervousness); d) increased fatigue; d) sleep disturbances; or e) problems in coping with reduced physical and psychosocial functioning due to cancer.



��

Patients who met any one of the following criteria were excluded: a) a very low level of activity according to the classification of Winningham [36], (e.g., ambulant for less than 50% of the day), apparent rapid fatigue when performing low levels of physical activity, or dependency in activities of daily living; b) inability to travel independently to the rehabilitation center; c) cognitive disturbances that may interfere with participation in the rehabilitation program; or d) serious psychopathology or emotional instability that may impede participation in the rehabilitation program.

All patients provided written informed consent to participate in the study and to allow the retrieval of medical information from their hospital charts. Medical data were verified by record linkage with the population-based cancer registry of the Comprehensive Cancer Center North Netherlands (cccn). The Medical Ethics Committee of the University Medical Center Groningen approved the study.

Procedures Setting and intervention The fifteen-week rehabilitation program was offered in an outpatient setting within the Center for Rehabilitation of the University Medial Center Groningen. The program took place in groups of between eight and twelve cancer patients. It consisted of a physical training component, which included programs in “Individual Exercise” and “Sports/Games”, along with a psychological training component, which consisted of programs in “Psycho-education” and “Information”.

The Individual Exercise program consisted of 15 sessions of 1.5 hours each and was supervised by a physical therapist. The program was divided into aerobic bicycle training and a muscle-force training program. Patients followed an incremental protocol in both training programs, with the goal of increasing aerobic exercise capacity, muscle force and endurance. The Sports and Games program consisted of seventeen one-hour sessions, which were supervised by a physical therapist. The sessions were directed towards “enjoying sports”, “self-confidence”, and “body knowledge”, and they provided a variety of sport and game activities.

The psycho-educational program consisted of nine two-hour sessions, each of which was supervised by an experienced psychosocial health care provider. The program was aimed at reducing negative emotions and improving the ability to cope with the disease. Rational-emotive therapy, breathing and relaxation exercises were aimed at reducing stress. Expressive-supportive techniques were addressed to emphasize the relevance of sharing emotions with others. Other aspects of social support (e.g., “asking for help from significant others and health care providers”) were also addressed. The information program, which consisted of ten one-hour sessions, was aimed at reducing possible uncertainty due to lack of knowledge about the disease and changing irrational perceptions about the illness [37]. Both goals were addressed through the provision of information regarding cancer-related subjects. The program has been described more extensively elsewhere [14,15].

In addition to the intended effect of improving quality of life, the program also included a number of components that could affect personal resources. Because of its group-oriented approach, the program was expected to have a positive effect on social support. The choice for a group-oriented program was based on studies that show that peer contact may facilitate processes of social support, social comparison, and modeling among


��


rehabilitation-program participants [21]. Peer contact may also provide opportunities for validation, reappraisal, and finding meaning [30]. The physical training program was expected to have a positive effect on self-efficacy through the successful performance of physical tasks and by changing the level of physiological arousal [38]. The psychological training component also provided tools for optimizing self-efficacy. The exercises that were included in the program could affect self-efficacy through the performance accomplishment of such psychological tasks [38] as gaining greater control over irrational cognitions [39] and decreasing feelings of distress [38]. Vicarious experiences among peers could also have positive effects on self-efficacy [38]. Finally, verbal persuasion by the health care providers could also be expected to increase self-efficacy [38].

DesignA single-group, pre-post test design was used to examine the effects of a multidimensional rehabilitation program on social support and self-efficacy. The design also allowed the examination of change in study measures over time, the concurrent and prospective effects of social support and self-efficacy on quality of life, and associations between change in perceived personal resources and change in quality of life.

Measures- Sociodemographic variables Age, gender, level of education, and employment status were assessed. - Disease and treatment-related variables Diagnosis, stage of disease at diagnosis, time since diagnosis, type of treatment

received, and time since completion of treatment were attained from the patients’ medical records.

- Quality of life Three sub-scales of the rand-36, a multidimensional self-report questionnaire,

were used to assess health-related quality of life: physical functioning (10 items), social functioning (2 items), and mental health (5 items) [40]. After recoding and transformation, scores on the questionnaire range from 0 to 100, with higher scores representing better health. Cronbach’s α scores for the present study ranged from .84 to .85 for the three subscales at T0 and from .76 to .88 at T1.

- Social support The Social Experiences Checklist (sec) is a self-report questionnaire consisting of

two subscales: one to measure experiences of positive (8 items) and one to assess experiences of negative (8 items) social support [41,42]. The sec covers various dimensions of social support. The following are examples of perceived positive social items: “Have you experienced ‘warmth’ or ‘the help of someone’ in interactions with others?” The following are examples of perceived negative social items: “In interactions with others, have you experienced situations in which people did not provide enough ‘information’ or ‘comprehension’?” Respondents were asked to recall their experiences in contacts with people during the previous week. Responses to the sixteen items were presented on a four-point Likert-type scale ranging from “never” to “often”, and they could be summed to compute two total scores. Higher scores (range 8-32) reflect higher levels of perceived positive or negative social support. Reference scores of a random sample from the Dutch general population (n=201, 59% female, mean age 45.4) and of a



�8

group of recently diagnosed and surgically treated cancer patients (n=109, 72% female, mean age 51.2) are available [41,42]. Cronbach’s α scores for the present study were .86 and .84 at T0 and T1, respectively, for positive support, and .64 and .74 at T0 and T1, respectively, for negative support.

- Self-efficacy was assessed with the General Efficacy Scale (ges), which is a 16-item scale developed by Sherer [43] and translated and validated by Bosscher [25]. The ges covers three concepts: general feeling of competence, perseverance/maintenance in times of stress, and showing initiative. The following are examples of items from this scale: “I am a self-reliant person”, and “Failure just makes me try harder”. Responses to the 16 items are presented on a five-point Likert-type scale ranging from “strongly agree” to “strongly disagree”, and they are summed to compute a total score that may range from 16 to 80. Higher scores reflect higher levels of self-efficacy. Cronbach’s α scores for the present study were .82 at both T0 and T1.

Statistical analysisDescriptive statistics were used to describe the study population. Paired t tests were used to assess differences in study outcome measures before and after the program. The following analyses were performed to examine the effect of the predictor variables on quality of life. Univariate associations of physical, social, and mental functioning with demographic variables, positive and negative social support experiences, and self-efficacy were examined using Pearson’s correlation analyses. Independent t tests were used to assess differences for dichotomous variables. Six multiple regression analyses were conducted to investigate the predictive effects of social support and self-efficacy on quality of life, concurrently (within time). Analyses were corrected for age and gender if these variables had significant effects on the outcome variable at baseline.

To investigate the prospective effects of social support and self-efficacy on quality of life, and to examine whether changes in social support and in self-efficacy were associated with changes in quality of life, we performed three separate hierarchical multiple regression analyses. In these analyses, a quality of life subscale post-intervention (T1) was the dependent variable. In the first step, quality of life at pre-intervention (T0) was entered to control for pre-intervention levels. In the second step, the personal resources pre-intervention (T0) were entered to investigate the prospective effect. In the third step, social support and self-efficacy (T1) were entered into the regression model to examine associations between changes in quality of life and changes in personal resources.

Correlational analyses between the independent variables and Variance Inflation Factors (vif= 1/1-R2) were calculated to assess multi-collinearity. Multi-collinearity is present if the mean vif is considerably larger than 1 and if the largest vif is greater than 10 [44].


��


Results

Patient characteristics Eighty-one patients entered the study and have been described extensively elsewhere [14]. Sixty-three patients (78%) completed the program and the questionnaires. Twelve patients developed a cancer recurrence and dropped out of the program of their own volition. An additional six patients left the program, two for personal reasons, two because of malaise, and two for unknown reasons. χ2tests and t tests revealed no significant differences in gender, age, having a partner, education level, or employment status between those who dropped out of the study and those who completed the program. T tests revealed no significant differences in the level of positive and negative social support and self-efficacy at T0 between those who dropped out of the study and those who completed the program.

Sixteen percent of the 63 patients were male. The mean age of the participants was 51.5 (sd=10.3) years. Most patients were living with partners and had moderately high levels of education. Forty percent of the patients were employed.

More than half of the patients were women with breast cancer. Two-thirds of the patients had either stage I or stage II disease. The vast majority of patients (90%) had received a combined treatment of chemotherapy and/or radiotherapy and/or surgery. The remaining patients (10 %) had received surgery only. Sixty-seven percent of the participants had completed treatment during the preceding year (Table 1).

Physician-indicated criteria for rehabilitation were as follows: physical complaints (65%), reduced physical capacity (83%), psychological problems (68%), fatigue (87%), sleep disturbances (63%), and coping/acceptance problems (43%).

Preliminary analysesAt baseline, patients who were referred to the rehabilitation program perceived more negative social support (mean=13.4, sd=3.1) than did a reference group of recently diagnosed and treated cancer patients (mean=10.96, sd=2.15, p<.001) and the general population (mean=11.97, sd=2.93, p<.001). The cancer patients who were referred to the program reported more experiences of positive social support (mean=24.0, sd=4.1) than did the normal population (mean=21.32, sd=4.22, p<.001). The reference group of cancer patients (mean=25.87, sd=3.93, p =.01), however, reported more positive experiences than did the study population.

The effects of a multi-dimensional rehabilitation program on personal resourcesPaired t tests between T0 and T1 showed a significant decrease in experiences of positive social support, but no significant changes in either negative social support or self-efficacy after the program (Table 2). As reported before, significant and clinically relevant improvements in physical, social, and mental functioning were found after the program [14].



�0

Table 1Patient characteristics, sociodemographic and disease-related characteristics, n=��

Mean age (SD), years 51.5 (10.3)

n %

Gender - Male - Female

10 53

15.984.1

Marital Status- Married/cohabiting - Single

5211

82.517.5

Level of education - Primary- Lower vocational/secondary- Middle vocational/secondary- Higher vocational/university

1173015

1.627.047.623.8

Employment - Employed for wages- Housekeeping- Retired- Disabled- Unemployed

2517

311

7

39.727.0 4.817.511.1

Diagnosis - Breast cancer- Non Hodgkin Lymphoma /M.Hodgkin- Gynaecological cancer- Head and neck cancer- Rest category < 5%

37553

13

58.8 7.9 7.9 4.820.6

Stage of disease - In situ- Stage I- Stage II- Stage III- Stage IV- Not applicable- Missing

1113013

341

1.617.547.620.6 4.8 6.3 1.6

Time between treatment and rehabilitation program - <6 months- >6-12 months- >12-18 months- >18 months- Mean (SD) in months: 11.3 (13.2)

20161413

31.725.422.220.6


��

Table 2Descriptive statistics of positive and negative social support experiences and self-efficacy, before (T0) and after (T�) the rehabilitation program, and paired t tests

Personal resourcesT0Mean (SD)

T1Mean (SD)

95% Confidence Intervalof the difference Lower - Upper

Positive social support24.0 (4.1) 23.0 (3.9) –1.71 to –.17 *

Negative social support13.4 (3.1) 13.2 (3.2) – .58 to 1.06

Self-efficacy 60.6 (10.0) 60.0 (10.1) –5.80 to 1.06

* p<.05

Univariate associations among the study variables Independent t tests revealed no significant differences between men and women in age, social support, self-efficacy, or quality of life. Pearson product-moment correlation coefficients showed a significant, but weak, negative association between age and physical functioning at T0 only (i.e., younger patients reported more physical problems).

Pearson product-moment correlation coefficients showed significant correlations between positive and negative social support at T0 and T1 (r=-.58, p<.001 and r=-.48, p<.001, respectively), between positive social support and self-efficacy at T0 and T1 (r=.47, p<.001 and r=.34, p<.01, respectively), and between negative social support and self-efficacy at T0 (r=-.38, p<.01), but not between negative social support and self-efficacy at T1 (r=.18, ns). Significant correlations were found between positive social support at T0 and at T1 (r=-.68, p<.001), between negative social support at T0 and T1, r=.51, p<.001), and between self-efficacy at T0 and T1 (r=.70, p<.001).

Univariate associations of positive and negative social support and self-efficacy with quality of life at the two measurement times are displayed in Table 3. Associations between quality of life at T0 and at T1 are shown in Table 4.

Multivariate effects of social support and self-efficacy on quality of life at T0 and T1, concurrently- Physical functioning: Age, positive and negative social support, and self-efficacy accounted

for 17% of the explained variance in physical functioning at T0. Age appeared to have only an independent effect. At T1, positive and negative social experiences each had a unique negative effect, and self-efficacy had an independent positive effect on physical functioning at T1. The total variance explained was 26%.

- Social functioning: Positive and negative social support and self-efficacy explained 21% of the variance in social functioning at T0 and 27% of the variance at T1. Only negative social experiences had a unique negative effect on both measurement times.

- Mental functioning: Positive and negative social support and self-efficacy explained 47% of the variance of mental functioning at T0. Only self-efficacy had a unique positive predictive effect. At T1, the three variables together explained 40% of the variance in mental functioning. Self-efficacy had a unique positive effect, and negative social support had a unique negative effect on mental functioning at T1 (Table 3). VIFs ranged from 1.1 to 1.7 in the regression models.



��

Tab

le 3

Univ

aria

te re

latio

nshi

ps b

etw

een

the s

tudy

varia

bles

, bas

ed o

n Pe

arso

n m

omen

t cor

rela

tiona

l ana

lyse

s (r)

, and

mul

tiple

regr

essio

n an

alys

es o

f qua

lity o

f life

and

pers

onal

reso

urce

s, co

ncur

rent

ly (=

with

in ti

me)

Phys

ical f

unct

ioni

ng

T0 r

Beta

R2 F

p

Socia

l fun

ctio

ning

T0 r

Beta

R2 F

p

Men

tal f

unct

ioni

ng

T0 r

B

eta

R2

F

p

Phys

ical f

unct

ioni

ng

T1 r

B

eta

R2

F

p

Socia

l fun

ctio

ning

T1 r

Beta

R

2 F

p

Men

tal f

unct

ioni

ng

T1 r

B

eta

R2

F

p

.1

7 3

.0

.03

.2

1 5.

4 .0

02

.

47 1

7.5

<.00

1

.2

6 6

.6 .0

01

.2

7 7

.0 .0

01

.4

0 12

.3 .0

01

Age

–.

27* –

.31*

-

-

-

-

-

Pos.

Soc.

Supp

ort T

0 / T1

.24

.1

7.3

8**

.16

.47**

1

2 .

02

–.3

2* .

19

–.1

2 .

24

–.1

2

Neg.

Soc.

Supp

ort T

0 / T1

.27* –

.25

.44**

–.3

2***

–.43

** –

.16

–.40

** –

.51**

*–.

48**

* –

.50**

*–.

42**

–.3

9**

Self-

effic

acy

T0 /

T1 .1

0 –

.07

.26*

.07

.65*

.53**

* .2

4

.26*

–.25

* .

20 .

53**

*

.50**

*

* p

<.05

, **p

<.0

1, *

** p

<.0

01.



��

Multivariate effects of social support and self-efficacy on quality of life, prospectively and change over time - Physical functioning: Physical functioning at T0 accounted for 51% of the variance in physical

functioning at T1. Social support and self-efficacy at T0 did not account for a significant increment. None of these baseline variables had significant unique effects. Social support and self-efficacy at T1 accounted for a significant increment of 13%. Self-efficacy had a unique positive effect, and negative social experiences had a negative effect. The predictor variables thus showed no evidence of prospective effects, but improvement in physical functioning was associated with increases in self-efficacy and with declines in negative social support. The total variance explained was 63%. VIFs ranged from 1.0 to 2.9.

- Social functioning: Social functioning at T0 accounted for 38% of the variance in social functioning at T1. Social support and self-efficacy at T0 accounted for a non-significant increment of 3%. None of the baseline variables had significant unique effects. Social support and self-efficacy at T1 accounted for a significant increment of 12%. Negative social experiences had a unique negative effect. The predictor variables thus showed no evidence of prospective effects, but improvement in social functioning was associated with declines in negative social experiences. The total variance explained was 53%. VIFs ranged from 1.0 to 2.6.

- Mental functioning: Mental functioning at T0 accounted for 30% of the variance in post-intervention mental functioning. Social support and self-efficacy at T0 accounted for a significant increment of 9%, and negative social experiences had a unique negative effect. Social support and self-efficacy at T1 accounted for a significant increment of 15%. Self-efficacy had a unique positive effect and negative social experience had a unique negative effect. Negative social support thus showed an unique prospective effect, and improvement in mental functioning was associated with increases in self-efficacy and declines in negative social experiences. The total variance explained was 55%. VIFs ranged from 1.0 to 2.7 (Table 4).



��

Tab

le 4

Mul

tiple

hie

rarc

hica

l reg

ress

ion

anal

yses

of q

ualit

y of l

ife an

d pe

rson

al re

sour

ces,

pros

pect

ivel

y and

chan

ge o

ver t

ime

Phys

ical f

unct

ioni

ng T1

Socia

l fun

ctio

ning

T1M

enta

l fun

ctio

ning

T1

Beta

r2 chFc

hp

Beta

r2 chFc

hp

Beta

r2 chFc

hp

Step

1T0

Qua

lity o

f life

.51

63.7

< .00

1.3

837

.4<.

001

.30

23.9

<.00

1

Step

2.0

0.2

6ns

.03

.92

ns.0

92.

8 .0

3

T0 P

ositi

ve so

cial s

uppo

rt –.

01 .1

3 .0

5

T0 N

egat

ive so

cial s

uppo

rt –.

07–.

15–.

29*

T0 Se

lf-ef

ficac

y .0

2.1

4 .1

4

Step

3.1

36.

0.0

01.1

24.

2.0

1.1

5 5.

5.0

02

T1 P

ositi

ve so

cial s

uppo

rt .1

4–.

003

.15

T1 N

egat

ive so

cial s

uppo

rt–.

29*

–.34

**–.

25*

T1 Se

lf-ef

ficac

y .3

8** .2

2 .4

7**

Tota

l R sq

uare

63

%

53%

55%

* p

<.05

, **p

<.0

1, *

** p

<.0

01.



��


Discussion

The present study revealed that this cancer rehabilitation program had no beneficial effects on the personal resources of the patients. Concurrently, negative social support and self-efficacy appeared to have a more consistent effect on quality of life than did positive social support. Prospectively, negative social support was found to have a small and negative effect only on mental functioning. Finally, although the program neither increased self-efficacy nor decreased experiences of negative social support for the whole group, improvements in quality of life were associated with increases in self-efficacy and reductions in negative social support.

Our first hypothesis was that social support and self-efficacy would change in a positive way following the multidimensional program. In contrast to the increase in positive support that was expected to follow the program (which consisted of a group program to stimulate the provision of peer support from fellow group members [17,21] and the request for positive social support from significant others and health care professionals if needed [45], patients reported receiving less positive social support after the program than they had received before the program. One explanation for the decrease in positive social support experiences after completion of the program may be that patients’ answers reflect the loss of support received from their fellow group members. Another explanation may be that due to the intervention, patients became aware that the social support received from their social network was less adequate. Such a change in patients’ internal standards, values or reconceptualization of social support may have occurred over the intervention trajectory [2], and may occur in any field where self-reported data are collected [46].

The lack of change in negative social support experiences may reflect social constraints that the patients experienced [30]. A social constraint refers to any social condition that causes trauma survivors to feel unsupported, misunderstood, or otherwise alienated from their social networks when they are seeking social support or attempting to discuss their cancer [30,47]. The possibility of such social constraints is supported by the finding that our patients had significantly higher scores on negative social support relative to the normal population and a reference group of recently diagnosed and treated cancer patients. They also experienced fewer positive social experiences relative to the recently diagnosed and treated cancer patients. Both of these findings suggest that the group of patients who were referred for rehabilitation might be a selected group of patients whose networks apparently do not fulfill their support needs in the desired way.

Contrary to the literature, which indicates that both physical and psychological intervention techniques may increase self-efficacy [31], no changes in self-efficacy were observed after the rehabilitation program. One possible explanation for this result is that the program was not powerful enough to strengthen self-efficacy. Future rehabilitation programs should therefore incorporate goal setting with a focus on self-generated, positive, and realistic goals. Such goals seem to be essential aspects of the motivation to change and to improve self-efficacy in specific situations [31,48,49]. Another explanation is that the General Self-efficacy Scale, while initially attractive because of its global nature may be problematic because of that same characteristic. Following Bandura’s original intent, the more specific the self efficacy rating, the more likely the measure is to detect the effect of an intervention. Therefore, behaviour specific or task specific self-efficacy ratings may be more appropriate.



��

Our second hypothesis focused on examining the effects of social support and self-efficacy on quality of life before and after rehabilitation. In general, the findings suggest that negative social support was a more important predictor of quality of life than was positive social support. Those who perceived less negative social support experienced better social functioning at baseline and better physical, social, and mental functioning after the program. Our findings are in line with other studies reporting that perceived negative social support has negative effects on psychological well-being [23,49].

“Positive social experiences” was the only variable to have a unique negative effect on physical functioning after the program. This finding is consistent with the results of another study, which reported a negative association between the number of quality of life problems that patients have and the level of positive social support they experience [42]. Conversely, patients who have fewer quality of life problems may need less social support; they may therefore be less likely to ask for social support, or their social networks may be less likely to provide positive social support [21,23,49].

Patients with higher levels of self-efficacy experienced better mental functioning at baseline and better mental and physical functioning post rehabilitation These findings support the notion that self-efficacy is associated with less psychological stress [18,49], fewer depressive symptoms [50], and better adjustment [49,51,52] in cancer patients.

The proportion of variance explained in the diverse domains of quality of life was found to be higher for mental functioning than it was for social and physical functioning. The variables that were included in our study were apparently more important predictors for the mental aspects of quality of life than they were for other aspects. This is not surprising. For example, self-efficacy expectancies are considered as cognitive control systems that determine the courses of action people choose, how much effort they make to attain particular goals, and how long they will persist in the event of failure [38]; all of these aspects refer to mental functioning.

The results revealed that personal resources had no prospective effect on physical and social functioning, with one exception: negative social experiences appeared to have a slight prospective predictive effect on mental functioning. Other variables that were not included in the present study may therefore be more relevant and should be taken into account in future studies. Possible relevant variables include personality characteristics, coping styles, and illness perceptions. Quality of life at baseline, however, was the most powerful predictor for later functioning; this finding is consistent with another study, which reported that pre-morbid distress is a strong predictor of short-term and later distress [53]. This suggests that patients who are at risk for problems should be identified earlier in the disease trajectory and referred for professional care.

Our last hypothesis concerned the positive associations between changes in quality of life and changes in personal resources. Although the program neither increased self-efficacy nor deceased experiences of negative social support for the whole group, the results suggest that individual-level improvements in quality of life were associated with increases in self-efficacy and reductions in perceived negative social experiences. Changes in positive social support did not affect quality of life at the individual level, although a group-level decrease in positive social support was found. These findings emphasize that the effects of rehabilitation in cancer patients may vary between patients.

Change in negative social support and self-efficacy were found to be associated with changes in quality of life. Decreases in perceived negative social support appeared to be associated


��


with improvements in all quality of life domains. This finding is consistent with other studies, which have revealed that those with poor social networks or socially constrained cancer survivors may benefit the most from supportive groups or psychosocial treatment [21,45]. In addition, increases in self-efficacy were associated with improvements in physical and mental functioning. This finding is consistent with self-efficacy theory, which is based on the idea that coping or adaptive skills can be learned, or on the belief that efficacy can change [16].

Practical implications Several implications can be derived from the results of the present study. The finding that negative social experiences had the most consistent negative effect on quality of life suggests that patients with more negative social experiences are at risk for lower functioning later. It would therefore be worthwhile to provide special care in an earlier stage to patients who have high levels of negative social experiences. In other words, clinical health care providers should assess the social networks of cancer patients and their ability to ask for social support, in addition to their usual practice of assessing the physical and psychological complaints and functioning of their patients.

In addition to its role as a potential risk factor, negative social support may also be considered an important ingredient in the rehabilitation process. It would therefore be interesting to develop interventions that can effectively reduce negative social experiences. We suggest considering the concept of “social comparison” because of its predictive effect for health behavior [29] and its reported mediating effect between resources and benefit findings, which is considered a desirable outcome of adjustment over time [54]. Another suggestion would be to involve patients’ relevant others such as the patients’ partner, adult child or a friend in the program to increase their awareness of the specific support needs of the patient.

In addition, it would be interesting to develop future programs that focus more on improving self-efficacy. Improvements in self-efficacy may be realized by systematically addressing and manipulating all four sources of self-efficacy (i.e., the performance accomplishment of (physical) tasks, modeling, verbal persuasion, and physiological arousal) [24]. Improved self-efficacy may also be realized by providing the cancer rehabilitation program in the form of a self-management program, as previously reported for patients with chronic conditions [55].

Limitations of the study The results regarding the program’s effectiveness should be interpreted with caution, as the study did not include a control group. Future research should involve prospective randomized controlled studies in order to examine the effects more thoroughly. The strength of the design is that we were able to determine predictors of quality of life at baseline in addition to examining the prospective effects of the predictor variables on quality of life, as well as investigating associations between change in predictors and change in quality of life over time.

The number of patients included in the study may be comparable to other intervention studies. However, considering the number of analyses conducted in the study, the number is relatively small. Therefore, the study should be repeated with a larger study group.

Multi-collinearity between the independent variables may be a point of concern with respect to the regression models. Correlation analyses and the low VIFs, however, show that this was not a concern in this study.



�8

ConclusionThe multidimensional rehabilitation program had little effect on the personal resources of the patients. Personal resources had concurrent but slight prospective effects on quality of life. Negative social support experiences and self-efficacy were more consistent and important predictors of quality of life than were positive social experiences, both before and after the program. Although the program neither increased self-efficacy nor decreased experiences of negative social support for the group as a whole, improvements in quality of life appeared to be associated with increased self-efficacy and a reduction in negative social experiences.

Conflict of interestNone declared.


��


ReferenceList


[2] Schwartz CE, Sprangers MA. An introduction to quality of life assessment in oncology: the value of measuring patient-reported outcomes. Am J Manag Care 2002; 8: S550-S559.







[9] Rehse B, Pukrop R. Effects of psychosocial interventions on quality of life in adult cancer patients: meta analysis of 37 published controlled outcome studies. Patient Educ Couns 2003; 50: 179-186.


[11] Galvao DA, Newton RU. Review of exercise intervention studies in cancer patients. J Clin Oncol 2005; 23: 899-909.



[14] van Weert E, Hoekstra-Weebers J, Grol B, Otter R, Arendzen HJ, Postema K, Sanderman R, van der Schans C. A multidimensional cancer rehabilitation program for cancer survivors: effectiveness on health-related quality of life. J Psychosom Res 2005; 58: 485-496.

[15] van Weert E, Hoekstra-Weebers J, Otter R, Postema K, Sanderman R, van der Schans C. Cancer-related fatigue: predictors and effects of rehabilitation. Oncologist 2006; 11: 184-196.

[16] Merluzzi TV, Nairn RC, Hegde K, Martinez Sanchez MA, Dunn L. Self-efficacy for coping with cancer: revision of the Cancer Behavior Inventory (version 2.0). Psychooncology 2001; 10: 206-217.

[17] Lepore SJ, Helgeson V. Psychoeducational support group enhances quality of life after prostate cancer. Cancer Res Ther Control 1999; 8: 81-91.

[18] Lev EL, Paul D, Owen SV. Age, self-efficacy, and change in patients’ adjustment to cancer. Cancer Pract 1999; 7: 170-176.

[19] Moos RH, Schaefer JA. The crisis of physical illness. In: Moos RH (ed.), Coping with physical illness, 2th. ed. New York: Plenum; 1984: 3-25.

[20] Cohen J. Stress and mental health: a biobehavioral perspective. Issues Ment Health Nurs 2000; 21: 185-202.


[22] Manne SL, Taylor KL, Dougherty J, Kemeny N. Supportive and negative responses in the partner relationship: their association with psychological adjustment among individuals with cancer. J Behav Med 1997; 20: 101-125.



�0

[23] Lincoln KD. Social support, negative social interactions, and psychological well-being. Soc Serv Rev 2000; 74: 231-252.

[24] Bandura A. Social foundations of thought and action: a social cognitive theory. Engelwoods Cliffs, NJ: Prentice Hall; 1986.

[25] Bosscher RJ, Smit JH. Confirmatory factor analysis of the General Self-Efficacy Scale. Behav Res Ther 1998; 36: 339-343.

[26] Wiedenfeld SA, O’Leary A, Bandura A, Brown S, Levine S, Raska K. Impact of perceived self-efficacy in coping with stressors on components of the immune system. J Pers Soc Psychol 1990; 59: 1082-1094.

[27] Bandura A. Personal and collective efficacy in human adaptation and change. In: Adair JGE, Belanger DE et-al (eds.), Advances in psychological science: Social, personal, and cultural aspects., 1 ed. Hove, England: Psychology Press/Erlbaum (UK) Taylor & Francis; 1998: 51-71.

[28] Cunningham AJ, Lockwood GA, Cunningham JA. A relationship between perceived self-efficacy and quality of life in cancer patients. Patient Educ Couns 1991; 17: 71-78.

[29] Luszczynska A, Gibbons FX, Piko BF, Tekozel M. Self-regulatory cognitions, social comparison, and perceived peers’ behaviours as predictors of nutrition and physical activity: a comparison among adolescents in Hungary, Poland, Turkey, and USA. Psychol Health 2005; 19: 577-593.

[30] Cordova M, Cunningham L, Carlson C, Andrykowski MA. Social constraints, cognitive processing, and adjustment to breast cancer. J Consult Clin Psychol 2001; 69: 706-711.

[31] Graves KD. Social cognitive theory and cancer patients’ quality of life: a meta-analysis of psychosocial intervention components. Health Psychol 2003; 22: 210-219.

[32] Henderson K, Cole J. The effects of exercise rehabilitation on perceived self-efficacy. Aust J Physiother 1992; 38: 195-202.

[33] Caruso CM, Gill DL. Strengthening physical self-perceptions through exercise. J Sports Med Phys Fitness 1992; 32: 416-427.

[34] Hoekstra-Weebers JE, Jaspers JP, Kamps WA, Klip EC. Psychological adaptation and social support of parents of pediatric cancer patients: a prospective longitudinal study. J Pediatr Psychol 2001; 26: 225-235.

[35] Lewis BA, Marcus BH, Pate RR, Dunn AL. Psychosocial mediators of physical activity behavior among adults and children. Am J Prev Med 2002; 23: 26-35.


[37] Petrie KJ, Cameron LD, Ellis CJ, Buick D, Weinman J. Changing illness perceptions after myocardial infarction: an early intervention randomized controlled trial. Psychosom Med 2002; 64: 580-586.


[39] Lau-Walker M. Relationship between illness representation and self-efficacy. J Adv Nurs 2004; 48: 216-225.


[41] Van Oostrom MA, Tijhuis MA, de Haes JC, Tempelaar R, Kromhout D. A measurement of social support in epidemiological research: the social experiences checklist tested in a general population in The Netherlands. J Epidemiol Community Health 1995; 49: 518-524.

[42] Tempelaar R, de Haes CJM, de Ruiter HJ, Bakker D, van den Heuvel WJ, Nieuwenhuizen MG. The social experiences of cancer under treatment: a comparative study. Soc Sci Med 1989; 29: 635-642.

[43] Sherer M, Maddux B, Mercandante S, Prentice-Dunn B, Jacobs B, Rogers RW. The self-efficacy scale construction and validation. Psychol Rep 1982; 51: 663-671.

[44] Chatterjee S, Hadi AS, Price B. Regression Analysis by Example. New York: Wiley; 2000.

[45] Lepore S, Helgeson V, Eton DT, Schulz R. Improving quality of life in men with prostate cancer: a randomized controlled trial of group education interventions. Health Psychol 2003; 22: 443-452.

[46] Visser MR, Oort FJ, Sprangers MA. Methods to detect response shift in quality of life data: a convergent validity study. Qual Life Res 2005; 14: 629-639.

[47] Lepore SJ, Ituarte PH. Optimism about cancer enhances mood by reducing negative social relations. Cancer Res Ther Control 1999; 8: 165-174.

[48] Kuijer R, Ridder de DT. Discrepancy in illness-related goals and quality of life in chronically ill patients: the role of self-efficacy. Psychol Health 2003; 18: 141-184.

[49] Gallagher J, Parle M, Cairns D. Appraisal and psychological distress six months after diagnosis of breast cancer. Br J Health Psychol 2002; 7: 365-376.


��


[50] Penninx BW, Tilburg van T, Boeke A, Deeg DJ, Kriegsman DM, Eijk van J. Effects of social support and personal coping resources on depressive symptoms: different for various chronic diseases? Health Psychol 1998; 17: 551-558.

[51] Boer H, Elving WJ, Seydel E. Psychosocial factors and mental health in cancer patients: opportunities for health promotion. Psychol Health Med 2005; 3: 1354-1371.

[52] Beckham J. Self-efficacy and adjustment in cancer patients: A preliminary report. Behav Med 1997; 23: 138-142.

[53] Ranchor AV, Sanderman R, Steptoe A, Wardle J, Miedema I, Ormel J. Pre-morbid predictors of psychological adjustment to cancer. Qual Life Res 2002; 11: 101-113.

[54] Schulz U, Mohamed NE. Turning the tide: benefit finding after cancer surgery. Soc Sci Med 2004; 59: 653-662.

[55] Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002; 48: 177-187.



��

5 Cancer-relatedfatigue:

predictorsandeffectsofrehabilitation

Ellen van Weert, Josette Hoekstra-Weebers, Renée Otter, Klaas Postem, Robbert Sanderman, Cees van der SchansOncologist 2006; 11:184-196

AbstractBackground. The aims of the study were to examine the effects of a multidimensional rehabilitation program on cancer-related fatigue, to examine concurrent predictors of fatigue, and to investigate whether change in fatigue over time was associated with change in predictors.Methods. Sample: 72 cancer survivors with different diagnoses. Setting: rehabilitation center. Intervention: 15-week rehabilitation program. Measures: Fatigue (Multidimensional Fatigue Inventory), demographic and disease/treatment-related variables, body composition (bioelectrical impedance), exercise capacity (symptom-limited bicycle ergometry), muscle force (handheld dynamometry), physical and psychological symptom distress (Rotterdam Symptom Check List), experienced physical and psychological functioning (rand- 36), and self-efficacy (General Self-Efficacy Scale, Dutch version). Measurements were performed before (T0) and after rehabilitation (T1).Results. At T1 (n=56), significant improvements in fatigue were found, with effect sizes varying from −0.35 to −0.78. At T0, the different dimensions of fatigue were predicted by different physical and psychological variables. Explained variance of change in fatigue varied from 42%-58% and was associated with pre-existing fatigue and with change in physical functioning, role functioning due to physical problems, psychological functioning, and physical symptoms distress.Conclusions. Within this selected group of patients we found that (a) rehabilitation is effective in reducing fatigue, (b) both physical and psychological parameters predicted different dimensions of fatigue at baseline, and (c) change in fatigue was mainly associated with change in physical parameters.


Cancer-related fatigue: predictors and effects of rehabilitation

��

Introduction

Fatigue is one of the most frequently reported complaints in cancer patients and survivors. Fatigue is a subjective condition, commonly defined as a patient’s feeling of lack of energy, weariness, or as “a persistent, subjective sense of tiredness related to cancer that interferes with usual functioning” [1]. In contrast to the tiredness sometimes felt by a healthy individual, cancer-related fatigue is perceived as being of greater magnitude, disproportionate to activity or exertion, and not relieved by rest [2]. Some cancer patients perceive fatigue as a psychological alteration, whereas others perceive fatigue as the most distressing symptom because of its impairing consequences on their physical activity level [3]. Whether fatigue has more psychological, physical, or combined consequences, patients generally associate fatigue with a high level of impairment in daily living and, therefore, a low quality of life [4].

The extent of the problem of cancer-related fatigue in the short and longer term is unclear. About 70% of people with cancer report feelings of fatigue during radiotherapy [5], chemotherapy [6], bone marrow transplantation [7, 8], or after surgery [9]. However, a minimal increase in fatigue after radiotherapy was also reported [10]. That fatigue may be a serious problem in the longer term is shown by the reported percentage of up to 30% of cancer survivors who experience fatigue for years after the end of their treatment [4, 11]. Whatever the percentages are, the problem of fatigue is still underestimated by oncologists [12].

The determinants of the onset and persistence of fatigue are still poorly understood [13]. Cancer-related fatigue is attributed to a variety of disease-related and treatment-related factors such as the cancer itself, anemia [12, 14, 15], cytokines, nutritional and fluid imbalances, etc. [3, 5]. Cancer-related fatigue is associated with treatment-related physiological and psychological mechanisms. Physiological mechanisms include the occurrence of reduced aerobic capacity, physical performance, and muscle wasting as a side effect of anticancer treatment [3, 4, 16]. These physiological mechanisms may be aggravated by the inactivity resulting from the advice of bed rest and to downscale activities. A low activity pattern may lead to more muscle deconditioning and disuse atrophy [17], which in turn may aggravate the feelings of fatigue [18]. In fact, a vicious circle may occur and account for the persistence of fatigue in the longer term [3,16].

Psychological factors are related to the onset and the persistence of fatigue in cancer patients. Over time, the different stages and phases of cancer, varying from diagnosis to treatment and post-treatment, have been associated with psychological symptoms such as anxiety and depression [14, 19], reduced self-efficacy [20], sleep disorders, distress [21], and difficulty coping [3]. However, whether fatigue is a cause or an effect of these factors is still unknown [22]. There are even studies that suggest that there is no strong cause-and-effect relationship between fatigue and, for example, depression [23].

Although the exact determinants of cancer-related fatigue need more scientific research, its multifactorial nature seems to be generally acknowledged [22]. Therefore, a diversity of psychological and physical interventions that have the potential to reduce cancer-related fatigue have been described. The described psychological interventions were aimed at reducing fatigue in cancer patients through facilitating coping with the disease and improving quality of life [21, 24, 25]. Since fatigue seems to be associated with a physical and a functional component, a growing number of studies reported on the effectiveness of physical training, that is, exercise training [26–29]. Exercise training is reported to be


��


beneficial for cancer patients because it is aimed at improving functional capacity and muscle strength and at decreasing cancer-related fatigue, which may in turn contribute to a better overall quality of life [7,29-32].

For the present study, because of the associations found between cancer-related fatigue and physical and psychological factors, we acknowledged fatigue as a problem with different dimensions, as previously proposed by others [33]. Accordingly, we theorized that such a multidimensional problem might require a multidimensional intervention that included physical and psychological components. Therefore, we developed a multidimensional rehabilitation program that includes exercise, sports and games, information, and psychoeducation. We first hypothesized that the multidimensional rehabilitation program would have beneficial effects on fatigue. Secondly, we hypothesized that different physical and psychological variables would be associated with different domains of fatigue and that decreased fatigue after the program would be associated with changes in both physical and psychological variables.

PatientsandMethods

SamplePatients were eligible for the study if they met the following criteria: age C18 years; referred by hospital specialists or general practitioners; last cancer-related treatment >3 months ago; estimated life expectancy C1 year, and an indication for rehabilitation. The latter meant a minimum of three positive findings on the following questions, as judged by a physician:a Physical complaints like aching muscles, problems with coordination, headache,

nausea, heart palpitations, shortness of breath;b Reduced physical capacity compared with before the illness (for example, less able to

walk or cycle);c Psychological problems like increased anxiety level, depression, uncertainty, lack of

energy, or nervousness;d Increased levels of fatigue;e Sleep disturbances;f Problems in coping with reduced physical and psychosocial functioning due to cancer.Patients were not included if they met one of the following criteria: (a) a very low level of activity according to the classification of Winningham [31], for example, <50% of their daytime ambulant, rapid fatigue appearance on performance of low physical activity and activity of daily living dependency; (b) inability to travel independently to the rehabilitation center; (c) cognitive disturbances that may interfere with participation in the rehabilitation program; and (d) serious psychopathology or emotional instability that may impede participation in the rehabilitation program.

DesignA pre-post test design was used to examine the effects of a multidimensional rehabilitation program on fatigue. The design allowed us to examine concurrent predictors of fatigue and, more importantly, to investigate whether change in fatigue over time was associated with change in predictors.



��

ProceduresAll patients gave written informed consent to participate in the study and for the acquisition of medical information from their hospital charts. Medical data were verified by record linkage with the population-based cancer registry of the Comprehensive Cancer Center North-Netherlands (cccn). The Medical Ethics Committee of the University Medical Center Groningen approved the study. After being referred to the study, patients were consecutively enrolled in groups of 8-12 patients. Then, an information session, including a video session, was organized to inform patients about the content of the four components of the multidimensional rehabilitation program.

Setting/InterventionThe 15-week program was offered at the Center for Rehabilitation of the University Medical Center Groningen in an outpatient setting. The choice for a multidimensional program was based on the acknowledgment of fatigue as a multidimensional construct [33]. The entire rehabilitation program consisted of (a) individual exercise, (b) sports, (c) psychoeducation, and (d) information (Fig. 1). Participants were urged to be present at all sessions. According to the session leaders, absence was negligible.

Figure 1 The content and frequency of the program components

Week � � � � � � � 8 � ��

Day 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5 2 5

I.E. (1.5 hours) + + + + + + + + + + + + + + +

Sp (1 hour) + + + + + + + + + + + + + + + + +

PE (2 hours) + + + + + + + + +

Inf (1 hour) + + + + + + + + + + +

Abbreviation: I.E, Individual Exercise; Sp, Sports; PE, Psycho-education; Inf, Information.

Individual ExerciseThe exercise program consisted of 15 sessions of 1.5 hours each and was supervised by a physical therapist. The exercise program was divided into an aerobic bicycle training and a muscle force training program. The bicycle training was performed at a trainings heart rate (thr) of HRrest + 50%-60% (HRmax − HRrest) during weeks 1–3 and at a thr of HRrest + 70%-80% (HRmax − HRrest) during weeks 4-9 [34]. General muscle force training of trunk and lower and upper extremities was performed and based on the individual 1-repetition maximum (1-rm) [35]. Individual intensity of muscle force training started at 50% of the 1-rm during the first week and was increased by 5%-10% during the following weeks with a frequency of 12 repetitions over three series. The rationale to include aerobic exercise training and muscle force training in the program is that it may mitigate fatigue because of physiological improvements [36].

SportsThe sports program consisted of 17 sessions of 1 hour each. The sessions were supervised by a physical therapist and were directed toward “enjoying sports”, “self-confidence”, and “body knowledge”. During the performance of a diversity of sports activities, patients


��


were instructed to become aware of physical sensations or limitations so they would recognize and respect limitations when performing sports or recreational activities at home. Sports were included in the program to stimulate patients to perform and enjoy sports and, consequently, to increase their level of activity in leisure times so that they may break through the vicious circle of a low activity pattern, muscle deconditioning, and fatigue [16, 17].

PsychoeducationThe psychoeducational program consisted of nine sessions of 2 hours each. The aims of the psychoeducational program were to reduce negative emotions, improve coping with the disease, and learn effective stress management techniques that may reduce fatigue [22]. A psychosocial specialist with several years of experience in conducting group sessions with cancer survivors led the psychoeducational program. Over several sessions, expressive–supportive techniques, breathing exercises, relaxation exercises, and exercises from Rational-Emotive Therapy were used to provide patients with stress-management techniques.

InformationThe information program consisted of 10 sessions of 1 hour each. The aim of this program was to reduce the uncertainty resulting from a lack of knowledge of the disease by providing information with respect to cancerrelated subjects. Better knowledge about cancer and cancer-related fatigue may lead to a better understanding of fatigue as a cancer treatment–related symptom, to change of irrational illness perceptions [37], and to the adoption of management strategies [22].

MeasuresDemographic variablesAge and gender were assessed.

Disease- and treatment-related variablesDiagnosis, stage of disease, time since diagnosis, type of treatment received, and time since end of treatment were recorded from the patient’s medical record.

FatigueFatigue was measured with the Multidimensional Fatigue Inventory (mfi), which measures the following five dimensions: general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue [10]. Every dimension contains four items and answers are given on a 5-point Likert-type scale. Scores have a range of 4–20, and a higher score reflects a greater sense of fatigue. Chronbach’s α of the present study ranged from 0.71–0.83.

Body composition Besides body weight and height, lean body mass (lbm) and body fat (bf) were assessed by bioelectrical impedance analyses (Bodystat®1500, Douglas, Isle of Man, British Islands). Bioelectrical impedance measures resistance, lbm, and bf with a frequency of 50 kHz, using empirically-derived formulas. Measurements were taken with the patient in the supine position at the right side with electrodes on the third metacarpal bone, wrist, the second metatarsal bone, and the dorsum of the ankle. Patients were asked to refrain from ingesting



�8

food or beverages prior to the measurement. Body Mass Index (bmi) is calculated as weight (kg)/height (m2). bmi has been used in evaluating cachexia and obesity. The normal range proposed by the World Health Organization (WHO) is 18.5–24.9 kg/m2.

Physiological functioningExercise capacity. A symptom-limited bicycle ergometry test was performed using a ramp 10, 15, or 20 protocol, depending on the patient’s fitness. The load was increased every minute by 10, 15, or 20 Watts, respectively, in such a way that patients could reach their maximal workload within 10 minutes. The test was terminated on the basis of the patient’s symptoms or at the physician’s discretion [38]. Maximal workload in Watts at maximal performance was taken for analysis. Muscle force. Maximal voluntary isometric muscle force of the right and left extremity of the following muscle groups was measured: extension of the knee, flexion of the elbow, and extension of the elbow, using a handheld dynamometer (Force Evaluating & Testing (microfet), Hoggan Health Industries Inc, West Jordan, ut). The “break method” was used for all measurements. To use this technique, the examiner gradually overcomes the force produced by the patient until the extremity gives way [39]. All measurements were performed at least three times with recovery intervals of at least 10 seconds. Peak forces (in Newtons) were recorded and mean values of three technically correct measurements were taken for analysis.

Physical symptoms and psychological distressThe Rotterdam Symptom Check List, a self-report questionnaire, was used to assess disease-related quality of life. The checklist contains 23 items for physical symptom distress and seven items for psychological distress. Responses are presented on a 4-point Likert-type scale. A higher score reflects a higher level of burden of impairment. Normal scores for the general population are available [40]. Cronbach’s α for the present study ranged from 0.67-0.87.

Perceived physical functioning, mental functioning, and role limitationsThree subscales, physical functioning (10 items), role limitations due to physical problems (four items), and mental health (five items), of the rand-36, which is a multidimensional self-report questionnaire, were used to assess global health-related quality of life. After recoding and transformation, scores range from 0–100, and a higher score represents better health. Normal scores for the general population are available [41]. Cronbach’s α for the present study ranged from 0.84–0.85.

Self-efficacyThe feeling of competence or having control over one’s life was measured with the alcos (16 items), which is the Dutch version of the General-Self-Efficacy Scale [42]. Responses are presented on a 5-point Likert-type scale. A higher score reflects a higher level of self-efficacy. Cronbach’s α for the present study was 0.82.

Data analysesDescriptive statistics were used to describe the study population. Paired t tests were used to assess differences between the two measurement times, T0 and T1. The effect size (es) and threshold at the 5% level were calculated as indices measuring the magnitude of a


��


treatment effect [43]. Middel et al. [44] showed that es reflects clinical relevance. An es <0.20 indicates “no change”, an es C0.20 but <0.50 indicates “a small change”, an es C0.50 but <0.80 indicates “a moderate change”, and an es C0.80 indicates “a considerable change”.

To examine the effects of the different predictor variables on fatigue at baseline, the following analyses were performed. First, univariate relationships between mfi dimensions on the one hand and demographic variables, disease- and treatment- related variables, body composition, physiological variables, physical and psychological symptoms, and perceived functioning on the other hand were examined using Pearson’s correlation analyses. In cases of dichotomous variables, differences were assessed by independent t tests. Analysis of variance (anova) was used to assess differences between treatment groups. Second, to investigate the main determinants of fatigue at baseline, variables significantly related to a subscale of the mfi were entered into a multiple regression model and analyzed stepwise. Five separate multiple regression analyses were performed, a separate one for each fatigue subscale. For nominal variables (treatment, diagnosis), we created dummy variables.

To examine whether change in fatigue was associated with change in baseline predictors, we performed five separate hierarchical multiple regression analyses. The subscales of fatigue postintervention were the dependent variables in the five regression models. The effect of fatigue at baseline (T0) on subsequent fatigue (T1) was first entered to control for earlier levels of fatigue. In the second step, the difference (L) between a predictor variable score at baseline (T0) and a subsequent predictor variable score (T1) was entered into the regression model. These analyses allow the examination of associations between change in fatigue and change in physical or psychological variables. Only those predictor variables that had a significant unique effect on preintervention fatigue were entered into the models.

Correlational analyses between the independent variables and variance inflation factors (vif=1/1 − R2) were calculated to assess multicollinearity. Multicollinearity is present if the mean vif is considerably larger than one and the largest vif is greater than 10 [45].

Results

Patient characteristicsSeventy-two patients entered the program. Fifteen percent of the participants were male. The mean (standard deviation (sd)) age of the participants was 51.4 (9.6) years. Sixty-one percent of the patients were women with breast cancer, and 39% had other cancer diagnoses. Two thirds of the patients had stage I or stage II disease. Two thirds of the participants had completed treatment during the preceding year (Table 1). The most often reported indication for referral to the rehabilitation program was fatigue. Fifty-six patients (77.8%) completed the program and the questionnaires: 10 patients developed cancer recurrence and dropped out of the program of their own volition. A further six patients left the program: for personal reasons (two patients), because of malaise (two patients), and for unknown reasons (two patients). Dropout was therefore 22.3%. tests and t tests revealed no significant differences between dropouts and those that stayed in with respect to gender, age, cancer diagnosis, time since diagnosis, time since completion of treatment, and fatigue at T0. χ2 tests revealed significantly more cancer recurrences in the dropout group than in the stay-in group (p < .001).



�0

table 1 Patient characteristics at time of inclusion (T0), n=��

n %

Physician-reported indication criteria for rehabilitation (yes)Physical complaints Reduced physical capacityPsychological problemsFatigueSleep disturbancesCoping/acceptance problems

445548594529

61.176.466.781.962.540.3

Diagnosis Breast cancerNon Hodgkin Lymphoma /M.Hodgkin’s diseaseGynaecological cancerHead and neck cancerOther < 5%

44654

13

61.1 8.4 7.0 5.617.9

Stage of disease In situStage IStage IIStage IIIStage IVMissing

1123714

35

1.416.751.419.4 4.2 6.9

Cancer treatment before rehabilitation Chemotherapy with/without surgeryRadiotherapy with/without surgeryCombination (chemotherapy and radiotherapy) with/without surgerySurgeryBone marrow transplant

14/217/429/1

41

19.4/2.823.6/5.640.3/1.4

5.61.4

Time between completion of treatment and rehabilitation program B6 months>6-12 months>12-18 months>18 monthsMissingMean (SD) in months 10.8 (13.4)

282113

82

38.329.218.111.1 2.8

Anthropometry Weight, mean (SD) in kgLength, mean (SD) in cmBMI, mean (SD) in kg/m2 Lean body mass, mean (SD) in kg Body fat, mean (SD) in %

Male84.8(17.4)184.5(6.8)

24.8(3.9)64.1(9.6)23.7(4.8)

Female72.1(15.0)168.5(7.8)

25.6(5.8)45.9(5.3)36.5(7.0)

Age, mean (SD) years ��.�(�.�)Gender, male:female, n (%) ��(��.�): ��(8�.�)

Abbreviations: BMI body mass index; SD standard deviation.


��

Effects of the multidimensional rehabilitation program on the different dimensions of cancer-related fatiguePaired t tests of mean scores at T0 and T1 showed that patients reported significant improvements in every domain of the mfi after the cancer rehabilitation program (Table 2). The es of T0 and T1 with respect to fatigue after the intervention varied from −0.35 (small change) to −0.78 (moderate change).

Mann-Whitney tests were performed to examine the effect of time since completion of treatment. The choice for this test was made because the distribution of time since completion was skewed; categorization was based on the median of 6.7 months. No significant differences were found between patients with a time since completion of treatment shorter than 6.7 months and patients with a longer time in any domain of fatigue before and after the program.

Table 2 Descriptives and comparison of Mulitdimensional Fatigue Inventory scores between patients before (T0) and after (T�) the rehabilitation program, based on paired t tests, and effect sizes with a ��% CI. A higher score represents more fatigue

Patients at T0n= 56Mean (SD)

Patients at T1n= 56Mean (SD) t Effect size

95% CI for ES

General fatigue 15.0 (3.9) 12.9 (4.7)*** 4.51 –0.48 –0.86 to –0.11

Physical fatigue 14.9 (4.2) 11.6 (4.2)*** 7.17 –0.78 –1.16 to –0.40

Reduced activity 12.9 (4.0) 10.7 (4.1)*** 4.22 –0.54 –0.92 to –0.16

Reduced motivation 10.4 (3.7) 09.1 (3.6)** 3.26 –0.35 –0.73 to –0.02

Mental fatigue 13.2 (4.1) 11.7 (4.2)** 2.98 –0.36 –0.73 to –0.01

** p<.01; *** p<.001 Abbreviations: SD, standard deviation

Main predictors of cancer-related fatigue in patients referred to a cancer rehabilitation programCorrelational analyses between the predictor variables showed low to moderate coefficients ranging from 0.27 (physical functioning and mental functioning) to 0.74 (mental functioning and psychological distress).

MFI-General fatigueanova showed that patients who had received radiotherapy combined with surgery had higher scores on general fatigue at baseline than those who had received chemotherapy or combined therapy with surgery. Correlational analyses showed that general fatigue at baseline was negatively associated with maximal workload, muscle force of lower extremity, physical functioning, role limitations, and psychological functioning. General fatigue appeared positively related to physical symptom distress and psychological distress (Table 3). Multiple stepwise regression analysis showed that physical functioning was the strongest predictor, followed by radiotherapy (with surgery) and physical symptom distress. Total variance explained was 48.8% (Table 4). VIFs ranged from 1.0-1.69.



��

MFI-physical fatiguePhysical fatigue at baseline appeared to be negatively associated with maximal workload, muscle force of upper extremity and lower extremity, physical functioning, role limitations, psychological functioning, and self-efficacy. Physical fatigue appeared to be positively related to physical symptom distress (Table 3). Multiple stepwise regression analysis showed that role limitation due to physical problems was the strongest predictor, followed by maximal workload. Total variance explained was 54.6% (Table 4). VIFs ranged from 1.02–2.03.

MFI-reduced activityReduced activity at baseline was negatively associated with maximal workload, role limitations, psychological functioning, and self-efficacy. Reduced activity appeared positively related to age (Table 3). Multiple stepwise regression analysis showed that role limitation due to physical problems was the strongest predictor of reduced activity at baseline, followed by psychological functioning. Total variance explained was 26.2% (Table 4). VIFs ranged from 1.0-1.84.

MFI-reduced motivationReduced motivation at baseline was negatively associated with maximal workload, muscle force of lower extremity, physical functioning, role functioning, psychological functioning, and self-efficacy. Reduced motivation appeared positively associated with age, physical symptom distress, and psychological distress (Table 3). Multiple stepwise regression analysis showed that self-efficacy was the strongest predictor, followed by physical functioning and age. Total variance explained was 38.7% (Table 4). VIFs ranged from 1.0-1.99.

MFI-mental fatigueMental fatigue at baseline was negatively associated with physical functioning, role limitations, psychological functioning, and self-efficacy. Mental fatigue appeared positively related to physical symptom distress and psychological distress (Table 3). Multiple stepwise regression analysis showed that physical symptom distress was the only significant predictor of mental fatigue at baseline. Total variance explained was 25.4% (Table 4). VIFs ranged from 1.0–1.29. Posthoc analyses revealed that female patients had a lower lbm and a higher percentage bf than male patients (p=<.001). lbm was significantly correlated with muscle force (r=0.46; p < .001), but not associated with any of the domains of fatigue.



��

Table 3 Fatigue at baseline: independent t tests and ANOVA of demographic characteristics and disease and treatment-related variables, and Pearson correlational analyses of physiological variables, symptom distress, and perceived functioning and the different sub-scales of fatigue pre intervention, n=��

Generalfatigue

F r

PhysicalFatigue

t r

Reduced Activity

t r

Reduced Motivationt r

Mental Fatigue

t r

Demographic variables AgeGender (female=1, male=0 )

.28 * .26 *

Disease and treatment-related variables

Diagnosis (breast cancer =1, other =0)Type of treatment - Chemotherapy with surgery- Radiotherapy with surgery - Combined therapy with surgery

Time since diagnosisTime since end of treatmentRecurrence

4.42 *

Anthropometry Lean body mass

Physiological variables Maximal workloadMuscle force upper extremityMuscle force lower extremity

–.33 **

–.39 **

–.50*** –.34 ** –.42 **

–.24 * –.26 *

–.30 *

Symptom distress variablesPhysical symptoms (RSCL)Psychological symptoms (RSCL)

.53*** .34 **

.49*** .31 ** .31 **

.49***

.30 *

Perceived functioning variablesPhysical functioning (RAND-36)Mental health (RAND-36)Role limitations physical problems (RAND-36)Self-efficacy (ALCOS)

–.53***

–.37 **

–.53***

–.57*** –.31 ** –.62***

–.25 *

–.32 ** –.44***

–.28 *

–.35 ** –.50 **

–.34 **

–.52***

–.29 * –.29 * –.34 **

–.26 *

Only significant relationships are depicted: * p<.05, ** p<.01, *** p<.001.Abbreviations: RSCL, Rotterdam Symptom Check List.



��

Table 4Multiple regression(stepwise) analyses of fatigue at baseline, beta and total R2

General fatigueβ

Physical fatigueβ

Reduced activityβ

Reduced motivationβ

Mental fatigueβ

Demographic characteristics

Age 0.19 0.23 *

Disease- and treatment-related variables

Type of treatment (radiotherapy with surgery,1; other, 0)

0.36 **

Physiological variables

Maximal workload –0.001 –0.40 ** –0.07 0.07

Muscle force upper extremity 0.03

Muscle force lower extremity –0.03 0.02 0.04

Symptom distress variables

Physical symptoms (RSCL) 0.27 * 0.13 0.01 0.50***

Psychological symptoms (RSCL) 0.16 0.06 0.14

Perceived functioning

Physical functioning (RAND-36) –0.40 ** –0.20 –0.27 * –0.13

Psychological functioning (RAND-36) –0.11 –0.14 –0.23 * –0.15 –0.09

Role limitations physical problems (RAND-36) –0.12 –0.44*** –0.40 ** –0.10 –0.13

Self-efficacy (ALCOS) –0.06 –0.10 –0.40 ** –0.11

Total R2 48.8% 54.6% 26.2% 38.7% 25.4%

Only variables entered into the model are depicted: * p<.05, ** p<.01, *** p<.001.Abbreviations: RSCL, Rotterdam Symptom Check List.



��


Associations between change in fatigue following the rehabilitation program and change in predictors identified as having an independent effect on fatigue at baseline (Table 5)MFI-change in general fatigueGeneral fatigue at baseline accounted for 46% of the variance in fatigue postintervention (step 1). The variables entered into the second step accounted for a significant increment of 7%. Change in physical functioning had significant unique effects, but change in physical symptom distress did not. Thus, decreased general fatigue was associated with better physical functioning. Total variance explained was 53%. VIFs ranged from 1.0-1.08.

MFI-change in physical fatiguePhysical fatigue at baseline accounted for 41% of the variance in fatigue postintervention. The variables entered into the second step accounted for a significant increment of 17%. Change in role limitations due to physical problems had a significant unique effect, but change in maximal workload did not. (Assessment of maximal workload was not possible in 12 patients due to mechanical breakdown of the apparatus [3], nausea [2], claustrophobia [1], or perceived irrelevance, painfulness, discomfort, or strenuousness of the test [6]. Consequently, the analysis examining change in physical fatigue was performed on 44 patients.) Thus, decreased physical fatigue was associated with fewer role limitations. Total variance explained was 58%. VIFs ranged from 1.0-1.3.

MFI-change in reduced activityReduced activity at baseline accounted for 38% of the variance in fatigue postintervention. The variables entered into the second step accounted for a significant increment of 11%. Change in role limitations due to physical problems and change in psychological functioning appeared to have a significant unique effect. Thus, a decrease in reduced activity was associated with fewer role limitations and better psychological functioning. Total variance explained was 49%. VIFs ranged from 1.0-1.01.

MFI-change in reduced motivationReduced motivation at baseline accounted for 44% of the variance in fatigue postintervention. The variables entered in the second step accounted for a significant increment of 8%. Change in physical functioning had a significant unique effect, but change in self-efficacy did not. Thus, a decrease in reduced motivation was associated with better physical functioning. Total variance explained was 52%. VIFs ranged from 1.0-1.02.

MFI-change in mental fatigueMental fatigue at baseline accounted for 36% of the variance in fatigue postintervention. Change in physical symptom distress entered in the second step accounted for a significant increment of 6%. Thus, decreased fatigue was associated with reduced physical symptom distress. Total variance explained was 42%. VIFs were all 1.0.



��

Table 5Hierarchical multiple regression analyses of change in fatigue

Predictors

General fatigue T1

Physical fatigue T1

Reduced activity T1

Reduced motivation T1

Mental fatigue T1

β R2ch Fch p β R2ch Fch p β R2ch Fch p β R2ch Fch p β R2ch Fch p

Step 1Fatigue pre- intervention (T0)

Step 2 Physiological variables∆ Maximal Workload∆ Muscle force upper extremity∆ Muscle force lower extremitySymptom distress variables∆ Physical symptoms∆ Psychological symptomsPerceived functioning ∆ Physical functioning ∆ Psychological functioning ∆ Role limitations physical problems ∆ Self-efficacy

.46 46.3 <.001

.68 ***

.07 3.8 <.05

.08

–.23 *

.41 26.9 <.001

.64 ***

17 7.1 <.001

–.02

–.42 ***

.38 31.2 <.001

.62 ***

.11 5.1 <.01

–.25 *

–.21 *

.44 42.3 <.001

.67 ***

.08 4.2 <.01

–.27 **

–.06

.36 30.0 <.001

.60 ***

.06 5.6 <.01

.25 *

Total R2 (%) 53% 58% 49% 52% 42%

* p<.05, ** p<.01, *** p<.001.∆, difference between T0 and T1.


��


Discussion

The present study assessed fatigue multidimensionally in a selected group of cancer patients referred to a rehabilitation program. Within this group of patients, we found that (a) rehabilitation is effective in reducing fatigue, (c) both physical and psychological parameters predicted different dimensions of fatigue, and (c) change in fatigue is mainly associated with change in physical parameters.

The first aim of the study was to assess the effects of a multidimensional rehabilitation program on cancer-related fatigue, a program of which the beneficial effects on quality of life have recently been reported [46]. The results of the present study showed that patients reported statistically significant and, more importantly, clinically relevant reductions in cancer-related fatigue after completion of the multidimensional program. Most reductions in fatigue were found in the domain of physical fatigue. One could argue that the effect found was due to maturation [47] rather than to the intervention. However, patients were eligible for the rehabilitation program only when (a) treatment had been completed at least 3 months prior to rehabilitation so that patients had time to naturally recover from cancer-related treatment effects and (b) the physician had judged that the presence of physical and psychological problems were persisting. In addition, the finding that there were no associations between time since completion of treatment and fatigue before and after the program argues against a maturation effect. This suggests that the beneficial effects on fatigue could be attributed to the intervention.

The second aim of the study was to examine the contribution of different variables to the determination of cancer-related fatigue reported by patients referred to a cancer rehabilitation program. Our study showed that gender was not a significant determinant of fatigue at baseline. Other studies reported that women suffer more from fatigue than men do [48]. We did not observe such a relationship perhaps because of the low number of men in our study. With respect to age, we found that age was not associated with any domain of fatigue except a greater reduction in motivation. This finding is in accordance with several other studies reporting no relationship between age and fatigue in cancer patients. However, it is in contrast to studies in the normal population reporting more fatigue in older people [48, 49]. With respect to disease- and treatmentrelated factors, we found no associations between type of cancer, time since diagnosis or completion of treatment, or type of treatment received and the different domains of fatigue, except that those who had undergone radiotherapy with surgery reported more fatigue than those who had received chemotherapy with surgery or a combination of chemotherapy, radiotherapy, and surgery. lbm and bf percentage appeared not to be related to any of the domains of fatigue.

Correlational analyses of the baseline data showed that the different dimensions of fatigue at baseline were associated with different physical and psychological parameters, supporting the notion that cancer-related fatigue is a multidimensional construct in nature. Regression analyses showed that maximal workload, physical symptoms, perceived physical functioning, psychological functioning, role limitations due to physical problems, and self-efficacy were the main determinants of fatigue at baseline.

The findings that physical and psychological parameters are predictive of fatigue are in agreement with our second hypotheses and are in accordance with earlier studies of cancer patients [50-52]. In addition, our results support the notion [51] that it is important to systematically assess and manage both physical and psychological symptoms of cancer-related fatigue.



�8

An interesting finding was that physical fatigue was determined by maximal workload. Other authors used the 6- or 12-minute walk test [53] to assess exercise capacity. However, those authors did not statistically examine the relationship between fatigue and the 6- or 12-minute walk test. Furthermore, the 6- and 12-minute walk test has the disadvantage that it is a self-paced and submaximal test [54] that reflects more general functional ability [53] rather than genuine exercise capacity. The extra value of our study is that we included bicycle ergometry with a protocol that forced patients to maximal performance, which has been reported to be a more adequate measure of maximal exercise capacity [38, 55].

Furthermore, we found that self-efficacy was a significant predictor of reduced motivation only. Apparently, self-efficacy seems to be a less important variable in cancer patients than has been suggested in studies of chronic fatigue syndrome [50] and rheumatoid arthritis [56], which indicate that patients with a lower self-efficacy perceive more fatigue in general. In addition, baseline results revealed that mental fatigue was not determined by psychological variables but by physical symptom distress only, indicating that patients with a high level of physical symptom distress experienced more mental fatigue.

The proportion of the variance of fatigue at baseline explained by the variables included in the regression models varied from 25.4%-54.6%. The proportion of variance explained in the domains general fatigue and physical fatigue was higher than that in the domains of reduced motivation, reduced activity, and mental fatigue. Apparently, the variables included in our study were more relevant in predicting the more physical areas of fatigue than the more ‘psychologically’ oriented areas of fatigue.

The results regarding the associations between change in fatigue and change in physical and psychological variables revealed that fatigue at baseline was the most powerful predictor. This finding is in line with an earlier study showing that fatigue after radiation was mainly determined by fatigue prior to radiation [10].

A further finding of the study was that a decrease in the different dimensions of fatigue was mainly associated with improvements in physical parameters, including a decrease in physical symptoms and an improvement in perceived physical functioning and perceived role limitations due to physical problems. These findings are partly in agreement with our second hypothesis.

Change in physical and, to a lesser degree, psychological variables accounted for a significant but small increment (6%-17%) in the prediction, suggesting that other variables not included in the present study may be more relevant and should be taken into account in future studies. Possible suggestions are personality characteristics, social support, pain, and quality of sleep.

Although the predictive power of change in physical and psychological variables is relatively small, such change may be clinically important. Any alleviation of fatigue induced by cancer rehabilitation may be relevant for patients, considering the 20%-40% of patients who continue to suffer from fatigue long after cancer treatment. Furthermore, there may be an additional indirect effect of the program, that is, that patients with less fatigue may have more potential to break through the vicious circle of inactivity, muscle deconditioning, and fatigue.

The question of which component of the presented rehabilitation intervention may have accounted for the results is difficult to answer on the basis of the present study design. It is not possible to compare the effects of the physical or psychological components separately. However, the finding that change in fatigue was predominantly associated with change in physical parameters may suggest that a program consisting only of physical components might be effective enough.


��


The results may further suggest that future research should examine whether early screening of cancer-related fatigue, suggested to take place at the patient’s initial contact with an oncologist [22], is feasible and effective in fatigue management and health-related quality of life.

Study limitations and clinical and research implicationsWith respect to the longitudinal design of the present study, the following remarks can be made. The interpretation of the results with respect to the effectiveness of the program should be made with caution because we did not include a control group. However, changes found in our study were not only statistically significant, but also appeared to be clinically relevant. In addition, the achieved beneficial effects on fatigue may be attributed to genuine effects of the intervention, regarding the long natural recovery time in most of the referred patients. In further research, a prospective randomized controlled study including a physical intervention, a psychological intervention, and/or a combined intervention seems to be necessary to examine the effects more thoroughly.

The strength of the longitudinal study design is that we were not only able to determine predictors of fatigue at baseline, but were also able to determine that change in fatigue was predominantly associated with change in physical parameters.

Multicollinearity between the independent variables may be a point of concern with respect to the regression models of fatigue. However, correlation analyses ranging from low to moderate and the low VIFs show that multicollinearity does not seem to be a point of concern in this study.

ConclusionDifferent dimensions of fatigue at baseline are associated with different physical and psychological symptom parameters, suggesting that cancer-related fatigue is a multidimensional construct in nature. The multidimensional rehabilitation program presented in the current study had statistically and clinically relevant and positive effects on cancer-related fatigue. Decreases in fatigue were found to be predominantly associated with beneficial changes in physical parameters such as a decrease in physical symptoms and an improvement in perceived physical (role) functioning. The results suggest that future interventions should at least include a physical training/sport component to reduce fatigue in cancer patients.

AcknowledgmentsThis study was supported by a Dutch Rotary/kwf jubilee grant.

Disclosure of Potential Conflicts of InterestThe authors indicate no potential conflicts of interest.



80

References

[1] Mock V, Atkinson A, Barsevick A, Cella D, Cimprich B, Cleeland C, Donnelly J, Eisenberger MA, Escalante C, Hinds P, Jacobsen PB, Kaldor P, Knight SJ, Peterman A, Piper BF, Rugo H, Sabbatini P, Stahl C. NCCN Practice Guidelines for Cancer-Related Fatigue. Oncology (Williston Park) 2000; 14: 151-161.

[2] Glaus A, Crow R, Hammond S. A qualitative study to explore the concept of fatigue/tiredness in cancer patients and in healthy individuals. Eur J Cancer Care (Engl ) 1996; 5: 8-23.

[3] Lucia A, Earnest C, Perez M. Cancer-related fatigue: can exercise physiology assist oncologists? Lancet Oncol 2003; 4: 616-625.

[4] Dimeo FC. Effects of exercise on cancer-related fatigue. Cancer 2001; 92: 1689-1693.

[5] Dimeo F. Radiotherapy-related fatigue and exercise for cancer patients: a review of the literature and suggestions for future research. Front Radiat Ther Oncol 2002; 37: 49-56.

[6] Greene D, Nail LM, Fieler VK, Dudgeon D, Jones LS. A comparison of patient-reported side effects among three chemotherapy regimens for breast cancer. Cancer Pract 1994; 2: 57-62.


[8] Knobel H, Loge JH, Nordoy T, Kolstad AL, Espevik T, Kvaloy S, Kaasa S. High level of fatigue in lymphoma patients treated with high dose therapy. J Pain Symptom Manage 2000; 19: 446-456.

[9] Nail LM, Winningham ML. Fatigue and weakness in cancer patients: the symptoms experience. Semin Oncol Nurs 1995; 11: 272-278.

[10] Smets EM, Visser MR, Willems-Groot AF, Garssen B, Schuster-Uitterhoeve AL, de Haes JC. Fatigue and radiotherapy: (B) experience in patients 9 months following treatment. Br J Cancer 1998; 78: 907-912.

[11] Berglund G, Bolund C, Fornander T, Rutqvist LE, Sjoden PO. Late effects of adjuvant chemotherapy and postoperative radiotherapy on quality of life among breast cancer patients. Eur J Cancer 1991; 27: 1075-1081.

[12] Tavio M, Milan I, Tirelli U. Cancer-related fatigue (review). Int J Oncol 2002; 21: 1093-1099.

[13] Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S. Cancer-related fatigue: evolving concepts in evaluation and treatment. Cancer 2003; 98: 1786-1801.

[14] Morrow GR, Andrews PL, Hickok JT, Roscoe JA, Matteson S. Fatigue associated with cancer and its treatment. Support Care Cancer 2002; 10: 389-398.

[15] Holzner B, Kemmler G, Greil R, Kopp M, Zeimet A, Raderer M, Hejna M, Zochbauer S, Krajnik G, Huber H, Fleischhacker WW, Sperner-Unterweger B. The impact of hemoglobin levels on fatigue and quality of life in cancer patients. Ann Oncol 2002; 13: 965-973.

[16] Evans W. Physical function in men and women with cancer. Effects of anemia and conditioning. Oncology (Williston Park) 2002; 16: 109-115.

[17] Germain P, Guell A, Marini JF. Muscle strength during bedrest with and without muscle exercise as a countermeasure. Eur J Appl Physiol Occup Physiol 1995; 71: 342-348.

[18] al Majid S, McCarthy DO. Cancer-induced fatigue and skeletal muscle wasting: the role of exercise. Biol Res Nurs 2001; 2: 186-197.

[19] Kallich JD, Tchekmedyian NS, Damiano AM, Shi J, Black JT, Erder MH. Psychological outcomes associated with anemia-related fatigue in cancer patients. Oncology (Williston Park) 2002; 16: 117-124.


[21] Stone P. The measurement, causes and effective management of cancer-related fatigue. Int J Palliat Nurs 2002; 8: 120-128.

[22] Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment and management of cancer-related fatigue in adults. Lancet 2003; 362: 640-650.




8�




[27] Kolden GG, Strauman TJ, Ward A, Kuta J, Woods TE, Schneider KL, Heerey E, Sanborn L, Burt C, Millbrandt L, Kalin NH, Stewart JA, Mullen B. A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits. Psychooncology 2002; 11: 447-456.


[29] Courneya KS, Mackey M, Jones LW. Coping with Cancer: can exercise help? Physician Sportsmed 2000; 28: 49-51.




[33] Smets EM, Visser MR, Garssen B, Frijda NH, Oosterveld P, de Haes JC. Understanding the level of fatigue in cancer patients undergoing radiotherapy. J Psychosom Res 1998; 45: 277-293.


[35] McCartney N, McKelvie RS, Haslam DR, Jones NL. Usefulness of weightlifting training in improving strength and maximal power output in coronary artery disease. Am J Cardiol 1991; 67: 939-945.


[37] Hagger MS, Orbell S. A meta-analytic review of the common-sense model of illness representations. Psychol Health 2003; 18: 141-184.





[42] Bosscher RJ, Smit JH. Confirmatory factor analysis of the General Self-Efficacy Scale. Behav Res Ther 1998; 36: 339-343.

[43] Cohen J. Statistical power analysis for the behavior sciences. New York: Academic Press; 1977.

[44] Middel B, Stewart R, Bouma J, Van Sonderen E, van den Heuvel WJ. How to validate clinically important change in health-related functional status. Is the magnitude of the effect size consistently related to magnitude of change as indicated by a global question rating? J Eval Clin Pract 2001; 7: 399-410.

[45] Chatterjee S, Hadi AS, Price B. Regression Analysis by Example. New York: Wiley; 2000.


[47] Cook TD, Cambell DT. Quasi experimentation: Design and analyses issues for field settings. Boston: Houghton Mifflin Company; 1979: 52.

[48] Aapro MS, Cella D, Zagari M. Age, anemia, and fatigue. Semin Oncol 2002; 29: 55-59.

[49] Cella D, Lai JS, Chang CH, Peterman A, Slavin M. Fatigue in cancer patients compared with fatigue in the general United States population. Cancer 2002; 94: 528-538.


[50] Servaes P, Prins J, Verhagen S, Bleijenberg G. Fatigue after breast cancer and in chronic fatigue syndrome: similarities and differences. J Psychosom Res 2002; 52: 453-459.

[51] Hwang SS, Chang VT, Rue M, Kasimis B. Multidimensional independent predictors of cancer-related fatigue. J Pain Symptom Manage 2003; 26: 604-614.

[52] Bartsch HH, Weis J, Moser MT. Cancer-related fatigue in patients attending oncological rehabilitation programs: prevalence, patterns and predictors. Onkologie 2003; 26: 51-57.

[53] Schwartz AL. Exercise and weight gain in breast cancer patients receiving chemotherapy. Cancer Pract 2000; 8: 231-237.

[54] Sadaria K, Bohannon R. The 6-minute Walk Test: A brief review of literature. Clin Exerc Physiol 2001; 3: 127-132.

[55] Rowland TW. Developmental exercise physiology., 2 ed. Champaign (IL), USA: Human Kinetics; 1996.

[56] Marks R. Efficacy theory and its utility in arthritis rehabilitation: review and recommendations. Disabil Rehabil 2001; 23: 271-280.


8�

6 Thedevelopmentofanevidence-based

physicalself-managementrehabilitation

programmeforcancersurvivors

Ellen van Weert, Josette E.H.M. Hoekstra-Weebers, Anne M. May, Irene Korstjens, Wynand J.G. Ros, Cees P. van der SchansSubmitted

AbstractObjective The present paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems were described, including decreased aerobic capacity, decreased muscle strength, fatigue and impaired role physical functioning. The study aimed to identify the optimal content for an exercise programme that addresses the four physical problems, based on the highest level of evidence available. The study further aimed to review the evidence available on the delivery of the programmes. The last goal was to develop a programme in which content and delivery are based on the best available evidence. Methods Literature searches (pubmed and medline, to July 2006) on content looked for evidence on the efficacy of exercise on aerobic capacity, muscle strength, fatigue and impaired role physical functioning. Literature searches on delivery looked for individual and/or group approaches, local fitness and/or sport programmes, self-management and/or self-efficacy enhancing techniques in relation to outcome, adherence and/or adoption of a physically active lifestyle. Results Evidence on the effectiveness of exercise varies and increases when moving from muscle strength (level of rct), fatigue and physical role functioning to aerobic capacity (all level of meta-analyses). No evidence was found that differentiated between individual and group approaches, or between muscle strength training programmes and sports. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour. Conclusion Evidence supports the positive effects of exercise on physiological, physical and psychological outcomes during and after completion of cancer treatment. Evidence supports the positive effects of self-management programmes and self-efficacy enhancing programmes on health outcomes, exercise adherence and later exercise behaviour.Practice Implications The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. Potential advantages of the programme are: a) tailored physical training towards focusing on the patient’s established problems; b) delivery of the training as a self-management programme that might have beneficial effects on health outcome, exercise adherence and a long-term physically active lifestyle.


Physical self-management rehabilitation programme

8�

Introduction

Due to improvements in diagnostics and treatment regimes, the survival rate of cancer patients is increasing. As a result, cancer is now considered to be a chronic disease and the attention paid to the quality of life of patients after cancer treatment is increasing. Approximately 30% of all survivors report a decreased quality of life due to physical and psychosocial problems following cancer and consequent treatment, and indicate that they need professional support [1] such as rehabilitation.

Physical training seems to be essential in the rehabilitation of cancer survivors. This is the case because, firstly, psychosocial interventions are less likely to improve physical and functional problems [2]. Secondly, physical training is reported to improve quality of life beyond the benefits of psychotherapy [3]. Thirdly, improvement in physical functioning following a rehabilitation programme is associated with a simultaneous decrease in fatigue [4]. Lastly, very recent studies reveal that increased physical activity after a cancer diagnosis reduces the risk of cancer recurrence and mortality [5,6].

Physical training should be aimed at reducing long-term physical problems. Physical side effects that occur during cancer treatment, such as anaemia, pain, nausea, vomiting and sleep disorders, may affect daily functioning and quality of life during that phase. Other physical and functional problems persist over time, including a decreased oxygen uptake, reduced muscle strength, fatigue and limited physical role functioning, and these continue to affect cancer patients’ quality of life. Physical exercise has the potential to overcome such long-lasting problems [4,7,8].

These four problems, which are further discussed in Box 1, are to some extent interrelated, but appear to be empirically different. For example, aerobic capacity seems to be no different in Hodgkin’s disease patients with or without chronic fatigue and it is therefore thought that aerobic capacity does not play a major role in the pathophysiology of fatigue [9]. Therefore, aerobic capacity and fatigue would require different physical training modalities. Although physical training programmes are commonly reported to be effective in improving aerobic exercise capacity and muscle strength, and in reducing fatigue and ameliorating physical role functioning [2,10,11], to date it is still unclear what type of exercise is most optimal in addressing each of the four defined problems. The optimal intervention modality, intensity, timing and duration are still unknown, despite the fact that there is growing evidence for the positive effects of physical training [12,13]. Standardized guidelines about the specific interventions are currently available for healthy individuals [14] but lacking for cancer patients. Until now, various programmes consisting of aerobic training, muscle strength training and/or flexibility training have been described for cancer patients, all with varying content [15].

In addition to the content, the efficacy of a physical training programme may depend on the delivery. However, no information is available concerning the best way to deliver a training programme for cancer patients. In that regard, the following approaches should be considered: an individual versus a group approach; a programme consisting of local exercise training or integrated exercises such as sport; and a traditional versus a self-management approach.

The choice of an individual or a group approach may depend on a number of issues. The efficacy of exercise may be higher if the training is personalized. However, the question could be asked whether personalized training should automatically imply individual training or whether a group approach is also applicable. A group approach might be preferred because


8�


peer contact provides opportunities for social support [16], social comparison [17] and modelling [18], validation, reappraisal and finding meaning [19]. Vicarious experiences among peers can also have positive effects on self-efficacy [20] which may in turn mediate physical [21] and mental health [22], and importantly, behaviour associated with physical activity [23]. In addition, social support processes seem to engender changes in lifestyle [24]. Finally, group programmes might be interesting because of cost-effectiveness.

Another point concerning delivery is the ‘transfer’ of local exercise training into daily activities. For example, muscle strength training may have significant positive effects on muscle strength and endurance and on physical functioning, but it is known that without the integration of functional training, improved muscle strength does not consistently result in improved functional task performance [25]. To undertake most daily activities an individual must be able to perform basic movements and also combinations of these in order to accomplish more complex tasks [26]. Sports such as indoor hockey, curling and badminton provide training in such complex tasks. Sports are often included in rehabilitation programmes to facilitate their integration into daily life, as it is more difficult to become physically active when sedentary [27]. Enjoyment of sport has also been reported to be a mediator for the adoption of an active lifestyle [28].

Finally, most physical training programmes are delivered in a traditional and therapist-oriented way, which means that the therapist prescribes the intervention and offers information and technical skills, while the patients follow these instructions [29]. However, managing the consequences of a disease such as cancer may require a patient-oriented intervention, characterized by active participation, taking personal responsibility and changing lifestyle [29,30]. Patient-oriented interventions such as self-management may include monitoring and managing symptoms, adherence to treatment regimes, maintaining a healthy lifestyle and managing the impact of the illness on daily functioning [30]. Self-management generally consists of six processes: goal selection, information collection through monitoring, information processing and evaluation (in relation to norms), decision-making, action and self-reflection [31]. In self-management, self-efficacy − which is a patient’s own belief in his or her ability to perform specific actions or change specific thinking patterns and, thus, manage and minimize the symptoms − is believed to be of primary importance [20,29]. Self-management may have more beneficial effects than traditional interventions.

Self-management programmes may also be relevant to exercise adherence and for the adoption of a physically active lifestyle after the completion of a physical training programme [32]. A good level of adherence to an exercise regime may be a prerequisite for the effectiveness of exercise because a certain combination of duration, intensity and frequency per week is needed to improve aerobic fitness [14]. Prior studies reveal that adherence to and compliance with physical training programmes ranges from 52−89% [33], and underline the need to promote adherence to physical training regimes. It is important that patients adopt a physically active lifestyle after the prescribed training programme because low activity levels, which appear to be common in cancer patients [34], are associated with morbidity and mortality. Low level physical activity might also be considered as a maintaining cause for several of the physical problems discussed above, which means that low activity levels may induce a vicious circle of reduced oxygen capacity, lower muscle strength and more fatigue [35]. To improve exercise adherence and encourage the adoption of a physically active lifestyle, a structured exercise programme combined with theory-based behavioural interventions has been recommended [33].



8�

Therefore, theoretical frameworks such as self-management [31] based on the self-regulation of behaviour [36], and self-efficacy stimulating techniques [20] based on social cognitive theory, may be relevant to exercise adherence and adoption, in addition to traditional physical training.

The aim of the present article is to describe the development of an exercise intervention that is designed to improve the four most relevant cancer-related physical problems (Box 1). Firstly, the literature will be reviewed for evidence regarding the content (such as modality and intensity) of the programme for each defined problem, and secondly for the evidence available regarding the three issues concerning delivery discussed above. Lastly, a programme will be presented in which content and delivery are based on the best available evidence.

Box 1 The most important and long-lasting physical problems in cancer patients

A decreased maximal oxygen uptake (VO2max<20 ml/kg.min) is reported in about 13−30% of survivors after Hodgkin’s disease [37;38] and non-Hodgkin’s disease patients [38]. The physical performance of 70% of patients with solid tumours and haematological cancers is classified as ‘poor’ (50−54% of reference VO2max) or ‘very poor’ (50% of reference VO2max) [39]. A decreased oxygen uptake or aerobic capacity may reflect the difficulty the cardio-respiratory system has in delivering oxygen throughout the body and/or problems of the musculoskeletal system in extracting oxygen from the blood during aerobic exercise. Both radiotherapy and chemotherapy appear to have negative side effects on the cardio-respiratory system [7,40] and on the musculoskeletal system [35]. Significant muscle wasting and consequent decreased muscle strength [41] affects about 50% of persons with cancer [35;42-44]. Although the exact mechanisms are unclear, it is generally accepted that cancer-induced muscle wasting is a multifactorial process that is mediated by factors such as reduced energy intake, proinflammatory cytokines [9;44], accelerated muscle protein degradation and bed rest [8;35].

About 61-99% of cancer patients experience fatigue during and following cancer treatment [45-47]. Cancer-related fatigue, which is multidimensional in nature [48], might be caused by cancer-induced anaemia and tumour necrosis, but is also attributed to a reduced activity pattern as a consequence of prescribed bed rest [45,46]. Fatigue is associated with psychosocial problems such as anxiety and depression [49,50], reduced self-efficacy [51], sleep disorders, distress [45] and difficulty coping [44]. However, whether fatigue is a cause or a consequence of these factors is still unknown [48].

Many cancer patients report reduced physical and reduced role functioning due to physical problems [47]. Physical performance limitations, e.g. climbing stairs, walking short and long distances [52], were found to be significantly more prevalent among recent (54%) and long-term (53%) cancer survivors when compared to subjects with no cancer history (21%) [53]. Limitations in role functioning due to physical problems, such as reduced participation in social and sport activities [43,47], are reported in about 30% of both short and long-term cancer survivors, compared to 13% of subjects with no cancer history [53].


8�


Methods

Our first aim was to review the evidence regarding the content of programmes that address the four physical problems mentioned in Box 1, based on the highest level of evidence available. A computerized search in pubmed and medline (to July 2006) was conducted using the Mesh terms ‘cancer’, ‘aerobic’ and ‘exercise capacity’. Additional searches were conducted using ‘cancer’, and ‘muscle strength’ and/or ‘resistance training’, and ‘cancer’ ‘exercise’ and ‘fatigue’. ‘Physical role functioning’ is not a Mesh term but this broad term includes physical abilities that range from simple mobility to the engagement in complex activities that require adaptation to an environment. Thus, it includes objective and perceived mobility and participation in daily activities, which are important quality of life domains. Therefore, a search was conducted with ‘cancer’, ‘exercise’ and ‘quality of life’, and only the relevant physical domains were taken into account. All searches were limited to ‘meta-analyses/systematic review’ and ‘English language’. When no meta-analyses/systematic reviews were found, the same Mesh terms were used and combined with ‘Randomized Controlled Trials’(RCTs). When no RCTs were found, the same Mesh terms were used and combined with ‘Clinical Trials’. Studies that focused only on exercise were included, while physical interventions combined with other interventions (such as diet or psychotherapy) were excluded. Controlled studies identified from meta-analyses that focused on the problems discussed above were taken into account. Furthermore, additional searches were performed to include controlled studies that were published after the RCTs included in the meta-analyses. If no studies of cancer patients were available, we searched for studies of other patient groups with chronic illness. We reviewed the evidence and analysed the content of the various programmes. If pre-intervention and post-intervention data were reported, we computed changes which were expressed as percentages of change from the baseline.

Our second aim was to review the evidence available on the delivery of the programme. A search in pubmed and medline (to July 2006) was conducted using the following terms related to delivery: ‘individual and/or group exercise’, ‘local exercise/fitness training and/or sports’, ‘self-management and/or self-efficacy’ and ‘adherence and/or physically active lifestyle’, all combined with ‘exercise and cancer’. All searches were limited to ‘meta-analyses/systematic review’ and ‘English language’. When no meta-analyses were found, additional searches were performed with the same terms combined with ‘Randomized Controlled Trials’ and ‘Clinical Trials’. If no studies were available for cancer patients, supplementary searches were performed using the same terms combined with other patient populations and/or the general population.

Results

Evidence concerning the contentFour meta-analyses [12,54-56] and two systematic reviews [13,57] on the effect of exercise and aerobic capacity, fatigue and quality of life in cancer patients were found. The meta-analyses and systematic reviews and additional controlled studies published after the meta-analyses revealed twelve relevant studies on exercise capacity [7,58-68], fourteen on fatigue [58,60,62,68-78] and nineteen on physical quality of life [58-60,63,64,67-69,71-81]. No meta-analyses or systematic reviews were found but nine randomized controlled studies reported on the effect of exercise training on muscle strength [63,66,77,79,80,82-85]. The controlled studies found are presented in Table 1.



88

Aerobic exercise capacity. The evidence for improvement in aerobic exercise capacity or oxygen uptake was found on the level of meta-analyses [56], with moderate weighted mean effect sizes (wmes) of .51 during and .65 after cancer treatment [12]. Further analyses of studies included in Table 1 revealed fairly consistent effects, which means that all but one showed positive effects on aerobic capacity. Due to variation in study populations, design and timing (during/after cancer treatment) and the relatively small number of studies, it was not possible to determine differences in effectiveness between the various programmes. With respect to the content it appeared that the programmes offered were quite similar. All programmes consisted of aerobic exercise modes such as cycling and walking [7,58-62, 64,65,67,68], and two programmes combined cardiovascular training with muscle resistance training [63,66]. Most programmes used a moderate to high aerobic training intensity with a training heart rate at 50-80% of the maximal heart rate (mhr), at 50−80% of VO2max or at 50−70% of the heart rate reserve (hrr), in line with the ascm guidelines [14]. In most cases, a training volume of 10-30 minutes was used and frequency varies between three times weekly to daily.

Muscle strength. No meta-analyses or systematic reviews were found on the effectiveness of exercise on muscle strength in cancer patients. However, a systematic review that reported on the effect of progressive resistance exercise (pre) on muscle strength in patients suffering from various other chronic diseases revealed moderate to large effect sizes [86]. For cancer patients, nine controlled studies (Table 1) were found that reported beneficial effects of aerobic exercise [83,85], pre [77,80,84] or pre in combination with aerobic exercise [63,66,79,82] on muscle strength. Because pre-intervention and post-intervention data were not available in five out of nine studies, it is not possible to determine differences in the effectiveness of the programmes. With respect to the content of the programmes it appeared that aerobic exercise consisted of walking or cycling with moderate to high intensity. pre mostly consisted of the exercise of large muscle groups of the upper and lower extremities. Although the intensity of pre should be based on the overload principle [14], weight settings were not precisely specified in most studies and varied from a fixed range of weights to the ability to lift weights until failure occurred in 8-20 repetitions. Only one study specified the intensity as moderate to high, based on 60-70% of 1-Repetition Maximum (1-rm) [77]. pre was commonly performed in two to three sets with 8-12 repetitions per set. The majority of the sessions lasted 20-40 minutes with a frequency of two to four times weekly.

Fatigue. The evidence for reduction in fatigue was found on the level of meta-analyses [56] with a small weighted effect size of .11 [54], but a zero effect size was also reported [55]. This inconsistency and the rather small effect size might be attributed to the variety of programmes aimed at the reduction of fatigue. Regarding the content (Table 1), aerobic programmes were described with intensity varying from moderate to high (at 50−80% mhr, at 50−80%VO

2max or at 50−70%hhr) [58,60,69-72,75-78], to programmes that were

self-paced [73,74] as well as programmes that were based on a ‘rate perceived exertion’ of 13-15 on the Borg Scale [62,68,87]. The latter two might be less intensive and aimed less at improvement of aerobic capacity than the first programmes. However, based on the studies included, no differences in effectiveness could be determined, although a frequency of at least three times a week seemed to be associated with a positive effect on fatigue. In addition, one study reported positive effects of progressive resistance exercise on fatigue [77]. One study comparing aerobic training combined with pre to placebo reported no significant differences in fatigue between the groups [72]. One study comparing aerobic


8�


exercise and relaxation reported equal beneficial effects on fatigue without differences between the groups [62]. The last aerobic training study reported no beneficial effect on fatigue, despite an improvement in VO

2max, and attributed this to an overly high training

intensity (60−70% mhr)[68]. Thus, regarding fatigue, aerobic exercise may be beneficial but a high intensity does not seem necessary or may even have negative effects. The results may support the need for further research. Perhaps the multidimensional nature of fatigue requires other approaches, which is supported by a systematic review of the management of chronic fatigue syndrome that concluded that graded exercise therapy and cognitive behavioural therapy showed the most promising results [88].

Quality of life/Physical role functioning. The evidence for the improvement of quality of life in cancer patients was found on the level of meta-analyses [56] with a weighted effect size of .30 [12,54]. These effect sizes may be due to inconsistent findings across the various studies and/or variety in the content of the programmes. Table 1 shows that both aerobic exercise programmes with a moderate training intensity [59,60,64,67,75-78] and self-paced programmes [73,74] were effective in increasing physical role functioning. Another study, using low and moderate aerobic exercise, found beneficial effects on physical wellbeing, despite a lack of effect on aerobic capacity [58]. One study found that stretching exercises with no resistance training may be feasible for improving physical well-being [71]. Interestingly, one aerobic training study reported that despite physiological improvement, no beneficial effect on quality of life, including physical functioning, occurred within the exercise group [68], and this was attributed to an overly high training intensity. Furthermore, programmes with a combination of aerobic exercise and pre [63,69,79,81] or pre alone [77,80] also showed beneficial effects on physical role functioning, except one [72]. Thus, with respect to physical functioning, aerobic exercise and/or pre may have beneficial effects. However, there are inconsistencies in the intensity of the programmes, varying from low to moderate intensity, and one study argues against a high intensity. Lastly and importantly, improvement in physical function may be independent of an increase in aerobic capacity.

With respect to all the problems defined and the studies included in Table 1, some overall findings were determined. In general, many programmes were offered under supervision or at home, and many used exercise logs. Both cycling and walking programmes were used, of which cycling may be the safest as it is a non-weight-bearing exercise [14]. The length of training programmes varied between three weeks and six months. Most studies presented used breast cancer patients, but positive findings were also found in patients with other types of cancer, such as leukaemia, stomach, prostate, colorectal and ovarian [15]. This may indicate that exercise is effective in a variety of cancer types. Furthermore, exercise is shown to be effective during and after completion of cancer treatment − both preventing deterioration and improving physical functioning.

Summary and conclusion concerning the content Although several studies were limited, using a small sample size (Table 1) and having insufficient reports on the methodological criteria, many studies support the positive effects of exercise on physiological, physical and psychological outcomes during and after completion of cancer treatment. However, the level of evidence on the effectiveness of exercise on the reduction of physical problems varies according to the defined problem, and evidence increases when moving from muscle strength, fatigue and physical role functioning to aerobic capacity.



�0

Concerning the content, two modalities of exercise are commonly described: aerobic exercise training and pre. Aerobic training seems to have beneficial effects on aerobic capacity, fatigue and physical role functioning. pre alone or combined with aerobic training may have a beneficial effect on muscle strength, fatigue and physical role functioning. Regarding the intensity, training programmes with a moderate to high intensity seem to be effective in improving aerobic capacity and muscle strength. Concerning reduction of fatigue and the improvement of physical role functioning, findings are not consistent and some argue against a high training intensity. Furthermore, aerobic training (cycling or walking) alone or combined with pre seems to be effective and applicable to all defined problems.

Evidence concerning the delivery Individual versus group programmes. No meta-analyses or RCTs were found that focused on differences in effect between individual or group exercise programmes. Literature on interventions other than physical exercise is divided regarding the relative merits of individual versus group therapy. One meta-analysis on the effect of cognitive behavioural therapy in breast cancer patients reported that individual treatment approaches had significantly larger effects on distress (p=0.04), but not on pain (p > 0.05) [89], than did group approaches. Another meta-analysis that examined the effect of psychological interventions on anxiety and depression in breast cancer patients concluded that group therapy is at least as effective as individual therapy [90]. A meta-analysis of self-management in diabetes showed that lifestyle interventions were generally more effective in group settings, whereas skills teaching was effective in individual and group settings [91]. In sum, evidence concerning the effects of individual as compared to group-based approaches on exercise is lacking, but most results in other interventions point out that conducting group programmes is feasible and effective. Based on the RCTs on exercise in cancer patients (Table 1), it is not possible to draw conclusions about the efficacy of group versus individual exercise because most studies do not specify the intervention as such. Most studies specify their intervention as home-based, which is most likely to be individual, or as supervised, which can be tailored to either the individual or a group. Two RCTs reported on the beneficial effects of a group exercise programme in cancer patients [62,69], and one of these considered that the effects of the programme may be attributed to the presence of support provided by peers [69]. An rct comparing a group exercise programme and individual physiotherapy for back pain reported no significant differences in efficacy but suggested lower costs for the group programme [92].

Local exercise/fitness training versus sports. No meta-analyses or RCTs were found that focused on comparing the effectiveness of local exercise/fitness and sport in cancer patients or in other patient groups. An rct on healthy elderly women reported that functional-task exercises were more effective than progressive muscle strength training at improving functional task performance [25]. RCTs in muscle strength training in cancer patients (Table 1) showed beneficial effects on muscle strength and on physical functioning. Regarding sports, an rct on rehabilitation programmes for patients who suffered a stroke or had neurological or back disorders reported beneficial physiological alterations after sport such as cycling, tennis and jogging compared to the control group [27]. A Cochrane review reported that playing sport might have a favourable effect on physical activity levels and physical health, help develop sport-specific skills, provide a sense of achievement and empowerment, develop self-esteem and teach self-discipline [93].


��

Self-management/self-efficacy interventions and effectiveness, adherence to exercise, and adoption of physically active lifestyle. A search on the effectiveness of self-management and self-efficacy in cancer patients revealed one meta-analysis. This meta-analysis of social cognitive theory, including components addressing self-efficacy, expectations and self-regulation, showed that psychosocial interventions including these components had greater effects on quality of life in cancer patients than interventions that involved fewer or no social cognitive theory components [94]. Additional searches on the effectiveness of self-management approaches as compared to controls and/or to routine care in other chronic diseases revealed eleven relevant meta-analyses which support the notion that self-management programmes are beneficial in controlling and preventing chronic disease complications. Self-management programmes appeared to have beneficial effects on health outcomes in diabetes [95-100], hypertension [95,101], cardiac [102], asthma/copd [98,103,104] and arthritis [105] patients. However, no effect of self-management was reported in meta-analyses of osteoarthritis [95] and arthritis [98]. Most evidence suggests that self-management programmes and self-efficacy enhancing techniques are more effective compared to no intervention, and some evidence suggests that self-management is more effective compared to traditional care programmes.

Adherence to and efficacy of exercise showed a linear dose response relationship; the higher the adherence the greater the efficacy of exercise [106]. It has been reported that two weekly sessions are needed to maintain and three to improve aerobic fitness [14]. Because adherence and compliance to physical training ranges from 52-89% [33], in traditional interventions some experiments have been reported concerning variations in exercise prescription. One rct compared adherence to aerobic exercise prescription with two levels of intensity (45-55% and 65-75% hrr) crossed with two levels of frequency (3-4 versus 5-7 days per week). A higher frequency seemed associated with an accumulation of exercise without a decline in adherence, whereas prescribing a higher intensity decreased adherence and resulted in the completion of fewer exercises [107]. Regarding adherence in weight training, a twice-weekly weight training programme under supervision appeared to be behaviourally feasible and effective in the short and long term [108]. In addition to exercise prescription, self-management programmes or self-efficacy enhancing techniques may also be relevant for adherence to and adoption of exercise. Self-management theory considers internal motivation as more effective for lifestyle change than external motivation (that is, ‘changing to please the physician’) [29]. The importance of self-efficacy for initiating and maintaining regular physical activity derives from social cognitive theory [20] and underlines the fact that efficacy beliefs are critical to the success in short-term structured exercise programmes due to their effect of enhancing adherence [109].

No meta-analyses were found on self-management/self-efficacy interventions related to exercise adherence and the adoption of a physically active lifestyle in cancer patients. One meta-analysis of cardiac patients revealed that self-management strategies were promising in improving cardiac rehabilitation uptake, adherence and/or lifestyle changes [102]. It was noted that performance self-efficacy seems to be more important in the early adoption phase of a clinical exercise programme, whereas self-regulatory skills are more important in the maintenance phase of exercise. This is in line with two meta-analyses of healthy elderly people, revealing that physical activity may lead to mastery experiences that can increase the level of self-efficacy [110], which may in turn have a moderating and positive effect on physical activity [28]. A third meta-analysis using the Trans-Theoretical model (ttm) of behaviour change revealed that changes in self-efficacy were moderately consistent with the predictions of ttm in the physical activity domain. Thus, self-efficacy



��

was associated with exercise behaviour [111]. In colorectal cancer patients, an rct reported that programmed exercise and perceived success − which can elevate levels of self-efficacy − were predictors of post-programme exercise [112]. Two RCTs also found that self-efficacy was a mediator of later physical activity in cardiac patients [113] and healthy elderly people, and the latter study additionally reported that two dimensions of self-efficacy were important for exercise adherence: the level of self-efficacy at baseline and the amount of change in self-efficacy [23].

Because behavioural changes, such as developing a physically active lifestyle, may require that adequate perceptions concerning the illness already exist, we performed an additional search on illness perceptions. The notion of illness perceptions is derived from the self-regulation theory that proposes that individuals construct schematic representations of illness [114]. Such representations or perceptions include five related but conceptually and empirically distinct components: identity (label and symptoms), timeline, cause consequences and curability/controllability. One meta-analysis of diverse patient populations revealed that a stronger perception of identity, timeline and consequences was associated with passive coping and lower functioning [115]. In contrast, patients who perceived high controllability seemed to have more active coping styles and better functioning than those with perceived low controllability [115]. Furthermore, several RCTs reported the beneficial effects of therapeutically manipulated illness perceptions on coping and quality of life in patients with myocardial infarction and cardiac surgery patients [116].

Conclusion concerning the deliveryRegarding the delivery, no evidence was found that differentiated between individual and group approaches, or between muscle strength training programmes and sports. There was some evidence that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

Presentation of the programme Guided by the conclusions concerning the content and the delivery we developed a physical training programme. In the present section we will describe the programme in general terms. Appendix I describes the programme in more detail, including information on the treatment elements during the various phases of the programme.

Based on the conclusions regarding the content of the programme we developed a supervised exercise programme, consisting of four separate modules tailored to the individual patient’s most prominent problem. These modules are formulated in terms of individual goals: 1) improvement of aerobic capacity, 2) improvement of muscle strength, 3) reduction of fatigue, and 4) improvement of role functioning. The four modules contain two personalized treatment modalities including aerobic exercise training and pre, which differ in intensity depending on the problem. The intensity of the programme is moderate to high in modules 1 and 2 and low to moderate in modules 3 and 4. The intensity of aerobic exercise and the pre is prescribed on the basis of the mhr and the 1-rm in line with the ascm guidelines [14]. With respect to aerobic exercise training, we chose a cycling programme because it is non-weight-bearing and, therefore, the safest exercise mode. pre includes various exercises for the large muscle groups of the lower and upper extremities using machine resistance and/or free weights. Training sessions are 20-30 minutes



��

duration for the aerobic cycling programme and 10−20 minutes duration for the pre. The entire programme takes 12 weeks.

Based on the results regarding the delivery we adjusted the programme along the following lines. Acknowledging the value of personalized exercise programmes, recognizing the potential advantages of group therapy, such as social support and modelling, and based on considerations of cost-effectiveness, we developed the physical training programme as a group programme in which the individual is able to work towards his or her own goals. Thus, the group as a whole performs aerobic exercise and progressive muscle strength training, but the individual exercise modules are tailored to individual problems and are therefore prescribed individually. Based on the potential advantages of sport we included group sports in addition to individual aerobic exercise training and progressive resistance exercises.

Regarding the results on adherence and exercise prescription, we chose to deliver the cycling exercise programme and the pre twice a week under supervision, and extended this with an aerobic home-based walking programme that allows for an increase in the frequency from once a week to daily. In addition, due to the evidence suggesting that self-management programmes and self-efficacy enhancing programmes have beneficial effects on functioning in chronic diseases, on quality of life in cancer patients, and on exercise adherence and later exercise behaviour, we integrated self-management and self-efficacy enhancing techniques into the programme. Because self-efficacy is enhanced through mastery experiences (perceived success in fitness), vicarious experiences (modelling), verbal persuasion (therapist) and physiological feedback (such as a decreased heart rate) [20], these sources are systemically manipulated during the aerobic exercise training, the pre and the sports undertaken. Self-management is integrated into the programme by including the six processes of self-management [31] in the physical exercise programme and sport. These were goal setting, which seems to fulfil a crucial role in rehabilitation [117] and is an important determinant of actual performance, motivation for change, and improving self-efficacy in specific situations [94,118]; followed by information collection through self-monitoring (for example, checking heart rate, scoring Borg Scale and Visual Analogue Scale); information processing and evaluation, involving detection of change, and evaluation of information against norms such as heart rate or Borg Scale; decision-making action, the actual performance of self-management skills such as exercise; and self-reaction, the evaluation of performance by providing feedback [31]. In addition, we included attention to illness perceptions during the programme because rational perceptions were considered to be a prerequisite for active coping and behavioural change.

Discussion

The present paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems were described, including decreased aerobic capacity, decreased muscle strength, fatigue and impaired role functioning, all probably the result of low physical activity. The paper aimed to identify the optimal content for an exercise programme that addresses the four physical problems, based on the highest level of evidence available. Although several studies were limited, using a small sample size and having insufficient reports on the methodological criteria, many studies support the positive effects of exercise on physiological, physical



��

and psychological outcomes during and after completion of cancer treatment. However, the level of evidence on the effectiveness of exercise on the reduction of physical problems varies according to the defined problem, and evidence increases when moving from muscle strength (level of rct), fatigue and physical role functioning to aerobic capacity (all level of meta-analyses). The paper further aimed to review the evidence available on the delivery of the programmes. The study revealed no evidence that differentiated between individual and group approaches, or between muscle strength training programmes and sports. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

Conclusion Evidence supports the positive effects of exercise on physiological, physical and psychological outcomes during and after completion of cancer treatment. Self-management programmes and self-efficacy enhancing programmes seem to have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour.

Practice Implications The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. Potential advantages of the programme are: a) tailored physical training towards focusing on the patient’s established problems; b) delivery of the training as a self-management programme that might have beneficial effects on outcome, adherence and a long-term physically active lifestyle. A randomized controlled trial (the Oncorev study) is currently ongoing and designed to examine the effectiveness of the physical training programme on exercise capacity, muscle force, fatigue and physical role functioning.

AcknowledgementsThis study was supported by grants from the Dutch Cancer Society (uu-2003-2782) and Maastricht University. We would like to acknowledge Prof. B. van der Borne (Department of Health Education and Promotion, Maastricht University) and Prof. Rutger W. Trijsburg (Department of Medical Psychology and Psychotherapy, Erasmus Medical Center Rotterdam) for their useful comments on this manuscript.



��


AppendixI:Adetaileddescriptionoftheprogramme:phasesandtreatmentingredients

The self-management and tailor-made physical training programme is preceded by a physical assessment, which defines a patient’s problems and needs by assessing exercise capacity (Symptom Limited Bicycle Ergometry, slbe) [119], testing muscle strength (1-rm test) [120] and anamnesis. The slbe is considered to be the most precise measure of cardio-respiratory fitness and is recommended for use in order to determine a patient’s objective or subjective reduction in exercise capacity and prescribe the intensity of the aerobic bicycle training programme [14]. An 1-rm test is performed to determine maximal muscle strength as an indicator of the intensity of the progressive resistance exercise [14]. Additional information about the patient’s reduction in exercise capacity, functioning and activity pattern is obtained by an extended anamnesis, to establish whether and to what extent a patient suffers from the following: decreased aerobic capacity, reduced muscle strength, fatigue or limited physical role functioning. The anamnesis further includes exploration of the presence of irrational illness perceptions [115], and the patient’s expectations and goals [117] according to the self-management approach.

Before the exercise programme starts, an education session is held to acquaint the patient with peers, therapists and the therapeutic surroundings. Patients are informed about the programme’s rationale of physical training, self-management processes [48] and illness perceptions. Patients are told that physical training has the potential to break through the vicious circle of physical cancer-related problems [15], and that self-management considers the patient’s responsibility to be central, whereas the role of the therapist is that of a guide. Patients have to commit themselves to this approach [31] and are invited to define their self-management goals as a necessary condition for behavioural change [30]. Finally, it is explained to the patient that rational illness perceptions [121] are the prerequisite for adequate and active self-management behaviour, and they are asked to explore their perceptions [115].

In the tailoring phase, the intervention is divided into an Individual Physical Training (ipt) programme and a group-oriented Sports and Games (sgp) programme, both supervised by a physical therapist. The ipt includes four individual modules tailored to individual problems and consists of improvement of 1) oxygen uptake/aerobic capacity, 2) muscle strength, 3) fatigue, and 4) physical role functioning. The four modules all use aerobic bicycle exercise training and progressive resistance training, which differ in intensity. The aerobic training is based on the maximal heart rate reached during the sleb test. The training heart rate (thr) is computed by using the Karvonen formulae [122]. Progressive resistance muscle training of the trunk and the lower and upper extremities are performed and is based on the individual 1-rm [123].

The first four weeks of the ipt are used to verify the patient’s main problem defined at intake and their physiological response to training [14] in order to establish the most optimal training module. The aerobic training is performed at a thr of HRrest + 30-50% (HRmax−HRrest) over 20 minutes. Progressive resistance muscle training starts at 30% of the 1-rm, with a frequency of 10−20 repetitions over three series. Illness perceptions are individually explored and their effect on active behaviour is generally discussed in the group. Two processes of self-management are practiced, including goal setting [94,124]and monitoring [31]. Goals should be self-generated and positively formulated, otherwise motivation will fade [30]. Therefore, patients are invited to set specific,



��

measurable, adequate, realistic and time-related (smart) goals. Monitoring includes measuring the heart rate, scoring the Borg Scale for fatigue and dyspnoea before and following exercise, and using an exercise log. Successful performance accomplishment as a source of self-efficacy [20,125] is achieved by a low training intensity in the first four weeks, providing the opportunity for all patients to perceive success.

During weeks five to twelve aerobic bicycle exercise training continues at a thr of HRrest + 50-80% (HRmax−HRrest). The progressive resistance training increases from 30% of the 1-rm by 5−10% up to 50-65% of 1-rm. Intensity and progression of both training modalities differ between modules and are moderate to high in modules 1 and 2, and mild to moderate in modules 3 and 4. Training sessions are 30-45 minutes long with 20-30 minutes of aerobic training and 10-15 minutes of muscle resistance training. Patients are advised to have at least one additional aerobic training session a week, using a home-based walking programme. The walking programme [126] starts in week six with 5−10 minutes walking, which increases to 20 minutes by the end of rehabilitation. Furthermore, all six processes of self-management are included in each module. Thus, in addition to goal setting [124,127] and monitoring, patients evaluate their scores against the norm provided [31], and undertake action in the form of physical training applied to their problem [15]. Finally, self-reflection [31] is accrued by visual and oral feedback, such as graphics combined with reflective questions by the physical therapist.

Irrational illness perceptions which are revealed in weeks one to four are challenged by providing information, raising doubt, and providing alternative perceptions [116]. Information about the application of physiological training principles in cases of cancer-related problems is provided to all patients so as to change irrational perceptions about exercise and cancer. Patients with fatigue as their main problem (module 3) further receive an illustrative ‘model of fatigue’ that explains fatigue as a multidimensional construct with different physical and psychological determinants [4]. These patients are encouraged to undertake physical activity to increase their exercise capacity gradually without ‘centralizing’ fatigue, which may be considered as a cognitive behavioural technique of the therapist. Patients who have problems with role functioning (module 4) are taught how to restore the balance between ‘demand’ and ‘capacity’ during tasks and activities [128]. Exercise is combined with information about the ‘demand and capacity model’ in order to reach a better understanding of methods to reduce ‘demand’ by reducing activities that cause fatigue, and to increase the ‘capacity’ by graded exercise [15,129]. Finally, self-efficacy enhancing techniques are applied, such as a patient’s perceived mastery experiences, a therapist’s verbal persuasion, and vicarious experiences of peers regarding the ability to perform exercise tasks and recognize an improved physiological status such as a decrease in heart rate during exercise [20,125].

The gsp includes twenty-four one-hour sessions over twelve weeks with various sports and games such as indoor hockey, curling and badminton that stimulate patients to engage in and to enjoy sports, both aimed at improvement through a physically active lifestyle. In line with the ipt, the gsp is based on a self-management approach. Patients are invited to set smart goals alongside the overall goal of increasing their activity level during leisure time [124,127]. Patients complete a Visual Analogue Scale to monitor their level of enjoyment during sport or games [31]. Action is fulfilled through the actual engagement in sport and games. Self-reflection is stimulated through reflective questions by the therapist. The gsp also includes, if necessary, attention to irrational perceptions [121] that may be


��


barriers to the adoption of an active lifestyle. Furthermore, the gsp module has a fixed structure, including warming-up, main part and cooling down, aimed at an increase in self-efficacy [20]. During warming-up, basic elements of the sports that will be performed during the main part are practised. The main part contains the actual sport performance and uses already learned movements in the sport and game activities, allowing patients to perceive success more easily. Peers are invited to engage in sport together so that modelling experiences may occur. Therapists guide these processes and use verbal techniques to persuade patients to engage in sport or games. Afterwards a cooling-down period takes place using relaxation techniques to lower physiological arousal [20].



�8

Overview of the relationship between physical problems in cancer patients, the proposed programme and guiding theories of the programme. Patient’s main problems including a decreased aerobic exercise capacity, loss of muscle strength, fatigue or limited physical role functioning. The low activity level is considered the maintaining factor. The individual training module is tailored to the individual problems. The Group Sports and Games are tailored to the adoption of a physically active lifestyle

Problems

AerobicCapacity

Muscle strength/endurance

Fatigue Physical (role) functioning

Low physical activity level

Programme

SELF-MANAGEMENT

Individual Physical Training Aerobic exercise training/progressive resistance exercises

Group Sports and Games

Module 1 Improvement of aerobic capacity

Module II Improvement of muscle strength

Module IIIReduction of fatigue

Module IVImprovement Physical roleFunctioning

Physically active life style

Guiding theories

Physical training programme extended with cognitive-behavioural and social-cognitive components- Application of physiological training principles - Self-management, including six phases (Self-regulation theory) - Self-efficacy; performance accomplishment, modeling, persuasion, physiological status (Bandura’s Social Cognitive Theory)- Illness perceptions: exploration and modification, providing alternative perceptions and information (Leventhal’s Common Sense model)


��


Overview of the programme including an assement phase to determine patient’s main problems and needs, an educational phase to explain the programme rationale, and a tailoring phase in which the physical training is tailored to the patient’s needs. The tailoring phase (12 weeks) consits of two self-management programmes: an Individual Physcal Training and Group Sport and Games. Tailoring is achieved by applying physiological training principles, exploring and changing individual irrational illness perceptions, self-management phases, and stimulating self-efficacy

Phase Assessment Education Tailoring

Structure/modalities

Intake Introduction session Physical training programme

Content

SLBE testMuscle test Anamnesis

AcquaintanceEducation and Information about programme rationale including exercise, self- management, and illness perceptions

Self-management

Individual Physical TrainingGroup

Sport and gamesAerobiccapacity

Musclestrength

Fatigue RoleFunctio-ning

Physically active lifestyle

Weeks -2 -1 0 1-12

FrequenceTime/hour

1/1 1/1 1/2 2x0.75 for 12 weeks = 18 hours2x1for 12 weeks = 24 hours

Aims

To define patient’s main physical problem To explore irrational perceptions To prepare self-management expectancies

To acquaint patient with peers, therapists, and surroundingTo increase knowledge To divide roles between patient and therapist

Tailor-made exercise training to reduce patient’s main physical problem To change irrational perceptions To increase self-management, exercise adherence and adoption of exercise in the longer termTo enhance self-efficacy

To perform and to increase enjoyment in various sports and games To increase self-efficacy and self-management in order to inspire a physically active lifestyle



�00

Tab

le 1

Desc

riptio

n of

cont

rolle

d st

udie

s of p

hysic

al ex

ercis

e on

exer

cise c

apac

ity, m

uscle

stre

ngth

, fat

igue

and

phys

ical f

unct

ioni

ng

I) Ef

fect

iven

ess o

n ox

ygen

upt

ake/

aero

bic c

apac

ity/m

axim

al ex

ercis

e per

form

ance

Stud

yDu

ring/

afte

r tre

atm

ent

Type

of c

ance

rTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Burn

ham

2002

[58]

Afte

r sur

gery

, ra

diat

ion,

surg

ery

Brea

st an

d co

lon

canc

erLo

w in

tens

ity ae

robi

c ex

ercis

eM

oder

ate-

high

in

tens

ity ex

ercis

eTr

eadm

ill an

d cy

cling

25−4

0% H

RR

40−6

0% H

RR

3/we

ek14

−32 m

inut

es

10 w

eeks

21

No d

iffer

ence

s bet

ween

low

and

high

inte

nsity

Com

bine

d gr

oups

sh

owed

sign

ifica

nt in

crea

se in

VO

2max

in EG

(18.

6%) c

ompa

red

to C

G (2

.7%

)

Cour

neya

2003

[59]

Afte

r sur

gery

, re

ceivi

ng ad

juva

nt

ther

apy

Colo

rect

alHo

me-

base

d ae

robi

c ex

ercis

eW

alki

ng an

d cy

cling

50−7

5% M

HR3−

5/we

ek10

−30 m

inut

es16

wee

ks

102

No d

iffer

ence

s bet

ween

gro

ups

with

resp

ect t

o car

diov

ascu

lar

fitne

ss

Cour

neya

2003

[60]

Afte

r sur

gery

, ra

diat

ion

and

chem

o-th

erap

y

Brea

st

Supe

rvise

d ae

robi

c ex

ercis

eCy

cling

70−7

5% V

O2m

ax

3/we

ek15

−35 m

inut

es15

wee

ks

5314

.5%

incr

ease

in V

O2m

ax in

EG

and

a dec

reas

e (-3

%) i

n (W

)CG

Dim

eo 19

97 [7

]Du

ring

chem

othe

rapy

and

auto

logo

us P

BSCT

Mixe

d so

lid tu

mou

rsSu

perv

ised

aero

bic

exer

cise

Cycli

ng on

bed

er

gom

eter

50%

HRR

(2

20-a

ge-r

esth

r) Da

ily

15−3

0 min

utes

durin

g ho

spita

li-za

tion

70Lo

ss of

max

imal

per

form

ance

was

27

% h

ighe

r in

CG co

mpa

red

to EG

EG h

ad si

gnifi

cant

ly hi

gher

sc

ores

on m

axim

al p

erfo

rman

ce

com

pare

d to

CG,

dat

a NA

Dim

eo 19

97[6

1]Af

ter

chem

othe

rapy

and

auto

logo

us P

BSCT

Mixe

d so

lid tu

mou

rs

and

non-

Hodg

kin’

s Su

perv

ised

inte

rval

-en

dura

nce e

xerc

iseTr

eadm

ill w

alki

ng

80%

MHR

(cal

cula

ted)

5 w

eek

3−30

min

utes

6 wee

ks

32In

crea

se in

max

imal

per

form

ance

(s

peed

) in

EG (3

4%) w

as

signi

fican

tly h

ighe

r com

pare

d to

co

ntro

l (21

%)

.


�0�


I) Ef

fect

iven

ess o

n ox

ygen

upt

ake/

aero

bic c

apac

ity/m

axim

al ex

ercis

e per

form

ance

Stud

yDu

ring/

afte

r tre

atm

ent

Type

of c

ance

rTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Dim

eo 20

04 [6

2]Af

ter s

urge

ryLu

ng an

d ga

stro

-in

test

inal

canc

erAe

robi

c exe

rcise

gro

up

vers

us re

laxa

tion

grou

p

80%

MHR

/Bo

rg 13

-14

5/we

ek15

−30 m

inut

es3 w

eeks

69EG

show

ed 8%

incr

ease

in m

axim

al

perfo

rman

ce, n

o cha

nge i

n RG

Herr

ero 2

006 [

63]

Afte

r sur

gery

and

radi

othe

rapy

Brea

stSu

perv

ised

aero

bic

exer

cise

Cycli

ng on

ergo

met

er

Resis

tanc

e tra

inin

g

70−8

0 % M

HR

Weig

ht th

at al

lowe

d 12

−15 r

epet

ition

s,

than

adju

sted

to 8−

10

repe

titio

ns, f

ollo

wed

by an

incr

ease

of

5−10

%

3/we

ek70

min

utes

(20−

30

min

utes

aero

bic)

11 ex

ercis

es

8−15

repe

titio

ns,

3 set

s 8 w

eeks

16EG

show

ed an

incr

ease

in V

O2m

ax

(9%

) and

a de

crea

se in

CG

(-6%

)

Kim

2006

[64]

Durin

g ch

emot

hera

py

or ra

diot

hera

pyBr

east

Su

perv

ised

aero

bic

exer

cise

Cycli

ng, w

alki

ng,

runn

ing

60-7

0% V

O2 m

ax3/

week

30 m

inut

es8 w

eeks

41EG

show

ed si

gnifi

cant

incr

ease

in

VO2

max

(8%

), no

sign

ifica

nt

chan

ges i

n CG

(2%

)

Mac

Vica

r 198

9 [65

]Du

ring

chem

othe

rapy

Brea

stSu

perv

ised

aero

bic

inte

rval

exer

cise;

al

tern

atin

g hi

gher

and

lowe

r int

ensit

yCy

cling

60–8

5% H

RR3/

week

, 20

−30 m

inut

es10

wee

ks

49VO

2max

and

max

imum

wor

k-lo

ad

impr

oved

in EG

(40%

) com

pare

d to

pla

cebo

(stre

tchi

ng ex

ercis

es)

and t

o CG

.



�0�

I) Ef

fect

iven

ess o

n ox

ygen

upt

ake/

aero

bic c

apac

ity/m

axim

al ex

ercis

e per

form

ance

Stud

yDu

ring/

afte

r tre

atm

ent

Type

of c

ance

rTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Niem

an 19

95 [6

6]Af

ter s

urge

ry, c

hem

o-th

erap

y rad

ioth

erap

y Br

east

Su

perv

ised

card

iova

scul

ar ex

ercis

e W

alki

ng

Resis

tanc

e tra

inin

g

75%

MHR

Weig

ht u

nspe

cified

3/we

ek30

min

utes

,

7 diff

eren

t exe

rcise

s 12

repe

titio

ns

8 wee

ks

16M

odes

t im

prov

emen

t in

aero

bic

capa

city E

G; w

alki

ng d

istan

ce

incr

ease

d sig

nific

antly

in EG

co

mpa

red

to C

G, h

eart

rate

tend

ed

to b

e red

uced

, dat

a NA

Sega

l 200

1 [67

]Du

ring

radi

othe

rapy

, ch

emot

hera

py

horm

onal

ther

apy

Brea

st

Card

iova

scul

ar

exer

cise s

elf-d

irect

ed

Wal

king

ve

rsus

supe

rvise

d pr

ogra

mm

e and

usu

al

care

50−6

0% V

O2m

ax5/

week

self-

dire

cted

gr

oup

3/we

ek su

perv

ised

grou

p, 2

days

at h

ome

No sp

ecifi

catio

n of

vo

lum

e26

wee

ks

123

K V

o2 m

ax in

CG,

and

incr

ease

d 3.

5% in

self-

dire

cted

gro

up an

d 2.

5% in

supe

rvise

d gr

oup

(NS)

Su

perv

ised

exer

cise s

howe

d sig

nific

antly

mor

e inc

reas

e in

VO2

com

pare

d to

usu

al ca

re an

d to

self-

dire

cted

gro

up on

ly in

pat

ients

not

re

ceivi

ng ch

emot

hera

py

Thor

sen

2005

[68]

Afte

r che

mot

hera

pyM

ixed

canc

er d

iagn

osis

Supe

rvise

d ho

me-

base

d ae

robi

c pr

ogra

mm

e Wal

king

an

d cy

cling

Borg

on 13

−15

60−7

0% M

HRM

inim

al 2/

week

, mor

e we

re al

lowe

d At

leas

t 30

min

utes

14 w

eeks

139

23%

incr

ease

in V

O2 m

ax in

EG,

and

10%

in C

G


�0�


II) E

ffect

iven

ess o

n m

uscle

stre

ngth

Stud

yDu

ring/

afte

r tre

atm

ent

Ty

pe of

canc

erTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Colem

an 20

03 [8

2]Du

ring

chem

o-th

erap

y and

stem

cell

trans

plan

tatio

n

Mul

tiple

mye

lom

a Ho

me-

base

d ae

robi

c ex

ercis

e W

alki

ngSt

reng

th re

sista

nce

train

ing

12−1

5 Bor

g

Mus

cle tr

aini

ng w

ith

stre

tch

band

s with

2−

27 lb

s of r

esist

ance

3/we

ek18

min

utes

4 s

ets o

f stre

ngth

tra

inin

g 6 m

onth

s

24Si

gnifi

cant

incr

ease

in le

an b

ody

mas

s in

EG co

mpa

red

to C

GIn

crea

se in

mus

cle st

reng

th in

EG

and

a dec

reas

e in

CG (n

s), d

ata N

A

Haye

s 20

03 [7

9]Af

ter c

hem

othe

rapy

an

d PB

SCT

Mixe

d ca

ncer

di

agno

ses

Aero

bic e

xerc

iseTr

eadm

ill w

alki

ng an

d cy

cling

Resis

tanc

e exe

rcise

70−9

0% M

HR

Weig

ht se

t to i

nduc

e fa

ilure

bet

ween

8−20

re

petit

ions

in la

rge

mus

cle g

roup

s

3/we

ek20

−40 m

inut

es3−

6 exe

rcise

s2/

week

, no

spec

ifica

tion

of se

ts3 m

onth

s

12Fa

t fre

e mas

s inc

reas

ed si

gnifi

cant

ly in

exer

cise g

roup

and

not i

n CG

, da

ta N

A

Herr

ero 2

006 [

63]

Afte

r sur

gery

and

radi

othe

rapy

Brea

stSu

perv

ised

aero

bic

exer

cise

Cycli

ng on

ergo

met

er

Resis

tanc

e tra

inin

g

70−8

0 % M

HR

Weig

ht th

at al

lowe

d 12

−15 r

epet

ition

s,

than

adju

sted

to 8−

10

repe

titio

ns, f

ollo

wed

by

an in

crea

se of

5−

10%

3/we

ek70

min

utes

(20−

30

min

utes

aero

bic)

11 ex

ercis

es

15 re

petit

ions

,3 s

ets

8 wee

ks

16Si

gnifi

cant

effe

ct of

gro

up an

d tim

e in

tota

l mus

cle m

ass;

EG sh

owed

an

incr

ease

in m

uscle

mas

s (3%

) and

a de

crea

se in

CG

(-1%

)Si

gnifi

cant

effe

ct of

gro

up an

d tim

e fo

r leg

pre

ss an

d sit

-sta

nd te

st, b

ut

not f

or b

ench

pre

ss

.



�0�

II) E

ffect

iven

ess o

n m

uscle

stre

ngth

Stud

yDu

ring/

afte

r tre

atm

ent

Ty

pe of

canc

erTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Niem

an 19

95 [6

6]Af

ter s

urge

ry ch

emo-

ther

apy r

adio

ther

apy

Brea

st

Supe

rvise

d ca

rdio

vasc

ular

ex

ercis

e W

alki

ng

Weig

ht tr

aini

ng

75%

MHR

Incr

ease

of w

eight

not

sp

ecifi

ed

3/we

ek60

min

utes

8 wee

ks2 s

ets

12 re

petit

ions

7 exe

rcise

s

16Le

g ex

tens

ion

stre

ngth

tend

ed to

in

crea

se m

ore i

n EG

com

pare

d to

CG

, (ns

) dat

a NA

Mell

o 200

3 [83

]Af

ter b

one m

arro

w tra

nspl

ant

CML,

AM

L, N

HL, M

DSIn

terv

al ae

robi

c ex

ercis

e W

alki

ng

Activ

e ran

ge of

mot

ion

exer

cises

/mus

cle

stre

tchi

ng

70%

MHR

Daily

40 m

inut

es

6 wee

ks

32EG

show

ed h

ighe

r val

ues f

or al

l m

uscle

gro

ups c

ompa

red

to C

GEx

ercis

e gro

up in

crea

sed

for 3

of 8

(UE)

and

5 of 1

0 mus

cle g

roup

s (LE

), da

ta N

A

Ohira

2006

[80]

Afte

r rad

ioth

erap

y su

rger

y che

mot

hera

pyBr

east

Su

perv

ised

weig

ht

train

ing

follo

wed

by

self-

dire

cted

weig

ht

train

ing

Com

paris

on EG

with

de

laye

d gr

oup

Resis

tanc

e mac

hine

s an

d fre

e weig

hts n

ot

spec

ified

2/we

ek9 e

xerc

ises

26 w

eeks

86Ch

ange

s in

benc

h pr

ess w

ere 6

3% in

EG

vers

us 12

% in

dela

yed

grou

pLe

g pr

ess 1

-RM

incr

ease

s wer

e 38%

ve

rsus

9% fo

r dela

yed

grou

p

Schm

itz 20

05 [8

4]Af

ter r

adia

tion,

ch

emot

hera

pyBr

east

Supe

rvise

d we

ight

tra

inin

g fo

llowe

d by

se

lf-di

rect

ed w

ith

train

ing,

com

paris

on

with

wai

tlist

cont

rols

No w

eight

for u

pper

ex

trem

ity

Weig

ht fo

r low

er

extre

mity

bas

ed on

th

e abi

lity t

o lift

8−10

tim

es

2/we

ek60

min

utes

3 set

s8−

12 re

petit

ions

. 12

mon

ths:

6 mon

ths

supe

rvise

d, 6

mon

ths

mai

nten

ance

WCG

from

mon

ths

7 to 1

2

85Si

gnifi

cant

incr

ease

in le

an m

uscle

m

ass (

2.3%

) com

pare

d to

cont

rols

(no c

hang

e)

.


�0�


II) E

ffect

iven

ess o

n m

uscle

stre

ngth

Stud

yDu

ring/

afte

r tre

atm

ent

Ty

pe of

canc

erTy

pe of

exer

cise

prog

ram

me

Inte

nsity

(loa

d)Fr

eque

ncy,

volu

me,

du

ratio

n

Num

ber

of

patie

nts

Outc

ome

Sega

l 200

3 [7

7]Du

ring

horm

one

ther

apy

Pros

tate

Su

perv

ised

resis

tanc

e ex

ercis

e 60

−70%

of 1-

RM

incr

ease

of 0.

5 lb

when

>1

2 rep

etiti

ons w

ere

com

plet

ed

3/we

ek2 s

ets

8−12

repe

titio

ns9 e

xerc

ises

12 w

eeks

155

EG sh

owed

hig

her l

evels

of u

pper

(4

0%) a

nd lo

wer b

ody (

32%

) m

uscu

lar fi

tnes

s com

pare

d to

WCG

(-

8% an

d -4

%, r

espe

ctive

ly)

Win

ning

ham

1989

[85]

Durin

g ad

juva

nt

chem

othe

rapy

Brea

st

Supe

rvise

d cy

cle

inte

rval

pro

toco

l 60

−85%

VO2

max

3/we

ek,

20−3

0 min

utes

10 w

eeks

24In

crea

se of

lean

mas

s in

EG

com

pare

d to

cont

rols,

dat

a NA



�0�

III) E

ffect

iven

ess o

n fa

tigue

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Burn

ham

2002

[58]

Afte

r sur

gery

, ra

diat

ion,

surg

ery

Mixe

d Lo

w in

tens

ity ae

robi

c ex

ercis

eM

oder

ate-

high

in

tens

ity ex

ercis

e Tr

eadm

ill an

d cy

cling

25−4

0% H

RR

40−6

0% H

RR

3/we

ek14

−32 m

inut

es10

wee

ks

21

Fatig

ue d

ecre

ased

in EG

but

not

di

fferin

g sig

nific

antly

from

CG

Cam

pbell

2005

[69]

Durin

g ad

juva

nt

chem

othe

rapy

/radi

o-th

erap

y/co

mbi

ned

Brea

stSu

perv

ised

aero

bic

train

ing

Wal

king

and

cycli

ng

Mus

cle st

reng

then

ing

exer

cises

60−7

0% M

HR(a

ge

adju

sted

) M

uscle

stre

ngth

e-ni

ng

not s

pecifi

ed

2/we

ek10

−20 m

inut

es12

wee

ks

22No

sign

ifica

nt d

iffer

ence

s in

fatig

ue b

etwe

en EG

and

CG

Cour

neya

2003

[60]

Afte

r sur

gery

, ra

diat

ion,

chem

o-th

erap

y

Brea

st

Supe

rvise

d ae

robi

c ex

ercis

e Cy

cling

70−7

5% V

O2m

ax

3/we

ek15

−35 m

inut

es15

wee

ks

53Si

gnifi

cant

redu

ctio

n in

fat

igue

in

EG (5

3%) c

ompa

red

to C

G (1

9%)

Dim

eo 19

99 [7

0]Du

ring

chem

othe

rapy

Mixe

d so

lid tu

mou

rs,

heam

ato-

logi

cal

Supe

rvise

d ae

robi

c ex

ercis

e Bi

king

on a

bed

ergo

met

er

50%

HRR

inte

rval

M

ean

work

load

30

(±5)

Wat

t

Daily

15 to

30 m

inut

es w

ith

rest

of 1

min

ute

Unsp

ecifi

ed d

urat

ion

63Fa

tigue

in EG

rem

aine

d un

chan

ged

and

incr

ease

d (2

5%) i

n CG

dur

ing

hosp

italis

atio

n

Dim

eo 20

04 [6

2]Af

ter s

urge

ryLu

ng an

d ga

stro

in-

test

inal

Aero

bic e

xerc

ise g

roup

ve

rsus

rela

xatio

n80

% M

HR/

Borg

13-1

45/

week

, 15

−30 m

in3 w

eeks

69Fa

tigue

impr

oved

in b

oth

grou

ps

(21 v

ersu

s 19%

), ns

.


�0�


III) E

ffect

iven

ess o

n fa

tigue

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Head

ley 20

04 [

71]

Durin

g ch

emot

hera

pyBr

east

Ho

me-

base

d st

retc

hing

and

repe

ated

flex

ion

and

exte

nsio

n ex

ercis

es,

video

inst

ruct

ion

No re

sista

nce

3/we

ek30

min

utes

2 wee

ks

32EG

show

ed si

gnifi

cant

ly les

s in

crea

se in

fatig

ue th

an C

G, d

ata

NA

Houb

org

2006

[72]

Afte

r sur

gery

Colo

rect

al

Supe

rvise

d m

obili

satio

n ex

ercis

es

Aero

bic t

rain

ing

Stre

ngth

trai

ning

Cont

inua

tion

at h

ome

EG co

mpa

red

to

plac

ebo

Not s

pecifi

ed

Not s

pecifi

edW

eight

at 50

-80%

of

1-RM

6/we

ek45

min

utes

du

ring

hosp

itali-

satio

n (K

10 d

ays)

an

d af

ter d

ischa

rge a

t ho

me:

K 11

wee

ks

119

No si

gnifi

cant

diff

eren

ces i

n fa

tigue

bet

ween

gro

ups,

data

NA

Moc

k 199

7 [73

]Du

ring

radi

atio

nBr

east

Hom

e-ba

sed

prog

ress

ive b

risk

prog

ram

me

Wal

king

Self-

pace

d 4−

5/we

ek20

−30 m

inut

es6 w

eeks

46Fa

tigue

dec

reas

ed in

EG an

d in

crea

sed

in C

G, si

gnifi

cant

, dat

a NA

Moc

k 200

1 [74

]Du

ring

radi

othe

rapy

, ch

emot

hera

pyBr

east

Hom

e-ba

sed

exer

cise

Wal

king

Self-

pace

d 5−

6 wee

k15

−30 m

inut

es6 w

eeks

to 6

mon

ths

durin

g ca

ncer

tre

atm

ent

52Fa

tigue

dec

reas

ed si

gnifi

cant

ly m

ore i

n HW

(i.e

. pat

ients

who

wa

lked

>90 m

inut

es p

er w

eek)

(-

14%

) com

pare

d to

LW (i

ncre

ase

of 37

%)

.



�08

III) E

ffect

iven

ess o

n fa

tigue

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Moc

k 200

5 [75

]Du

ring

radi

othe

rapy

, ch

emot

hera

pyBr

east

Hom

e-ba

sed

exer

cise

Brisk

wal

king

50

−70%

MHR

5−6 /

week

15−3

0 min

6 wee

ks

119

No d

iffer

ence

s in

fatig

ue b

etwe

en

EG an

d CG

due

to d

ilutio

n of

tre

atm

ent F

atig

ue in

crea

sed

signi

fican

tly m

ore i

n no

n-co

mpl

iers t

han

in fu

ll co

mpl

iers

and

mor

e in

low

walk

ers (

77%

) th

an in

hig

h wa

lker

s (20

%)

Pint

o 200

5 [76

]Af

ter r

adia

tion,

su

rger

y and

chem

o-th

erap

y

Brea

stHo

me-

base

d ex

ercis

e Wal

king

, bi

king

, swi

mm

ing,

co

unse

lling

and

pedo

met

ers

55−6

5% M

HR2−

5/we

ek10

−30 m

inut

es12

wee

ks

68M

ore r

educ

tion

in fa

tigue

in EG

(3

6%) c

ompa

red

to co

ntro

ls (1

.4%

)

Sega

l 200

3 [77

]Du

ring

horm

one

ther

apy

Pros

tate

Su

perv

ised

resis

tanc

e ex

ercis

e 60

−70%

of 1-

RM,

incr

ease

of 0.

5 lb

when

>1

2 rep

etiti

ons w

ere

com

plet

ed

3/we

ek2 s

ets

8−12

repe

titio

ns,

9 exe

rcise

s12

wee

ks

155

EG sh

owed

impr

ovem

ent i

n fa

tigue

du

ring

daily

livin

g ac

tiviti

es (2

%)

com

pare

d to

WCG

that

show

ed a

decli

ne in

fatig

ue (-

5%)

Thor

sen

2005

[68]

Afte

r che

mot

hera

pyM

ixed

canc

er

diag

nosis

Su

perv

ised

hom

e-ba

sed

aero

bic

prog

ram

me W

alki

ng

and

cycli

ng

Borg

on 13

-15

60−7

0% M

HRM

inim

al 2/

week

, mor

e al

lowe

dAt

leas

t 30 m

inut

es14

wee

ks

139

Fatig

ue d

ecre

ased

mor

e in

CG

(40%

) com

pare

d to

EG (1

5%)

Win

dsor

2004

[78]

Durin

g ra

diot

hera

py

Pros

tate

Ho

me-

base

d ae

robi

c ex

ercis

e W

alki

ng

60−7

0% M

HR3/

week

30 m

inut

es4 w

eeks

66Fa

tigue

incr

ease

d in

CG

and K

in

EG d

urin

g RT

, dat

a NA


�0�


IV) E

ffect

iven

ess o

n ph

ysica

l (ro

le) f

unct

ioni

ng/ f

unct

iona

l wel

lbei

ng/a

ctiv

ity le

vel

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Burn

ham

2002

[58]

Afte

r sur

gery

, ra

diat

ion,

surg

ery

Mixe

d Lo

w in

tens

ity ae

robi

c ex

ercis

eM

oder

ate-

high

in

tens

ity ex

ercis

e tre

adm

ill

Cycli

ng

25−4

0% H

RR

40−6

0% H

RR

3/we

ek14

−32 m

inut

es10

wee

ks

21

Com

bine

d ex

ercis

e gro

ups

show

ed si

gnifi

cant

incr

ease

in

QoL (

9.4%

) in

EG co

mpa

red

to C

G (-

1.9%

) Ene

rgy m

easu

re im

prov

ed

signi

fican

tly in

EG (-

16%

) co

mpa

red

to co

ntro

l (3.

5%)

Cam

pbell

2005

[69]

Durin

g ad

juva

nt

chem

othe

rapy

, rad

io-

ther

apy,

com

bine

d

Brea

stSu

perv

ised

aero

bic

train

ing

Wal

king

and

cycli

ng

Mus

cle-s

treng

then

ing

exer

cises

60−7

0% M

HR

(age

adju

sted

)

Mus

cle st

reng

then

ing

not s

pecifi

ed

2/we

ek10

−20 m

inut

es12

wee

ks

22EG

show

ed si

gnifi

cant

ly m

ore

impr

ovem

ent t

han

CG in

wal

king

di

stan

ce (3

2% ve

rsus

-5%

) and

in

phy

sical

activ

ity (1

03%

vers

us

1.2%

) and

in Q

oL (1

7% ve

rsus

- 4

%).

Cour

neya

2003

[59]

Afte

r sur

gery

, re

ceivi

ng ad

juva

nt

ther

apy

Colo

rect

al

Hom

e-ba

sed

aero

bic

exer

cise

Wal

king

and

cycli

ng

50−7

5 % M

HR3−

5/we

ek10

−30 m

inut

es16

wee

ks

102

No d

iffer

ence

s bet

ween

gro

ups

Patie

nts w

ho im

prov

ed in

fitn

ess

show

ed m

ore i

mpr

ovem

ent (

4%)

than

dec

reas

ed fi

tnes

s gro

up (-

2%)

Cour

neya

2003

[60]

Afte

r sur

gery

, ra

diat

ion,

ch

emot

hera

py

Brea

st

Supe

rvise

d ae

robi

c ex

ercis

e Cy

cling

70−7

5% V

O2m

ax

3/we

ek15

−35 m

inut

es15

wee

ks

53In

crea

se in

phy

sical

well

bein

g in

EG

(8%

) com

pare

d to

(W)C

G (-

.8%

)

Haye

s 200

3 [79

]Af

ter c

hem

othe

rapy

an

d PB

SCT

Mixe

d lym

phat

ic ca

ncer

dia

gnos

es

Aero

bic e

xerc

ise

tread

mill

Wal

king

and

cycli

ngRe

sista

nce t

rain

ing

70−9

0% M

HRW

eight

set t

o ind

uce

failu

re b

etwe

en 8−

20

repe

titio

ns

3/we

ek

2/we

ek20

−40 m

inut

es3 m

onth

s

12Ph

ysica

l QoL

impr

oved

(20%

) in

EG

and

not i

n CG

.



��0

IV) E

ffect

iven

ess o

n ph

ysica

l (ro

le) f

unct

ioni

ng/ f

unct

iona

l wel

lbei

ng/a

ctiv

ity le

vel

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Head

ley 20

04 [7

1]Du

ring

chem

othe

rapy

Stre

tchi

ng an

d re

peat

ed fl

exio

n an

d ex

tens

ion

exer

cises

No re

sista

nce

3/we

ek30

min

utes

12 w

eeks

32EG

show

ed si

gnifi

cant

ly les

s dec

line

in p

hysic

al w

ellbe

ing

com

pare

d to

CG

dur

ing

CT, d

ata N

A

Herr

ero 2

006 [

63]

Afte

r sur

gery

and

radi

othe

rapy

Br

east

Supe

rvise

d ae

robi

c ex

ercis

e Cy

cling

on er

gom

eter

Re

sista

nce t

rain

ing

70−8

0 % M

HR

Weig

ht th

at al

lowe

d 12

−15 r

epet

ition

s,

than

adju

sted

to 8−

10

repe

titio

ns, f

ollo

wed

by an

incr

ease

of

5−10

%

3/we

ek70

min

utes

(20−

30

min

utes

aero

bic)

11 ex

ercis

es

15 re

petit

ions

3 set

s 8 w

eeks

16EG

show

ed an

incr

ease

in p

hysic

al

func

tion

(7%

) and

no c

hang

e in

CG

Houb

org

2006

[72]

Afte

r sur

gery

Colo

rect

al

Supe

rvise

d m

obili

satio

n ex

ercis

es

aero

bic t

rain

ing

Stre

ngth

trai

ning

Cont

inua

tion

at h

ome

EG co

mpa

red

to

plac

aebo

Not s

pecifi

ed

Not s

pecifi

edW

eight

at 50

-80%

of

1-RM

6/we

ek45

min

utes

du

ring

hosp

itali-

satio

n (K

10 d

ays)

an

d af

ter d

ischa

rge a

t ho

me:

K 11

wee

ks

119

All i

ndice

s of p

hysic

al fu

nctio

n de

crea

sed

post

oper

ative

day

seve

n an

d re

turn

ed to

pre

oper

ative

leve

l 90

day

s pos

t ope

rativ

ely, w

ith n

o sig

nific

ant d

iffer

ence

s bet

ween

gr

oups

, dat

a NA

Kim

2006

[64]

Durin

g ch

emot

hera

py

or ra

diot

hera

pyBr

east

Su

perv

ised

aero

bic

exer

cise

Cycli

ng, w

alki

ng,

runn

ing

60-7

0% V

O2 m

ax3/

week

30 m

inut

es8 w

eeks

41No

bet

ween

gro

up ch

ange

sSi

gnifi

cant

incr

ease

in EG

co

mpa

red

to C

G in

volu

ntar

y ex

ercis

e (31

%ve

rsus

4%) a

nd in

en

ergy

expe

nditu

re (3

1ver

sus 4

%)

and

a dec

reas

e in

sede

ntar

y act

ivity

(-

12%

vers

us -

6%)

.


��


IV) E

ffect

iven

ess o

n ph

ysica

l (ro

le) f

unct

ioni

ng/ f

unct

iona

l wel

lbei

ng/a

ctiv

ity le

vel

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Moc

k 19

97 [7

3]Du

ring

radi

atio

n Br

east

Hom

e-ba

sed

prog

ress

ive

Brisk

wal

king

Self-

pace

d 4−

5/we

ek20

−30 m

inut

es6 w

eeks

46EG

show

ed si

gnifi

cant

ly hi

gher

sc

ores

on 12

min

WD

(4%

) co

mpa

red

to C

G (-

5%)

Moc

k 200

1 [74

]Du

ring

radi

othe

rapy

, ch

emot

hera

pyBr

east

Hom

e-ba

sed

exer

cise

Wal

king

Self-

pace

d 5−

6 wee

k15

−30 m

inut

es6 w

eeks

to6 m

onth

dur

ing

canc

er tr

eatm

ent

52HW

(i.e

. pat

ients

who

wal

ked

>90 m

inut

es p

er w

eek)

show

ed

signi

fican

tly h

ighe

r sco

res t

han

LW on

func

tiona

l abi

lity (

12 m

in

WD:

6% ve

rsus

-0.3

%) a

nd on

se

lf-re

porte

d ph

ysica

l act

ivity

(39%

ve

rsus

-38%

) tha

n LW

. Phy

sical

fu

nctio

ning

dec

reas

ed si

gnifi

cant

ly m

ore i

n LW

(45%

) com

pare

d to

HW

(16%

)

Moc

k 200

5 [75

]Du

ring

radi

othe

rapy

or

chem

othe

rapy

Brea

stHo

me-

base

d ae

robi

c ex

ercis

e Br

isk w

alki

ng

50−7

0% M

HR5−

6 /we

ek15

−30 m

in6 w

eeks

119

EG sh

owed

sign

ifica

ntly

high

er

scor

es on

WD

than

CG,

but

no

diffe

renc

es in

phy

sical

func

tioni

ng

(dat

a NA)

wer

e fou

nd

HE sh

owed

hig

her s

core

s tha

n LE

on

wal

king

dist

ance

(6%

vers

us -

.02%

), on

phy

sical

func

tioni

ng (5

%

vers

us -8

%) a

nd on

activ

ity le

vels

(34%

vers

us -1

4%)

.



��

IV) E

ffect

iven

ess o

n ph

ysica

l (ro

le) f

unct

ioni

ng/ f

unct

iona

l wel

lbei

ng/a

ctiv

ity le

vel

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Ohira

2006

[80]

Afte

r rad

ioth

erap

y su

rger

y che

mo-

ther

apy

Brea

st ca

ncer

Supe

rvise

d we

ight

tra

inin

gFo

llowe

d by

own

we

ight

trai

ning

Resis

tanc

e mac

hine

s an

d fre

e weig

hts n

ot

spec

ified

2/we

ek9 e

xerc

ises

26 w

eeks

86Ph

ysica

l glo

bal s

core

impr

oved

by

2.1%

in EG

com

pare

d wi

th a

wors

enin

g by

1.2

% in

CG

Pint

o 200

3 [81

]Af

ter s

urge

ry, r

adio

-th

erap

y, ch

emo-

ther

apy o

ver t

he p

ast

3 yea

rs

Brea

st (s

eden

tary

) Su

perv

ised

aero

bic

exer

cise

Trea

dmill

wal

king

, cy

cling

Stre

ngth

trai

ning

60−7

0% M

HR

Weig

ht 1−

5lb

3/we

ek30

min

utes

12 w

eeks

24EG

show

ed 8%

redu

ctio

n in

hea

rt ra

te at

75W

, con

trols

were

not

m

easu

red

Chan

ges i

n se

lf-re

porte

d co

nditi

on

were

hig

her (

31%

) in

EG th

an in

CG

(-19

%)

Pint

o 200

5 [76

]Af

ter r

adia

tion,

su

rger

y and

chem

o-th

erap

y

Brea

st

Hom

e-ba

sed

card

iova

scul

ar ex

ercis

eW

alki

ng, b

ikin

g,

swim

min

g,

coun

selli

ng an

d pe

dom

eter

s

55−6

5% M

HR2−

5/we

ek10

−30 m

inut

es12

wee

ks

68EG

repo

rted

high

er sc

ores

than

CG

on w

alki

ng sp

eed

(6%

vers

us

1%),

on p

hysic

al ac

tivity

leve

l (1

42%

vers

us 6%

) and

on en

ergy

ex

pend

iture

(7%

vers

us 0.

5%)

Sega

l 200

1 [67

]Du

ring

radi

othe

rapy

, ch

emot

hera

py

horm

onal

ther

apy

Brea

st

Card

iova

scul

ar

self-

dire

cted

pr

ogra

mm

e W

alki

ng

Vers

us su

perv

ised

prog

ram

me a

nd u

sual

ca

re

50−6

0% V

O2m

ax5/

week

self-

dire

cted

gr

oup

3/we

ek su

perv

ised

grou

p2 d

ays a

t hom

eno

spec

ifica

tion

of

dura

tion

26 w

eeks

123

Incr

ease

in p

hysic

al fu

nctio

ning

in

self-

dire

cted

gro

up (7

.5%

) and

in

supe

rvise

d gr

oup

(3.5

%) a

nd a

decr

ease

in u

sual

care

.


��


IV) E

ffect

iven

ess o

n ph

ysica

l (ro

le) f

unct

ioni

ng/ f

unct

iona

l wel

lbei

ng/a

ctiv

ity le

vel

Stud

yDu

ring/

afte

r tre

at-

men

t

Type

of ca

ncer

Type

of ex

ercis

e pr

ogra

mm

e In

tens

ity (l

oad)

Freq

uenc

y, vo

lum

e,

dura

tion

Num

ber

of

patie

nts

Outc

ome

Sega

l 200

3 [77

]Du

ring

horm

one

ther

apy

Pros

tate

Su

perv

ised

resis

tanc

e ex

ercis

e60

−70%

of 1-

RM,

incr

ease

of 0.

5 lb

when

>1

2 rep

etiti

ons w

ere

com

plet

ed

3/we

ek2 s

ets

8−12

repe

titio

ns9 e

xerc

ises

12 w

eeks

155

Impr

ovem

ent i

n fu

nctio

ning

in

EG (2

%) c

ompa

red

to W

CG th

at

show

ed a

decli

ne (3

%)

Thor

sen

2005

[68]

Afte

r che

mot

hera

pyM

ixed

canc

er

diag

nosis

Ho

me-

base

d ae

robi

c pr

ogra

mm

e,W

alki

ng an

d cy

cling

.

Borg

13-1

5 60

−70%

MHR

Min

imal

2/we

ek, m

ore

were

allo

wed

At le

ast 3

0 min

utes

14 w

eeks

139

No d

iffer

ence

s in

phys

ical f

unct

ion

(QoL

) bet

ween

EG (1

5%) a

nd C

G (1

4%)

Win

dsor

2004

[78]

Durin

g ra

diot

hera

py

Pros

tate

Ho

me-

base

d ae

robi

c ex

ercis

eW

alki

ng

60−7

0% M

HR3/

week

30 m

inut

es4 w

eeks

6613

.2%

incr

ease

in w

alki

ng d

istan

ce

(shu

ttle r

un te

st) i

n EG

and

a de

crea

se (2

.4%

) in

CG

Abbr

evia

tions

HR

R =

hear

t rat

e res

erve

; MHR

= m

axim

al h

eart

hat

e; V

O2m

ax =

max

imal

oxy

gen

upta

ke; Q

oL =

qua

lity o

f life

; EG

= ex

ercis

e gro

up; (

W)C

G =

(wai

ting

list)

cont

rol g

roup

; RG

= re

laxa

tion

grou

p; P

A= p

hysic

al a

ctivi

ty;

PBSC

T = p

erip

hera

l blo

od st

em ce

ll tr

ansp

lant

atio

n; C

ML =

chro

nic m

yelo

id le

ukae

mia

; AM

L = a

cute

mye

loid

leuk

aem

ia; N

HL =

non

-Hod

gkin

’s ly

mph

oma;

MDS

= m

yelo

dysp

last

ic sy

ndro

me;

UE

= up

per e

xtre

mity

; LE

= lo

wer e

xtre

mity

; RM

= re

petit

ion

max

imum

; SLB

E =

Sym

ptom

Lim

ited

Bicy

cle E

rgom

etry

; HW

= h

igh

walk

ers;

LW =

low

walk

ers;

RT =

radi

othe

rapy

; CT =

chem

othe

rapy

; WD

= wa

lkin

g di

stan

ce; N

.S. =

non

sign

ifica

nt;

NA =

no

pre-

or p

ost i

nter

vent

ion

data

ava

ilabl

e. If

exac

t pre

and

pos

t-in

terv

entio

n da

ta w

ere a

vaila

ble c

hang

es w

ere e

xpre

ssed

in %

of b

asel

ine s

core

s.



��

ReferenceList


[2] Courneya KS, Mackey M, Jones LS. Coping with Cancer. Physician Sportsmed 2000; 28: 49-75.


[4] van Weert E, Hoekstra-Weebers J, Otter R, Postema K, Sanderman R, van der Schans C. Cancer-related fatigue: predictors and effects of rehabilitation. Oncologist 2006; 11: 184-196.

[5] Meyerhardt JA, Giovannucci EL, Holmes MD, Chan AT, Chan JA, Colditz GA, Fuchs CS. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol 2006; 24: 3527-3534.

[6] Meyerhardt JA, Heseltine D, Niedzwiecki D, Hollis D, Saltz LB, Mayer RJ, Thomas J, Nelson H, Whittom R, Hantel A, Schilsky RL, Fuchs CS. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol 2006; 24: 3535-3541.


[8] van Weert E, Hoekstra-Weebers J, Grol B, Otter R, Arendzen J, Postema K, van der Schans C. Physical functioning and quality of life after cancer rehabilitation. Int J Rehabil Res 2004; 27: 27-35.

[9] Oldervoll LM, Kaasa S, Hjermstad MJ, Lund JA, Loge JH. Physical exercise results in the improved subjective well-being of a few or is effective rehabilitation for all cancer patients? Eur J Cancer 2004; 40: 951-962.



[12] Schmitz KH, Holtzman J, Courneya KS, Masse LC, Duval S, Kane R. Controlled physical activty trials in cancer survivors: a systematic review and meta-analyses. Cancer Epidemiol Biomarkers Prev 2005; 14: 1588-1595.

[13] Knols R, Aaronson NK, Uebelhart D, Fransen J, Aufdenkampe G. Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials. J Clin Oncol 2005; 23: 3830-3842.

[14] American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998; 30: 975-991.




[18] Bandura A. Social foundations of thought and action: a social cognitive theory. Engelwoods Cliffs, NJ: Prentice Hall; 1986.

[19] Cordova MJ, Cunningham LL, Carlson CR, Andrykowski MA. Social constraints, cognitive processing, and adjustment to breast cancer. J Consult Clin Psychol 2001; 69: 706-711.


[21] Wiedenfeld SA, O’Leary A, Bandura A, Brown S, Levine S, Raska K. Impact of perceived self-efficacy in coping with stressors on components of the immune system. J Pers Soc Psychol 1990; 59: 1082-1094.

[22] Bandura A. Personal and collective efficacy in human adaptation and change. In: Adair JGE, Belanger DE et-al (eds.), Advances in psychological science: Social, personal, and cultural aspects., 1 ed. Hove, England: Psychology Press/Erlbaum (UK) Taylor & Francis; 1998: 51-71.


��


[23] Brassington GS, Atienza AA, Perczek RE, DiLorenzo TM, King AC. Intervention-related cognitive versus social mediators of exercise adherence in the elderly. Am J Prev Med 2002; 23: 80-86.

[24] Gotay CC. Behavior and cancer prevention. J Clin Oncol 2005; 23: 301-310.

[25] de Vreede PL, Samson MM, van Meeteren NL, Duursma SA, Verhaar HJ. Functional-task exercise versus resistance strength exercise to improve daily function in older women: a randomized, controlled trial. J Am Geriatr Soc 2005; 53: 2-10.

[26] Schwartz AL. Physical activity after a cancer diagnosis: psychosocial outcomes. Cancer Invest 2004; 22: 82-92.

[27] van der Ploeg HP, Streppel KR, van der Beek AJ, van der Woude LH, Vollenbroek-Hutten MM, van Harten WH, van MW. Counselling increases physical activity behaviour nine weeks after rehabilitation. Br J Sports Med 2006; 40: 223-229.

[28] Lewis BA, Marcus BH, Pate RR, Dunn AL. Psychosocial mediators of physical activity behavior among adults and children. Am J Prev Med 2002; 23: 26-35.

[29] Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002; 288: 2469-2475.

[30] Schreurs KM, Colland V, Kuijer R, de Ridder D, van Elderen T. Development, content, and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviours. Patient Educ Couns 2003; 51: 133-141.

[31] Creer TL. Self-management of chronic illness. In: M.Boekaerts & P.R.Pintrich (ed.), Handbook of self-regulation. San Diego, CA, US.: Academic Press.; 2000: 601-629.

[32] Pinto BM, Eakin E, Maruyama NC. Health behaviour changes after a cancer diagnosis, what do we know and where do we go from here? Ann Behav Med 2000; 22: 38-52.

[33] Pickett M, Mock V, Ropka ME, Cameron L, Coleman M, Podewils L. Adherence to moderate-intensity exercise during breast cancer therapy. Cancer Pract 2002; 10: 284-292.

[34] Pinto BM, Trunzo JJ, Reiss P, Shiu SY. Exercise participation after diagnosis of breast cancer: trends and effects on mood and quality of life. Psychooncology 2002; 11: 389-400.

[35] al Majid S, McCarthy DO. Cancer-induced fatigue and skeletal muscle wasting: the role of exercise. Biol Res Nurs 2001; 2: 186-197.

[36] Carver C, Scheier M. On the self-regulation of behavior. Cambridge, UK: Cambridge University Press; 1998.

[37] Adams MJ, Lipsitz SR, Colan SD, Tarbell NJ, Treves ST, Diller L, Greenbaum N, Mauch P, Lipshultz SE. Cardiovascular status in long-term survivors of Hodgkin’s disease treated with chest radiotherapy. J Clin Oncol 2004; 22: 3139-3148.

[38] Elbi L, Vasova I, Tomaskova I, Jedlicka F, Navratil M, Pospisil Z, Vorlicek J. Cardiac function and cardiopulmonary performance in patients after treatment for non-Hodgkin’s lymphoma. Neoplasma 2006; 53: 174-181.

[39] Dimeo F, Stieglitz RD, Novelli-Fischer U, Fetscher S, Mertelsmann R, Keul J. Correlation between physical performance and fatigue in cancer patients. Ann Oncol 1997; 8: 1251-1255.

[40] Dimeo F. Radiotherapy-related fatigue and exercise for cancer patients: a review of the literature and suggestions for future research. Front Radiat Ther Oncol 2002; 37: 49-56.

[41] Winett RA, Carpinelli RN. Potential health-related benefits of resistance training. Prev Med 2001; 33: 503-513.

[42] Tisdale MJ. Cachexia in cancer patients. Nat Rev Cancer 2002; 2: 862-871.


[44] Lucia A, Earnest C, Perez M. Cancer-related fatigue: can exercise physiology assist oncologists? Lancet Oncol 2003; 4: 616-625.

[45] Stone P. The measurement, causes and effective management of cancer-related fatigue. Int J Palliat Nurs 2002; 8: 120-128.

[46] Evans W. Physical function in men and women with cancer. Effects of anemia and conditioning. Oncology (Williston Park) 2002; 16: 109-115.

[47] Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. Loss of physical functioning among geriatric cancer patients: relationships to cancer site, treatment, comorbidity and age. Eur J Cancer 1997; 33: 2352-2358.



��

[48] Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment and management of cancer-related fatigue in adults. Lancet 2003; 362: 640-650.


[50] Kallich JD, Tchekmedyian NS, Damiano AM, Shi J, Black JT, Erder MH. Psychological outcomes associated with anemia-related fatigue in cancer patients. Oncology (Huntingt) 2002; 16: 117-124.


[52] Schwartz CE, Sprangers MA. An introduction to quality of life assessment in oncology: the value of measuring patient-reported outcomes. Am J Manag Care 2002; 8: S550-S559.

[53] Ness KK, Wall MM, Oakes JM, Robison LL, Gurney JG. Physical performance limitations and participation restrictions among cancer survivors: a population-based study. Ann Epidemiol 2006; 16: 197-205.

[54] Conn VS, Hafdahl AR, Porock DC, McDaniel R, Nielsen PJ. A meta-analysis of exercise interventions among people treated for cancer. Support Care Cancer 2006; 14: 699-712.

[55] Stevinson C, Lawlor DA, Fox KR. Exercise interventions for cancer patients and survivors: systematic review of controlled trials. Cancer Causes Control 2004; 15: 1035-1056.

[56] McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ 2006; 175: 34-41.

[57] Watson T, Mock. Exercise as an intervention for cancer-related fatigue. Phys Ther 2004; 84: 736-743.


[59] Courneya KS, Friedenreich CM, Quinney HA, Fields AL, Jones LW, Fairey AS. A randomized trial of exercise and quality of life in colorectal cancer survivors. Eur J Cancer Care (Engl ) 2003; 12: 347-357.

[60] Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS. Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. J Clin Oncol 2003; 21: 1660-1668.


[62] Dimeo FC, Thomas F, Raabe-Menssen C, Propper F, Mathias M. Effect of aerobic exercise and relaxation training on fatigue and physical performance of cancer patients after surgery. A randomised controlled trial. Support Care Cancer 2004; 12: 774-779.

[63] Herrero F, San Juan AF, Fleck SJ, Balmer J, Perez M, Canete S, Earnest CP, Foster C, Lucia A. Combined aerobic and resistance training in breast cancer survivors: A randomized, controlled pilot trial. Int J Sports Med 2006; 27: 573-580.

[64] Kim CJ, Kang DH, Smith BA, Landers KA. Cardiopulmonary responses and adherence to exercise in women newly diagnosed with breast cancer undergoing adjuvant therapy. Cancer Nurs 2006; 29: 156-165.

[65] MacVicar MG, Winningham ML, Nickel JL. Effects of aerobic interval training on cancer patients’ functional capacity. Nurs Res 1989; 38: 348-351.

[66] Nieman DC, Cook VD, Henson DA, Suttles J, Rejeski WJ, Ribisl PM, Fagoaga OR, Nehlsen-Cannarella SL. Moderate exercise training and natural killer cell cytotoxic activity in breast cancer patients. Int J Sports Med 1995; 16: 334-337.


[68] Thorsen L, Skovlund E, Stromme SB, Hornslien K, Dahl AA, Fossa SD. Effectiveness of physical activity on cardiorespiratory fitness and health-related quality of life in young and middle-aged cancer patients shortly after chemotherapy. J Clin Oncol 2005; 23: 2378-2388.

[69] Campbell A, Mutrie N, White F, McGuire F, Kearney N. A pilot study of a supervised group exercise programme as a rehabilitation treatment for women with breast cancer receiving adjuvant treatment. Eur J Oncol Nurs 2005; 9: 56-63.

[70] Dimeo FC, Stieglitz RD, Novelli-Fischer U, Fetscher S, Keul J. Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer 1999; 85: 2273-2277.


��


[71] Headley JA, Ownby KK, John LD. The effect of seated exercise on fatigue and quality of life in women with advanced breast cancer. Oncol Nurs Forum 2004; 31: 977-983.

[72] Houborg KB, Jensen MB, Rasmussen P, Gandrup P, Schroll M, Laurberg S. Postoperative physical training following colorectal surgery: a randomised, placebo-controlled study. Scand J Surg 2006; 95: 17-22.

[73] Mock V, Dow KH, Meares CJ, Grimm PM, Dienemann JA, Haisfield-Wolfe ME, Quitasol W, Mitchell S, Chakravarthy A, Gage I. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum 1997; 24: 991-1000.

[74] Mock V, Pickett M, Ropka ME, Muscari LE, Stewart KJ, Rhodes VA, McDaniel R, Grimm PM, Krumm S, McCorkle R. Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer Pract 2001; 9: 119-127.

[75] Mock V, Frangakis C, Davidson NE, Ropka ME, Pickett M, Poniatowski B, Stewart KJ, Cameron L, Zawacki K, Podewils LJ, Cohen G, McCorkle R. Exercise manages fatigue during breast cancer treatment: a randomized controlled trial. Psychooncology 2005; 14: 464-477.

[76] Pinto BM, Frierson GM, Rabin C, Trunzo JJ, Marcus BH. Home-based physical activity intervention for breast cancer patients. J Clin Oncol 2005; 23: 3577-3587.

[77] Segal RJ, Reid RD, Courneya KS, Malone SC, Parliament MB, Scott CG, Venner PM, Quinney HA, Jones LW, D’Angelo ME, Wells GA. Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. J Clin Oncol 2003; 21: 1653-1659.

[78] Windsor PM, Nicol KF, Potter J. A randomized, controlled trial of aerobic exercise for treatment-related fatigue in men receiving radical external beam radiotherapy for localized prostate carcinoma. Cancer 2004; 101: 550-557.

[79] Hayes S, Davies PS, Parker T, Bashford J. Total energy expenditure and body composition changes following peripheral blood stem cell transplantation and participation in an exercise programme. Bone Marrow Transplant 2003; 31: 331-338.

[80] Ohira T, Schmitz KH, Ahmed RL, Yee D. Effects of weight training on quality of life in recent breast cancer survivors: the Weight Training for Breast Cancer Survivors (WTBS) study. Cancer 2006; 106: 2076-2083.


[82] Coleman EA, Hall-Barrow J, Coon S, Stewart CB. Facilitating exercise adherence for patients with multiple myeloma. Clin J Oncol Nurs 2003; 7: 529-34, 540.

[83] Mello M, Tanaka C, Dulley FL. Effects of an exercise program on muscle performance in patients undergoing allogeneic bone marrow transplantation. Bone Marrow Transplant 2003; 32: 723-728.

[84] Schmitz KH, Ahmed RL, Hannan PJ, Yee D. Safety and efficacy of weight training in recent breast cancer survivors to alter body composition, insulin, and insulin-like growth factor axis proteins. Cancer Epidemiol Biomarkers Prev 2005; 14: 1672-1680.

[85] Winningham ML, MacVicar MG, Bondoc M, Anderson JI, Minton JP. Effect of aerobic exercise on body weight and composition in patients with breast cancer on adjuvant chemotherapy. Oncol Nurs Forum 1989; 16: 683-689.

[86] Taylor NF, Dodd KJ, Damiano DL. Progressive resistance exercise in physical therapy: a summary of systematic reviews. Phys Ther 2005; 85: 1208-1223.

[87] Grant S, Aitchison T, Henderson E, Christie J, Zare S, McMurray, Dargie H. A comparison of the reproducibility and the sensitivity to change of visual analogue scales, Borg scales, and Likert scales in normal subjects during submaximal exercise. Chest 1999; 116: 1208-1217.

[88] Whiting P, Bagnall AM, Sowden AJ, Cornell JE, Mulrow CD, Ramirez G. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. JAMA 2001; 286: 1360-1368.

[89] Tatrow K, Montgomery GH. Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: a meta-analysis. J Behav Med 2006; 29: 17-27.

[90] Sheard T, Maguire P. The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 1999; 80: 1770-1780.

[91] Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002; 25: 1159-1171.

[92] Carr JL, Klaber Moffett JA, Howarth E, Richmond SJ, Torgerson DJ, Jackson DA, Metcalfe CJ. A randomized trial comparing a group exercise programme for back pain patients with individual physiotherapy in a severely deprived area. Disabil Rehabil 2005; 27: 929-937.



��8

[93] Jackson NW, Howes FS, Gupta S, Doyle JL, Waters E. Interventions implemented through sporting organisations for increasing participation in sport. Cochrane Database Syst Rev 2005; CD004812.

[94] Graves KD. Social cognitive theory and cancer patients’ quality of life: a meta-analysis of psychosocial intervention components. Health Psychol 2003; 22: 210-219.

[95] Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, Rhodes S, Shekelle P. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med 2005; 143: 427-438.

[96] Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005; CD003417.

[97] Sarol JN, Nicodemus NA, Tan KM, Grava MB. Self-monitoring of blood glucose as part of a multi-component therapy among non-insulin requiring type 2 diabetes patients: a meta-analysis (1966-2004). Curr Med Res Opin 2005; 21: 173-184.

[98] Warsi A, Wang PS, LaValley MP, Avorn J, Solomon DH. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med 2004; 164: 1641-1649.

[99] Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ 2003; 29: 488-501.

[100] Jansen JP. Self-monitoring of glucose in type 2 diabetes mellitus: a Bayesian meta-analysis of direct and indirect comparisons. Curr Med Res Opin 2006; 22: 671-681.

[101] Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2006; CD005182.

[102] Beswick AD, Rees K, West RR, Taylor FC, Burke M, Griebsch I, Taylor RS, Victory J, Brown J, Ebrahim S. Improving uptake and adherence in cardiac rehabilitation: literature review. J Adv Nurs 2005; 49: 538-555.

[103] Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev 2003; CD004107.

[104] Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, Bauman A, Hensley MJ, Walters EH. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003; CD001117.

[105] Warsi A, LaValley MP, Wang PS, Avorn J, Solomon DH. Arthritis self-management education programs: a meta-analysis of the effect on pain and disability. Arthritis Rheum 2003; 48: 2207-2213.

[106] Courneya KS, Friedenreich CM, Quinney HA, Fields AL, Jones LW, Vallance JK, Fairey AS. A longitudinal study of exercise barriers in colorectal cancer survivors participating in a randomized controlled trial. Ann Behav Med 2005; 29: 147-153.

[107] Perri MG, Anton SD, Durning PE, Ketterson TU, Sydeman SJ, Berlant NE, Kanasky WF, Newton RL, Limacher MC, Martin AD. Adherence to exercise prescriptions: effects of prescribing moderate versus higher levels of intensity and frequency. Health Psychol 2002; 21: 452-458.

[108] Schmitz KH, Jensen MD, Kugler KC, Jeffery RW, Leon AS. Strength training for obesity prevention in midlife women. Int J Obes Relat Metab Disord 2003; 27: 326-333.

[109] Woodard CM, Berry MJ. Enhancing adherence to prescribed exercise: structured behavioral interventions in clinical exercise programs. J Cardiopulm Rehabil 2001; 21: 201-209.

[110] Netz Y, Wu MJ, Becker BJ, Tenenbaum G. Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol Aging 2005; 20: 272-284.

[111] Marshall SJ, Biddle SJ. The transtheoretical model of behavior change: a meta-analysis of applications to physical activity and exercise. Ann Behav Med 2001; 23: 229-246.

[112] Courneya KS, Friedenreich CM, Quinney HA, Fields AL, Jones LW, Fairey AS. Predictors of adherence and contamination in a randomized trial of exercise in colorectal cancer survivors. Psychooncology 2004; 13: 857-866.

[113] Sniehotta FF, Scholz U, schwarzer R, Fuhrmann B, Kiwus U, Voller H. Long-term effects of two psychological interventions on physical exercise and self-regulation following coronary rehabilitation. Int J Behav Med 2005; 12: 244-255.

[114] Leventhal H, Safer MA, Panagis DM. The impact of communications on the self-regulation of health beliefs, decisions, and behavior. Health Educ Q 1983; 10: 3-29.




��


[117] Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns 2002; 48: 177-187.

[118] Kuijer R, Ridder de DT. Discrepancy in illness-related goals and quality of life in chronically ill patients: the role of self-efficacy. Psychol Health 2003; 18: 313-330.

[119] Wasserman K, Hansen J, Sue D, Stringer W, Whipp B. Principles of exercise training and interpretation, 4 ed. Philadelphia: 2005: 1-585.




[123] McCartney N, McKelvie RS, Haslam DR, Jones NL, McCartney N, McKelvie RS, Haslam DR, Jones NL. Usefulness of weightlifting training in improving strength and maximal power output in coronary artery disease. Am J Cardiol 1991; 939-945.

[124] Ponte-Allan M, Giles GM. Goal setting and functional outcomes in rehabilitation. Am J Occup Ther 1999; 53: 646-649.

[125] Lev EL, Daley KM, Conner NE, Reith M, Fernandez C, Owen SV. An intervention to increase quality of life and self-care self-efficacy and decrease symptoms in breast cancer patients. Sch Inq Nurs Pract: 2001; 15: 277-294.


[127] Malec JF. Goal attainment scaling in rehabilitation. Neuropsychol. Rehabil 1999; 9: 253-275.

[128] Lawrence RH, Jette AM. Disentangling the disablement process. J Gerontol B Psychol Sci Soc Sci 1996; 51: S173-S182.

[129] Bennett JA, Winters-Stone K, Nail L. Conceptualizing and measuring physical functioning in cancer survivorship studies. Oncol Nurs Forum 2006; 33: 41-49.



��

7 Generaldiscussion

The increased survival rate brings challenges for increasing the quality of life of cancer survivors. Approximately 30% of all survivors report a decrease in the quality of life due to the physical and psychological after-effects of cancer and consequent treatment [1;2] and express a need for professional support such as rehabilitation [3]. The present thesis focused on oncological rehabilitation. The study was primarily set up to examine the effects of a 15-week multidimensional rehabilitation programme on the quality of life and the degree of fatigue of cancer survivors. The aims of the study were to investigate the effect of the intensive part (i.e., the first six weeks) and the entire multidimensional rehabilitation programme on physiological functioning and on the quality of life. Another goal was to obtain more insight into patients’ appreciation of the multidimensional programme and into patients’ preferences regarding mono- and multi-dimensional rehabilitation programmes. Furthermore, the study aimed at obtaining more insight into variables associated with improvements in the quality of life. To this end, the correlations between sociodemographic characteristics and internal and external resources and quality of life before and after rehabilitation were explored. Because fatigue is one of most frequently-reported complaints among cancer patients, an additional goal of the study was to explore predictors of fatigue at baseline in patients referred for rehabilitation, and to examine whether or not a change in fatigue would be associated with a change in the predictors identified at baseline. Finally, as part of the thesis and within the context of a multi-centre follow-on study on oncological rehabilitation, an evidence-based physical training programme for cancer patients was developed.

This final chapter aims to discuss the results of the study in a broader context. The chapter first summarizes the main findings of the study, and overall methodological considerations are discussed. Then the clinical implications of the study are presented. Finally, theoretical reflections and future research are outlined.

Mainfindings

The multidimensional cancer rehabilitation programme, which was the theme of this study, consisted of the following four components: individual physical training, sports and games, psycho-education, and information. The study revealed that this group-wise rehabilitation programme had statistically significant and beneficial effects on various domains of cancer patients’ functioning, including improvements in physical variables, quality of life, and fatigue. Regarding physical variables, a statistically significant increase in oxygen pulse was found after six weeks of rehabilitation, reflecting genuine physiological improvements. Furthermore, a statistically significant increase in muscle strength was found in the lower extremity. With respect to quality of life , the 15-week multidimensional rehabilitation programme appeared to have beneficial and clinically relevant effects on both general and disease-specific health-related quality of life. In addition, the programme had statistically significant and clinically relevant effects on all domains of cancer-related fatigue. Patients appeared to be highly satisfied with the programme and the components, with the exception of the information component. In addition, patients seem to prefer a multidimensional programme rather than a programme with one component.


General Discussion

��

Further, the results gave insight into the processes of change. Although the rehabilitation programme had little effect on personal resources, improvements in quality of life appeared to be associated with increased self-efficacy and reductions in negative social support. Change in fatigue appeared to be predominantly associated with change in physical variables. The main predictors of fatigue and quality of life after the intervention were fatigue and quality of life at baseline.

Within the context of a national multi-centre trial, the last chapter of the present thesis focused on the development of a physical training programme based on the best available evidence. Evidence for the effectiveness of exercise on aerobic capacity, fatigue, and physical (role) functioning quality of life was found at meta-analysis level. Evidence for the beneficial effect of exercise on muscle strength was found at rct level. Aerobic exercise and progressive resistance exercise alone or combined appeared to be beneficial to cancer patients. In addition, evidence supported the notion that self-management and self-efficacy-enhancing programmes have beneficial effects on health outcomes among people suffering from various diseases, on the quality of life of cancer patients, on exercise adherence, and on later exercise behaviour. Based on these findings, a physical training programme tailored towards the patients’ individual needs and problems was developed, and consisted of aerobic exercise, progressive resistance exercise, and self-management and self-efficacy-enhancing techniques.

Methodologicalconsiderations

The results of the study should be interpreted with caution. The most important limitation of the study was the lack of a control group, which reduces the evidence for the effectiveness of the multi-dimensional programme. Furthermore, the design of the study did not provide the opportunity to compare the effects of the physical and psychological components separately. In addition, due to the response such as an over-representation of breast cancer, the results cannot be generalized to the entire cancer population. However, the group of patients covered seems to be a good reflection of clinical and daily practice, and thus the findings may be generalized to clinical practice.

The results of the study are based on the use of valid and reliable measures. Most of them appeared to have a rather good Cronbach’s alpha in the present study. However, one of the measures, the General Efficacy Scale, while initially attractive because of its global nature, may be problematic because of that same characteristic and therefore not sensitive enough to detect change in self-efficacy. As a result, behaviour specific or task specific self-efficacy ratings may be more appropriate.

An advantage in this study was the fact that the choice of a pre-post design gave no ethical problems concerning the allocation of an intervention, a control group or a waiting period, which may legitimize the choice during a pilot study. It may be assumed that the beneficial effects found may be attributed to the intervention rather than to maturation, because of the long timeline between the completion of treatment and the start of the rehabilitation programme. Another advantage of the study was that information about patients’ functioning was obtained from a medium-sized group of cancer patients referred to rehabilitation. The study provided insight into risk and resistances variables for quality of life, predictors of fatigue, and mechanisms of change in quality of life and fatigue.


��

General Discussion

Clinicalimplications

The patients in this study were referred on the presence of physical and psychological problems that appeared to be severe. The quality of life of the referred group of patients appeared to be low in relation to the normal population and to a reference group of cancer patients. Many patients reported higher scores on psychological distress than the cut-off score [4]. Moreover, the patients suffered highly from fatigue and their physical functioning appeared to be lower than predicted on the basis of age and gender. These findings underline the fact that (a) at least a part of the patients show poor adaptation to cancer or show a considerable amount of problems, and (b) this target population can be detected by the inclusion criteria used.

The results show that the rehabilitation programme under study has beneficial effects, with effect sizes ranging from ‘a small change’ to ‘a considerable change’ in the quality of life and degree of fatigue. Based on the low quality of life reported at baseline, these clinically relevant effects indicate that rehabilitation is beneficial and worthwhile for this group of patients. The findings are in line with findings of meta-analyses on the effect of psychosocial [5-7] and physical interventions [8;9], and with studies on combined interventions [10-12]. However, more research on the effectiveness of the programme is necessary, taking account of the methodological problems mentioned.

The programme appeared to be feasible for cancer survivors with various cancer diagnoses. This may also indicate that patients with several types of cancer apparently apply for rehabilitation or are referred to rehabilitation. However, an over-representation of breast cancer patients was included in the study population. Regarding disease-related variables, no effects of type of cancer, stage of disease, or time since completion of treatment were found, with the exception of change in health and pain. Regarding demographic variables, no effects of age and gender were found. Furthermore, the drop-out rate of the study was low and not related to age, gender, cancer diagnosis, time since diagnosis, and completion of treatment. Drop-out was predominantly based on cancer recurrence, and seemed not to be related to the intervention. It may therefore be concluded that the programme is applicable to a broad group of cancer patients.

The findings about patients’ preferences revealed that patients seem to prefer a multidimensional programme rather than a programme with one component. These findings may indicate that cancer survivors have a general preference for multidimensional programmes. An explanation for this may be the presence of complaints that are physical, psychological and /or social in nature. Patients may also consider ‘more’ as being ‘better’. The patients’ appreciation of the programme appeared to be high. The findings concerning patients’ preferences and appreciation imply that the programme is highly valued by the patients, which is of importance in ‘demand-driven’ working conditions. In addition, both findings plead for the implementation of the programme. However, one could argue that, when offered the choice before rehabilitation, patients may tend to label the ‘most’ as the most appropriate and, if asked after the completion of the rehabilitation course, they tend to remain satisfied with their choice, or, in other words, that a sort of ‘cognitive dissonance’ may occur [13]. Furthermore, although patients’ satisfaction is, of course, very important, it is not the same as quality of care.

Despite the fact that the effectiveness of the programme has been examined as a whole, some findings, such as the physiological improvements and the association between


General Discussion

��

reduction in fatigue and improvements in physical variables, indicate that the physical component (individual exercise and sports and games) seems to be a key component in cancer rehabilitation. The findings from recent meta-analyses [8;9;14;15] on the effect of aerobic exercise on aerobic capacity, fatigue, and quality of life underline the importance of physical exercise in cancer patients. The value of physical activity is also emphasized by recent cohort studies reporting that physical activity post-diagnosis has beneficial effects on cancer recurrence and survival [16;17]. Consequently, a comment entitled ‘Time to get moving?’[18] appeared in the Journal of Clinical Oncology in 2006, and aimed to draw attention to the protective associations of physical activity that occur post-diagnosis.

Although the results of the study showed no group effects on patients’ personal resources, improvements in the quality of life were associated with increased self-efficacy. This may indicate that it would be useful and beneficial to aim future programmes at an improvement in self-efficacy. In rehabilitation, two dimensions of self-efficacy seem to be important: self-efficacy at baseline and the amount of change in self-efficacy [19]. The former has been described as a predictor of quality of life [20] and of exercise adherence [21], while the latter is mostly the result of a feeling of having mastered something and is associated with improvement in quality of life and exercise adoption. It is known that self-efficacy is enhanced through experiences of mastery [22] but it is questionable whether mastery experiences of psychological tasks (such as stress management) or physical tasks (exercises or sports) actually result in the enhancement of self-efficacy. It has been reported that the successful performance of physical tasks results in an increase in self-efficacy. Furthermore, as a consequence of an increase in task-specific self-efficacy, a general feeling of self-efficacy may occur, indicating that a person may feel more competent to perform better in daily life [22]. Finally, a change in self-efficacy may be associated with an enhancement of mood and affective responses [21] which may be the reason why people feel better after physical training. Although physical training is mainly aimed at improving cardiovascular capacity, muscle strength and daily physical functioning, these latter results may also enhance the feeling of mastery [21].

Improvements in the quality of life also appeared to be associated with reductions in negative social support. What does this mean? On the one hand, such findings may refer to an inadequate social network which may imply, in that case, that significant others such as the partner, another family member, a friend, a colleague, or employer should be involved in the programme. On the other hand, patients may also have negative perceptions about relatively ‘neutral’ events, indicating that patients themselves may profit from a cognitive training in which they learn to change negative perceptions into more neutral cognitions.

Summarizing, the results of the this study indicate that a multidimensional rehabilitation programme has positive and clinically relevant effects on the quality of life and the degree of fatigue. These results induced the start of a follow-on study. This multi-centre study includes a rct on the effects of multidisciplinary rehabilitation on the quality of life compared to physical training and a waiting-list control group. A physical training programme, which was also the last subject of the present thesis, was developed for this rct. The physical training programme was developed on the best available evidence for the positive effects of aerobic exercise and progressive muscle-resistance training on aerobic capacity, muscle strength, fatigue, and physical role functioning [8;9;14;15]. The physical training programme was integrated with self-management and self-efficacy-enhancing techniques, based on the evidence for the positive effects of self-management


��

General Discussion

programmes and self-efficacy-enhancing techniques on health outcomes in various chronic diseases, on quality of life in cancer patients, on exercise adherence, and on the adoption of a physically active lifestyle. The resulting group training programme consists of several self-management modules. It is aimed at improving physical problems and may have the following advantages: (a) tailored physical training towards focusing on the patient’s established problems, and (b) provision of the training as a self-management programme that may have beneficial effects on health outcome, adherence, and a long-term physically active lifestyle. It is quite possible that an integrated physical programme of this type will have beneficial effects on quality of life, comparable to the multi-dimensional programme with four components. However, research ought to be conducted in order to examine the efficacy of the integrated programme more thoroughly.

How can rehabilitation help optimize cancer patients’ functioning? This question may refer to the amount of trainability: the amount by which patients are able to reduce the discrepancy between their current and their intended physical, psychological and social functioning [23]. Some patients may be more able to train than others, probably due to the presence or absence of certain characteristics. Furthermore, trainability refers to the construct of ‘training’, which reflects ‘the systematic appliance of (..) stimuli to force the body to adapt to and recover on a higher level of functioning’. Training often refers to physical training, but it may also include training from a psychosocial view, in line with the Biopsychosocial model [24] and the notion that interventions that dovetail with each other may enhance one another. In consensus with this, the literature on exercise among cancer patients reports that exercise combined with theory-based cognitive behavioural interventions (cbt) may improve exercise adherence and adoption of exercise in the long term [25]. The underlying thoughts here include the notion that rational cognitions and self-efficacy are predictors of exercise adherence and behavioural techniques – such as the enhancement of self-efficacy and stimulation of self-management regulation – and may be needed for the adoption of a physically active lifestyle [25]. Thus, in attempting to improve physical problems relevant to cancer patients, such as aspects of exercise capacity and fatigue, aerobic exercise seems to have a positive effect and can be combined with cbt. To improve psychological problems relevant to cancer patients, such as anxiety and depression, cbt is reported to have beneficial effects [7] while physical training can also positively affect depression [26]. So, combined intervention techniques may be the most appropriate.

Furthermore, rehabilitation techniques seem to be most beneficial and effective if they are provided in a way that patients themselves are able to reduce the discrepancy between current and intended functioning. This implies, for example, that problems and goals will be defined in collaboration with the individual patient [27]. Furthermore, rehabilitation seems to be most beneficial and effective if the physical and psychosocial techniques are provided in a tailor-made manner, which means applied individually and according to the individual’s needs. For physical training, this implies a programme that is tailored to individual physical problems, which are defined using maximum bicycle ergometry, for example, while the improvement of these problems can be reached using a plan based on this same ergometry. For the psychosocial component, tailor-made may imply that the cbt is defined as ‘exploration and change of individual and irrational perceptions, enhancement of self-management, including individual goal setting, self-monitoring, and self-reaction,


General Discussion

��

or the appliance of self-efficacy enhancing techniques’. Tailor-made does not imply, however, that the interventions are only geared to individuals; a tailor-made approach can also be used within a group-programme. The additional advantages of a group programme may be the opportunity to enhance self-efficacy through the processes of modelling, and the possibility to affect social support [28].

Implementation?Based on the above-mentioned results of the intervention study and on literature, a wholehearted ‘Yes’ would be the appropriate answer to the question as to whether rehabilitation may be beneficial to cancer patients. The response to the question as to whether oncological rehabilitation should be implemented also seems to be ‘Yes’. The question as to whether rehabilitation for cancer patients should be multidimensional in its nature also seems to require a positive answer. However, the methodological considerations of the present study do not make it possible to answer the question as to whether or not the programme should be implemented as a multidimensional programme including four components. Nevertheless, cancer rehabilitation programmes should be comprehensive and ought to address the multidimensional needs of the cancer patients during recovery [29].

From a normative and social perspective, however, it seems to be legitimate to say that it is a good initiative to implement the four-component multidimensional programme as a part of regular care for cancer patients. Definitively: the need for rehabilitation exists, patients are satisfied with the programme, and the programme seems to be feasible, beneficial, and to have clinically relevant effects. In the meantime, it is necessary to conduct more and good clinical research on the topic of oncological rehabilitation.

Further research on the effects of a physical training programme that is tailor-made and integrated with attention to illness perception and self-management ought to clarify whether this type of programme would be equally effective as a programme with four components. This seems to be interesting because of the aspect of cost-effectiveness. Until now (spring of 2007) the programme with four components has not been compensated by the basic health insurance policies in the Netherlands. The physical self-management programme developed could be more interesting to the health insurance companies. Beside the content of the programmes, however, the growing number of patients referred to rehabilitation demands open access to structural care provision.

When implementing oncological rehabilitation, attention should be paid to the referral of patients. The present inclusion and exclusion criteria for the programme seem to be appropriate, selecting a population of patients with persistent physical and psychosocial complaints after the completion of cancer treatment; thus, those who are most likely to need it are selected. However, our experience shows that there is a discrepancy between the percentage of patients that need rehabilitation (25-30%) [3] and the percentage of patients that are actually referred to rehabilitation. The impression exists that about 10% of the patients are currently referred to rehabilitation. Thus, referral seems to lag behind the need, whereas an adequate system of referral is essential for the cancer rehabilitation programme. Cancer rehabilitation seems an area that will continue to grow as medical professionals realize the necessity for post-cancer treatment intervention to improve the quality of life.

Furthermore, the question may be raised as to whether the figure of 25% is a good estimation of the number of patients that need rehabilitation, taking into account the


��

General Discussion

literature reporting a higher number of patients suffering from physical problems. For example, Chapter 6 reports that the number of cancer patients suffering from fatigue varies from 61% to 99%. Based on these figures, the 25% mentioned may be an underestimation of the need for rehabilitation. In contrast, not every person with problems actually needs support.

The way in which the cardiac rehabilitation is embedded in regular care could be taken into greater consideration when reviewing oncological rehabilitation. A distinctive feature of cardiac rehabilitation is the extent to which screening and selection are embedded in the process of referring patients to cardiac rehabilitation. Prior to cardiac rehabilitation, all patients who have undergone myocardial infarcts or bypass surgery are screened during hospitalization, just before discharge. Based on the extent and the nature of the problems, patients are selected for various forms of rehabilitation, such as a short programme for patients with physical problems or a lengthier programme for patients with both physical and psychological problems, and finally, a complex rehabilitation programme for those patients with severe physical and/or psychological problems. The screening prior to cardiac rehabilitation during the hospitalization period could serve as an example for oncological rehabilitation. The Comprehensive Cancer Centre North Netherlands has recently started a screening project in which the problems of cancer patients can be explored using a distress thermometer. On this basis, patients can be referred for support such as social work or rehabilitation.

If a cancer rehabilitation programme is implemented, it is important that the intervention is provided and implemented as intended. To ensure the integrity of the treatment, it is necessary that the designer of the programme delivers a good manual [30] with clear specifications of the content and procedures of the programme [31]. Besides this, it is recommended that therapists have affinity with the manner of working and should receive special training in physiology, psychology, and oncology. In addition, in chronic diseases such as cancer, it is quite possible that the approaches taken will be increasingly aimed at self-management. This may imply that the interventions change from therapist-oriented (i.e., the therapist prescribes the intervention while the patients follow these instructions) to patient-oriented, where the role of the therapist shifts from health-care provider to ‘coach’ [32]. A patient-oriented intervention is characterized by the patients’ active participation, taking personal responsibility and changing their lifestyle. Therapists supervise the self-management process by setting goals in collaboration with the patient, for example, guiding his or her actions (such as physical training), and initiating processes of self-reflection (providing feedback). During the pilot study of the integrated physical self-management programme, we observed that therapists relapsed into their usual roles and preferences, which is a threat to the integrity of the treatment [33]. Finally, to ensure the integrity of the treatment, patients should also understand and commit themselves to the self-management approach by assuming responsibility and displaying active participation. Providing good information and an estimation of expectations and goal-setting may contribute to this end.

Theoreticalreflections

At the start of the study, the International Classification of Functioning, Disability and Health (icf) model was taken as a starting point, as it is useful for the classification of problems. The problems of cancer patients can be adequately reported in terms of function, activities and participation, especially from a rehabilitation perspective. However, despite


General Discussion

��8

the usefulness of this model to classify problems, it may be less useful as a framework for guiding research aiming to understand relationships between physical and psychological problems, to capture the adaptation process, and to develop supportive interventions.

Other frameworks such as the Biopsychosocial model [34] may be more useful for understanding associations between physical and psychosocial problems and for developing interventions. The Biopsychosocial model may also be useful as an entry point, and also indicates the interdependence between the various dimensions, which seems to be useful in the rehabilitation of cancer patients. This interdependence includes the situation that physical problems may also result in psychosocial problems and vice versa, and that, besides physical effects, physical interventions may have psychosocial effects, and that psychosocial interventions may have a conditional effect on physical problems. Additionally – and importantly – interventions that fit together may also enhance one another. In the present thesis on cancer rehabilitation in patients who were referred on the basis of the presence of combined physical and psychosocial problems, the Biopsychosocial model functioned as (1) a framework for problems and for the development of the multidimensional programme with four components, and as (2) a theoretical fundament in the integrated physical self-management programme in which a deliberate choice was made in favour of physical and psychosocial intervention techniques that would enhance one another.

In addition, the Self-regulatory model [35] and the Common Sense model of Leventhal [36] may provide better guidance in understanding the process of adaptation to changes in life. Furthermore, the Self-regulatory model may provide more tools to develop behavioural interventions such as self-management programmes, whereas the Common Sense model may be helpful in developing cognitive interventions. Self-regulation theory focuses on the ways in which individuals direct and monitor their activities and emotions in order to attain their goals [37]. Self-management covers the six phases of goal setting, monitoring, comparing, decision making, taking action, and self-reaction that may also determine the development of future programmes, in addition to providing insight. Leventhal’s Common Sense model [36] illustrates that patients’ perceptions about their disease may affect their coping with the disease and their final functioning [38]. It appears that perceptions of illness can be changed therapeutically [39], and may serve as predictors for the attendance during cardiac rehabilitation [40].

To capture the physical adaptation process and to develop a physical training intervention, a study of physiology and of the model of Wasserman [41] may be helpful. This model illustrates that patients’ exercise capacity may be reduced due to various reasons, which also seem relevant in cancer rehabilitation. Through the appropriate application of physiological training principles, a number of causes of reduced exercise capacity, such as loss of oxygen uptake or muscle strength, for example, may be treated adequately.

Finally, Bandura’s Social Cognitive theory [22] provides a framework with the main construct of self-efficacy that mediates physical and psychological health. In addition, the construct appears to be predictive for quality of life and for exercise adherence, while change in self-efficacy is associated with the adoption of exercise in the longer term. Because self-efficacy originates from four sources – mastery experiences, verbal persuasion, modelling and physiological arousal – it seems to be very applicable to integrate the construct in physical interventions.


��

In sum, the above-mentioned models can play a role in oncological rehabilitation programmes because they provide insight into associations and provide a foundation for interventions. The Biopsychosocial system perspective provides a basis for the understanding of associations between physical and psychosocial problems and their consequent interventions in cancer patients. The Self-regulation model [35], the Common Sense model [36] and the Social-Cognitive theory [22] may be of importance for the development of future interventions aimed at behavioural change, such as the adoption of a physically active lifestyle. This assumption is made on the knowledge that cognitive preparation precedes behavioural change [42] and that phases of self-regulation (such as goal setting) and self-efficacy-enhancing techniques may be easily incorporated in an intervention, and may therefore be valuable for oncological rehabilitation programmes.

Futureresearch

Future research should examine the effects of the multidimensional programme more thoroughly, and should also be aimed at the examination of the effects of the various components. Therefore, a rct should examine the effects on the quality of life, using a full factorial design which means a multidimensional programme (psycho-education and physical training), a physical programme, a psycho-educational programme, and a (waiting) list control group.

Further research is required in order to explore the association between physical training, illness perception and self-efficacy and the effectiveness on proactive coping, exercise adherence, self-management skills and a physically active lifestyle in cancer patients. In addition, future research could also examine the effects of the integrated physical self-management programme on the quality of life and on fatigue, in comparison to a control group and a placebo group. Besides the effect on the quality of life, it would be interesting to conduct more research on the effects of the programme on the resumption of work.

Although the multidimensional programme was feasible for various types of cancer, the number of patients with cancer types other than breast cancer was low per diagnosis group. Therefore, future research should include more patients with various types of cancer and should investigate whether or not different programmes would be effective for patients with different types of cancer.

Furthermore, the study showed that fatigue and quality of life after the rehabilitation programme were mainly associated with fatigue and quality of life at the baseline. This suggests that it could be more beneficial if problems could be prevented and/or that it would be interesting to examine the effect of screening and of early intervention. Further research may be aimed at the examination of the effects of only physical or combined rehabilitation performed at an earlier stage of the disease, such as during cancer treatment. Until now, no rcts to measure the effects of physical training during chemotherapy or radiotherapy have been conducted in the Netherlands. However, a number of foreign studies show that ‘aerobic exercise’ during cancer treatment may prevent physical deterioration [43-45]. In line with this, the effects of pre-surgery exercise on exercise capacity, muscle strength, fatigue and post-surgery complications can be examined in some types of cancer.

More research should be done on the intensity of physical training. The current impression is that the intensity of physical training may vary between 60 to 80% of the maximum heart rate in patients without co-morbidity and with an objective reduction of

General Discussion


��0

exercise capacity. However, it has been reported that over-intensity of physical training may have negative effects on fatigue and on quality of life [46]. This is supported by a meta-analysis [21] that concluded that moderate intensity in healthy subjects may be more effective in enhancing psychological well-being than high intensity. Because moderate intensity is also recommended for its beneficial effect on physical health, this implies that a high intensity is not necessary to promote physical and psychological health, but further research in cancer patients seems to be warranted. In addition, more research should be devoted to the safety of increased physical activity, especially among groups of survivors in which cardiotoxity is frequently reported.

Finally, further research should pay more attention to the role of social support in cancer rehabilitation. The finding that the experience of negative social support has both a concurrent and prospective negative effect on quality of life, and that change of negative social support is associated with improvements in quality of life should be involved in the development of screening measures, future interventions, and consequent research.

General Discussion


��

ReferenceList

[1] Zabora JR, Blanchard CG, Smith ED, Roberts CS, Glajchen M, SHarp JW, BrintzenhofeSzoc KM, Locher JW, Carr EW, Best-Castner S, Smith PM, Dozier-Hall D, Polinsky LM, Hedlund SC. Prevalence of psychological distress among cancer patients across the disease continuum. J Psychosocial oncol 1997; 15: 73-87.



[4] de Haes JC, van Knippenberg FC, Neijt JP. Measuring psychological and physical distress in cancer patients: structure and application of the Rotterdam Symptom Checklist. Br J Cancer 1990; 62: 1034-1038.

[5] Meyer TJ, Mark MM. Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 1995; 14.: 101-108.

[6] Sheard T, Maguire P. The effect of psychosocial interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 1999; 80: 1770-1780.

[7] Osborn RL, Demoncada AC, Feuerstein M. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses. Int J Psychiatry Med 2006; 36: 13-34.

[8] Schmitz KH, Holtzman J, Courneya KS, Masse LC, Duval S, Kane R. Controlled physical activty trials in cancer survivors: a systematic review and meta-analyses. Cancer Epidemiol Biomarkers Prev 2005; 14: 1588-1595.

[9] McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ 2006; 175: 34-41.




[13] Festinger L. Cognitive dissonance. Sci Am 1962; Oct: 93-102.

[14] Conn VS, Hafdahl AR, Porock DC, McDaniel R, Nielsen PJ. A meta-analyses of exercise interventions among people treated for cancer. Support Care Cancer 2006; 14: 699-712.

[15] Stevinson C, Lawlor DA, Fox KR. Exercise interventions for cancer patients: systematic review of controlled trials. Cancer Causes Control 2004; 15: 1035-1056.

[16] Meyerhardt JA, Heseltine D, Niedzwiecki D, Hollis D, Saltz LB, Mayer RJ, Thomas J, Nelson H, Whittom R, Hantel A, Schilsky RL, Fuchs CS. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol 2006; 24: 3535-3541.

[17] Meyerhardt JA, Giovannucci EL, Holmes MD, Chan AT, Chan JA, Colditz GA, Fuchs CS. Physical activity and survival after colorectal cancer diagnosis. J Clin Oncol 2006; 24: 3527-3534.

[18] Demark-Wahnefried W. Cancer survival: time to get moving? Data accumulate suggesting a link between physical activity and cancer survival. J Clin Oncol 2006; 24: 3517-3518.

[19] Brassington GS, Atienza AA, Perczek RE, DiLorenzo TM, King AC. Intervention-related cognitive versus social mediators of exercise adherence in the elderly. Am J Prev Med 2002; 23: 80-86.


[21] Netz Y, Wu MJ, Becker BJ, Tenenbaum G. Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol Aging 2005; 20: 272-284.

[22] Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol-Rev 1977; 84: 191-215.

[23] van Weert E, Meijer S, Nijkrake P. Trainbaarheid van patiënten in het UMCG, onderzoekslijn van de discipline Fysiotherapie. Groningen: 2006: 1-17.

General Discussion


��

[24] Engel GL. From biomedical to biopsychosocial. Being scientific in the human domain. Psychosomatics 1997; 38: 521-528.

[25] Pickett M, Mock V, Ropka ME, Cameron L, Coleman M, Podewils L. Adherence to moderate-intensity exercise during breast cancer therapy. Cancer Pract 2002; 10: 284-292.

[26] Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001; 322: 763-767.

[27] Ponte-Allan M, Muir Gilles G. Goal setting and functional outcomes in rehabilitation. Am J Occup Ther 1999; 53: 646-649.


[29] Schneider CM, Dennehy CA, Roozeboom M, Carter SD. A model program: exercise intervention for cancer rehabilitation. Integr Cancer Ther 2002; 1: 76-82.

[30] Fuhrer MJ. Overview of clinical trials in medical rehabilitation: impetuses, challenges, and needed future directions. Am J Phys Med Rehabil 2003; 82: S8-15.

[31] Bond GR, Evans L, Salyers MP, Williams J, Kim HW. Measurement of fidelity in psychiatric rehabilitation. Ment Health Serv Res 2000; 2: 75-87.

[32] Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002; 288: 2469-2475.

[33] Waltz J, Addis ME, Koerner K, Jacobson NS. Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. J Consult Clin Psychol 1993; 61: 620-630.

[34] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129-136.

[35] Carver C, Scheier M. On the self-regulation of behavior. New York: Cambridge University Press; 1998.

[36] Leventhal H, Safer MA, Panagis DM. The impact of communications on the self-regulation of health beliefs, decisions, and behavior. Health Educ Q 1983; 10: 3-29.

[37] Creer TL. Self-management of chronic illness. In: M.Boekaerts & P.R.Pintrich (ed.), Handbook of self-regulation. San Diego, CA, US.: Academic Press.; 2000: 601-629.



[40] French DP, Cooper A, Weinman J. Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: a systematic review with meta-analysis. J Psychosom Res 2006; 61: 757-767.

[41] Wasserman K, Hansen JE, Sue D, Stringer W, Whipp B. Principles of exercise training and interpretation, 4 ed. Lippincott Williams & Wilkins; 2005: 1-585.

[42] Schreurs KM, Colland V, Kuijer R, de Ridder D, van Elderen T. Development, content, and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviours. Patient Educ Couns 2003; 51: 133-141.

[43] Segal RJ, Reid RD, Courneya KS, Malone SC, Parliament MB, Scott CG, Venner PM, Quinney HA, Jones LW, D’Angelo ME, Wells GA. Resistance exercise in men receiving androgen deprivation therapy for prostate cancer. J Clin Oncol 2003; 21: 1653-1659.

[44] Coleman EA, Hall-Barrow J, Coon S, Stewart CB. Facilitating exercise adherence for patients with multiple myeloma. Clin J Oncol Nurs 2003; 7: 529-34, 540.

[45] Campbell A, Mutrie N, White F, McGuire F, Kearney N. A pilot study of a supervised group exercise programme as a rehabilitation treatment for women with breast cancer receiving adjuvant treatment. Eur J Oncol Nurs 2005; 9: 56-63.

[46] Thorsen L, Skovlund E, Stromme SB, Hornslien K, Dahl AA, Fossa SD. Effectiveness of physical activity on cardiorespiratory fitness and health-related quality of life in young and middle-aged cancer patients shortly after chemotherapy. J Clin Oncol 2005; 23: 2378-2388.

General Discussion


��

8 Summary

Despite the life-threatening nature of the illness, many cancer patients seem to be able to cope well with the diagnosis and the treatment. However, cancer and its treatment often go hand in hand with physical, psychological and social problems. Fatigue is one of the most important complaints expressed by cancer patients. After treatment, around 30% of the patients experience so many problems in the field of quality of life that they require professional support to help them deal with these.

Oncological rehabilitation is one form of support. The number of cancer patients in the Netherlands requiring rehabilitation is expected to rise from 5000 in the year 2000 to 7000 in 2015. There is still much uncertainty concerning the effect of cancer rehabilitation on the quality of life. For example, it is unclear why some people benefit from cancer rehabilitation while others do not. This doctoral thesis is the first in the Netherlands to devote attention purely to oncological rehabilitation. The aims of this thesis are to examine the effect of cancer rehabilitation on the quality of life and on the degree of fatigue experienced by cancer patients, and to gain more insight into the factors that are related to the quality of life and the feeling of fatigue before and after cancer rehabilitation.

Chapter 1 describes the background to the study. A concise picture of cancer and cancer treatment is sketched, as well as the consequences of these for the quality of life of cancer patients. The chapter further discusses the concept of ‘quality of life’ and the need for professional support such as forms of psychosocial and physical intervention. The relevant literature indicates that such intervention has positive effects upon physical and psychosocial problems and consequently upon the quality of life of cancer patients. From this intervention, a transition is made to multidimensional oncological rehabilitation, based on the notion that the multidimensional problems of cancer patients may be effectively treated by means of a programme that consists of several components. The problems of the cancer patients are charted with the help of the International Classification of Functioning, Disability and Health (icf) model. Subsequently, an overview is provided of the thesis, which is primarily oriented toward research of the effect of a multidimensional rehabilitation programme that was developed in 1999. The last chapter of the thesis devotes attention to the development of a physical training programme for cancer patients that was developed for a national follow-on study.

The multidimensional programme that was developed consists of physical training, sport and games, psycho-education, and information. The programme is implemented in a group setting, and is intended for adult cancer patients with various forms of cancer whose cancer-related treatment has been completed, who have a life expectancy of more than a year, and who have been referred for rehabilitation. This last element implies the presence of persistent physical or psychosocial complaints that have been determined by a doctor.

Chapter 2 examines the effect of the intensive part of the multidimensional rehabilitation programme (the first 6 weeks) on physiological functioning and the


Summary

��

quality of life. The study expected that the intensive part of the programme would have a positive effect on the quality of life and would also bring physiological improvements. Thirty-four patients participated in this study. Two third of those were women with breast cancer, the average age was 53 years. The results showed that the most common reasons for referral were a reduced exercise capacity and fatigue. The participants turned out to be perfectly capable of following the programme and the drop-out rate was low (8%). After 6 weeks, statistically significant improvements were found in measurements of physical capabilities such as oxygen pulse, oxygen uptake, muscle strength and muscle fatigue, but not in dyspnoea. After 6 weeks, significant improvement was also found in various physical and psychosocial domains of the quality of life. Moreover, patients reported significantly less fatigue in a number of domains. The hypothesis that the intensive part of the programme would result in physiological improvements was confirmed. The hypothesis that the intensive part of the programme would result improvements in quality of life was confirmed in a number of domains of both disease-specific and generic quality of life and degree of fatigue. On the basis of these results, the conclusion can be drawn that a 6-week intensive multidisciplinary rehabilitation programme is feasible and effective. Despite the fact that it was not possible to examine the effect of the separate components of the programme, the physiological improvements found do indicate that they can be attributed to physical training.

Chapter 3 researches the effect of the total multidimensional programme on the quality of life and on the exercise capacity. At the same time, the participants’ appreciation of the programme was also studied. Because patients are increasingly being regarded as experts in the field of their own health, the aim was also to obtain more insight into the preferences of patients for mono- or multi-dimensional rehabilitation. Accordingly, in the study, after group randomization, half of the groups were offered a multi-dimensional programme, while the other half could choose the programme components they wished to follow. Eighty-one patients participated in this study, the average age was fifty-two years, sixteen per cent of the participants were male, and two-thirds of the participants were women with breast cancer. The drop-out was twenty-two per cent and primarily related to a recurrence, and was not associated with age, gender, diagnosis, and time since treatment or diagnosis. The study population appeared to have significantly more problems in the field of quality of life than a matched reference group of cancer patients who had not been referred for rehabilitation, and more than the normal Dutch population. Ninety-seven per cent of the participants scored above the cut-off psychological distress score. Muscle-strength tests indicated that the strength of the lower extremities in particular had diminished. The results after the completion of the programme showed significant and clinically relevant improvements in all domains of quality of life, most of which also persisted into the follow-up measurement three months later. The maximum cycling ergometric tests and muscle-strength tests demonstrated significant improvement after the completion of the programme. No differences were found in the results between men and women, nor between the women who had breast cancer and people who had a different form of cancer. The patients were satisfied with the entire programme and also with the various components of the programme. An interesting finding was that most patients who had the opportunity to make a choice between the different components of the programme tended to choose the entire programme rather than only a part of it. At the completion of the programme, the majority of the participants would again choose the entire programme


��

Summary

if they were asked, although the percentage of people who opted for a multidimensional programme after the completion of the programme was lower than it was before the start. On the basis of the results of the study, it can be concluded that the referred patients have a low quality of life and that the programme has a positive, significant and clinically relevant effect on the quality of life in terms of physical, psychological and social functioning. In addition, a multidimensional programme appears to be feasible for a broad group of patients. Finally, if patients are offered the choice, the majority will opt for multidimensional rehabilitation.

Chapter 4 attempts to acquire more insight into variables that are correlated to improvements in the quality of life. For this reason, both prior to and after the rehabilitation programme, the relationship between a number of sociodemographic data and personal resources such as social support (external resource) and self-efficacy (internal resource) on the one hand, and the quality of life, on the other, was studied. At the same time, investigation was performed into whether or not the programme had an effect on the personal resources. Prior to the study, it was expected that, besides the positive effect on the quality of life, the programme would also have a positive effect on the social support experienced and on self-efficacy. Due to the group-oriented approach, it was expected that the programme would have a positive effect on the social support experienced because contact with peers facilitates processes of social support and social comparison. It was expected that the physical training programme and the psycho-education would have a positive effect on self-efficacy because this form of control arises on the basis of success experiences in the performance of tasks, vicarious experiences, verbal persuasion, and physiological arousal. With regard to the relationship between the personal resources and the quality of life, it was expected that the personal resources would have a positive effect on the physical, psychological and social functioning of the participants. The results showed that the referred patients experienced more negative support than a reference group of recently-diagnosed patients, and more than the normal population. The referred population also experienced more positive social support than the normal population but less than the reference group of newly-diagnosed patients. Further, at the conclusion of the programme, a statistically significant reduction in positive social support seemed to have occurred while no change in negative social support and self-efficacy was found. People with more negative social support reported poorer social functioning prior to the programme and poorer physical, social and psychological functioning after completion of the programme. Negative support, as experienced prior to the programme, also had a negative effect on mental functioning after the programme. People with a high degree of self-efficacy reported better mental functioning prior to the programme and better physical and mental functioning after the programme. Furthermore, the quality of life prior to the rehabilitation programme turned out to be the best predictor for the quality of life after the programme. Finally, reduction in negative social support and improvement in self-efficacy seemed to be related to improvement in the quality of life. On the basis of the results, it can be concluded that the rehabilitation programme has little effect on the personal resources of the participants, although a question mark may be inserted against the sensitivity of the questionnaire for measuring this self-efficacy. Further, negative social support and self-efficacy turned out to be more consistent predictors of the quality of life than positive social support. Finally, the conclusion can be drawn that although the programme does not lead to improvement in self-efficacy and to a reduction of negative social support at group


Summary

��

level, improvement in the quality of life at individual level is associated with increased self-efficacy and diminished negative social support. Accordingly, the recommendation is made that future programmes ought to be structured with the aim of improving self-efficacy and reducing negative social support. A practical implication of the study is also that cancer patients who experience much negative social support form a high-risk group in terms of poorer functioning and therefore ought to be given more attention.

In view of the fact that fatigue is one of the most commonly reported complaints after cancer has been diagnosed, Chapter 5 presents a study on the fatigue of patients who have been referred for rehabilitation. Fatigue is regarded as a multidimensional construct and the primary aim of the study is to research the effect of diverse variables on fatigue prior to rehabilitation. A second aim is to study the effect of the multidisciplinary rehabilitation programme on fatigue, and to investigate if, and to what extent, any change in fatigue after an intervention is related to changes in predictors that have been identified prior to rehabilitation. Within 72 patients, the relation between the different variables and the five different dimensions of fatigue was examined prior to the intervention. The effect upon fatigue of demographic variables, disease and treatment-related variables, anthropometric data, physiological variables, physical and psychological distress symptoms, and experienced functioning was investigated. Analyses indicated that various dimensions of fatigue were related to various physical and psychosocial parameters, which underlines the multidimensional nature of fatigue. Further analyses showed that the maximum workload, physical symptoms, the experienced physical functioning, mental functioning, role limitation on the basis of physical functioning, and self-efficacy were the most important predictors of fatigue at the baseline. The results of the 56 participants who had completed the programme further indicated that the rehabilitation programme had positive and, more importantly, clinically relevant effects upon all dimensions of fatigue. The largest reduction in fatigue was found in the physical dimension. Furthermore, it turned out that fatigue prior to the rehabilitation programme was the most important predictor of fatigue after the intervention. Finally, it was found that reduction in fatigue was largely related to improvement in the physical parameters. The patients who reported less physical symptom stress, better physical functioning, and fewer limitations based on physical functioning had fewer problems with fatigue. Despite the fact that it was not possible to investigate the effect of the various programme components, the findings seem to support the recommendation that future interventions ought to include a physical training component.

Chapter 6 describes the development of a physical self-management programme. This programme was developed for a national randomized controlled trial (rct, the Onco-Rev study) which investigates, between 2003 and 2007, the effects of a multidisciplinary rehabilitation programme on the quality of life and compared it to physical training and to a (waiting list) control group. The aim of the study outlined in this thesis is to develop a physical training programme whose content and delivery are based upon the best available evidence. For the content of the programme, four frequently-occurring, related, but conceptually and empirically different physical problems of cancer patients were distinguished, namely, a reduced aerobic capacity, diminished muscle strength, fatigue, and role limitation due to physical problems. A study of the relevant literature was performed to find evidence of the effect of exercise programmes on aerobic capacity, muscle strength, fatigue and limited physical (role) functioning. With regard to the delivery, investigation was carried out into differences in evidence with regard to individual


��

Summary

versus group-oriented programmes, local fitness exercises versus sport programmes, and self-management or self-efficacy-enhancing programmes versus traditional interventions. With regard to the effect of exercise, the study produced findings that varied from evidence at rct level for muscle strength to evidence at meta-analysis level for fatigue, physical (role) functioning, and aerobic capacity. With regard to the delivery, no evidence was found for differences in the effect between individual and group programmes, or between local exercise and sport. There was evidence at meta-analysis level that self-management programmes and programmes with self-efficacy-enhancing techniques have positive effects on health-related outcomes with various chronic illnesses, on the quality of life among cancer patients, and on exercise therapy adherence and the adoption of physically active behaviour. The rehabilitation programme was developed on the basis of the best available evidence with regard to the content and the delivery. The possible advantages of the programme are (a) tailor-made physical training oriented to the established problems of the patient, (b) the delivery of the training as a self-management programme that can have positive effects on health-related outcomes, the quality of life, exercise adherence, and a physically active lifestyle in the long run.

In Chapter 7, the results of the study are placed in a broader context. Attention is devoted to the most important findings, methodological considerations, clinical implications, and future research.



��

Samenvatting

Ondanks het levensbedreigende karakter van de ziekte blijkt een groot deel van de mensen met kanker de diagnose en de behandeling goed te verwerken. Echter, kanker en de behandeling daarvan gaat vaak gepaard met fysieke, psychische en sociale problemen. Een van de belangrijkste klachten na kanker is vermoeidheid. Ca 30% van de patiënten ervaart na de behandeling nog zoveel problemen op het gebied van kwaliteit van leven dat zij daarvoor professionele ondersteuning nodig hebben.

Een vorm van ondersteuning is oncologische revalidatie. Verwacht wordt dat het aantal kankerpatiënten in Nederland dat revalidatie nodig heeft, zal stijgen van 5000 in het jaar 2000 tot 7000 in 2015. Nog veel is onduidelijk over het effect van kankerrevalidatie op de kwaliteit van leven. Ook is het bijvoorbeeld nog onduidelijk waarom sommige mensen wel en andere mensen geen baat hebben bij kankerrevalidatie. Dit proefschrift is het eerste in Nederland dat zich richt op oncologische revalidatie. Het doel van dit proefschrift is om het effect van kankerrevalidatie op de kwaliteit van leven en vermoeidheid te onderzoeken, en om meer inzicht te krijgen in factoren die samenhangen met de kwaliteit van leven en vermoeidheid voor en na kankerrevalidatie.

In hoofdstuk 1 wordt de achtergrond van het onderzoek beschreven. Eerst wordt een beknopt beeld geschetst van kanker en kankerbehandelingen, en de gevolgen daarvan op de kwaliteit van leven van kankerpatiënten. Er wordt ingegaan op het begrip kwaliteit van leven en op de behoefte aan professionele ondersteuning, zoals psychosociale en fysieke interventies. Van beide interventies worden in de literatuur positieve effecten op de fysieke en psychosociale problemen en daarmee op de kwaliteit van leven van kankerpatiënten gerapporteerd. Daarna wordt een overgang gemaakt naar multidimensionele oncologische revalidatie, gebaseerd op de gedachte dat multidimensionele problemen van kankerpatiënten mogelijk effectief behandeld kunnen worden met een programma dat uit meerdere componenten bestaat. De problemen van kankerpatiënten worden met behulp van het International Classification of Functioning, Disability and Health (icf) model in kaart gebracht. Daarna wordt een overzicht gegeven van de thesis die zich met name richt op onderzoek naar het effect van een in 1999 ontwikkeld multidimensioneel revalidatieprogramma. Het laatste hoofdstuk van de thesis besteedt aandacht aan ontwikkeling van een fysiek trainingsprogramma voor kankerpatiënten ten behoeve van een landelijke vervolgonderzoek.

Het ontwikkelde multidimensionele programma bestaat uit fysieke training, sport en spel, psycho-educatie en voorlichting en vindt groepsgewijs plaats. Het programma is bedoeld voor volwassen kankerpatiënten met verschillende vormen van kanker, bij wie de kankergerelateerde behandeling afgerond is, die een levensverwachting van meer dan 1 jaar en een indicatie voor revalidatie hebben. Dit laatste impliceert aanwezigheid van persisterende fysieke en/of psychosociale klachten, vastgesteld door een arts. In hoofdstuk 2 wordt het effect van het intensieve deel (i.e. de eerste 6 weken) van het multidimensionele revalidatieprogramma op fysiologisch functioneren en kwaliteit van leven onderzocht. In de beschreven studie werd verondersteld dat het intensieve deel van het programma positieve effecten zou hebben op kwaliteit van leven en fysiologische verbeteringen met zich mee zou brengen. 34 patiënten namen deel aan deze studie. Twee derde van de revalidanten was vrouw met borstkanker, de gemiddelde leeftijd lag op 53 jaar. Uit de resultaten bleek


��0

dat de meest voorkomende reden van verwijzing een gereduceerd inspanningsvermogen en vermoeidheid was. De deelnemers bleken goed in staat het programma te volgen en de uitval was laag (8%). Na 6 weken werden statistisch significante verbeteringen gevonden in fysieke uitkomstmaten zoals zuurstofpuls, zuurstofopname, spierkracht en spiervermoeidheid, maar niet in dyspneu. Na 6 weken werden ook significante verbeteringen gevonden in diverse fysieke en psychosociale domeinen van kwaliteit van leven. Verder rapporteerden patiënten in een aantal domeinen significant minder vermoeidheid. De hypothese dat het intensieve gedeelte van het programma zou resulteren in fysiologische verbetering werd bevestigd. De hypothese dat dit programma een positief effect zou hebben op de kwaliteit van leven werd bevestigd in een aantal domeinen van zowel ziektespecifieke als generieke kwaliteit van leven en vermoeidheid. Op basis van deze resultaten kan geconcludeerd worden dat een intensief multidimensioneel revalidatieprogramma van 6 weken haalbaar en effectief is. Ondanks het feit dat het niet mogelijk was het effect van de afzonderlijke componenten van het programma te onderzoeken, wijzen de gevonden fysiologische verbeteringen erop dat deze toegeschreven kunnen worden aan de fysieke training.

In hoofdstuk 3 wordt eerst het effect van het totale multidimensionele programma op de kwaliteit van leven en het inspanningsvermogen onderzocht. Tevens wordt onderzocht hoe het programma wordt gewaardeerd door de deelnemers. Omdat patiënten steeds meer gezien worden als experts op het gebied hun eigen gezondheid, is tevens het doel meer inzicht te krijgen in de preferenties van patiënten voor mono- of multidimensionele revalidatie. In de beschreven studie werd daarom, na groepsrandomisatie, de helft van de groepen een multidimensioneel programma aangeboden, terwijl de andere helft kon kiezen welke programma onderdelen zij wilden volgen. 81 patiënten namen deel aan deze studie, de gemiddelde leeftijd was 52 jaar, 16 procent van de participanten was man, en tweederde van de deelnemers was vrouw met borstkanker. De uitval was 22% en voornamelijk gerelateerd aan het optreden van een recidief en niet geassocieerd met leeftijd, geslacht, diagnose en tijd sinds behandeling of diagnose. De studiepopulatie bleek significant meer problemen te hebben op het gebied van de kwaliteit van leven dan een gematchte referentiegroep van kankerpatiënten die niet verwezen was voor revalidatie en de normale Nederlandse bevolking. Voorafgaand aan het programma scoorde 97% van de deelnemers boven de cut-off score van psychische stress, en spierkrachttesten lieten zien dat de spierkracht van de onderste extremiteit aanzienlijk gereduceerd was. De resultaten na afloop van het programma lieten significante en klinisch relevante verbeteringen zien in alle domeinen van kwaliteit van leven, waarvan de meeste ook persisteerden bij de follow-up meting na 3 maanden. Ook de maximale fietsergometrietesten en spierkrachttesten lieten een significante verbetering na afloop van het programma zien. Er werden geen verschillen gevonden voor mannen en vrouwen en tussen vrouwen die borstkanker hadden en mensen die een andere vorm van kanker hadden. Patiënten waren tevreden over het gehele programma en over de diverse onderdelen ervan. Een interessante bevinding was dat de meeste patiënten die in de gelegenheid werden gesteld een keuze te maken uit de diverse componenten van het programma, eerder de neiging hadden het gehele programma te kiezen, dan slechts onderdelen ervan. Na afloop van het programma zou de meerderheid van de deelnemers ook het gehele programma opnieuw kiezen als hen dat gevraagd werd, hoewel het percentage mensen dat voor een multidimensioneel programma koos na afloop van het programma lager was dan voor de start. Op basis van de resultaten van de studie

Samenvatting


��

kan geconcludeerd worden dat de verwezen patiënten een lage kwaliteit van leven hebben en dat het programma positieve, significante en klinische relevante effecten heeft op de kwaliteit van leven zoals het fysieke, psychische en sociale functioneren. Verder blijkt een multidimensioneel programma voor een brede groep patiënten haalbaar. Ten slotte, als patiënten de keuze krijgen, kiest de meerderheid voor multidimensionele revalidatie.

In hoofdstuk 4 wordt getracht meer inzicht te krijgen in variabelen die verband houden met verbetering van kwaliteit van leven. Daarom wordt de relatie onderzocht tussen een aantal sociodemografische gegevens en persoonlijke kenmerken zoals sociale steun (extern kenmerk) en zelfeffectiviteit (intern kenmerk) aan de ene kant, en kwaliteit van leven aan de andere kant, zowel voor als na afloop van het revalidatieprogramma. Tevens wordt onderzocht of het programma effect heeft op de persoonlijke kenmerken. Voorafgaand aan de studie werd verwacht dat het programma naast het beoogde positieve effect op kwaliteit van leven ook een positief effect zou hebben op de ervaren sociale steun en zelfeffectiviteit. Vanwege de groepsgeoriënteerde benadering werd verwacht dat het programma een positief effect zou hebben op de ervaren sociale steun, omdat door het contact met lotgenoten processen van sociale steun en sociale vergelijking gefaciliteerd worden. Van het fysieke trainingsprogramma en de psychoeducatie werd een positief effect op de zelfeffectiviteit verwacht omdat deze vorm van controle onder andere tot stand komt op basis van succes ervaringen bij het uitvoeren van taken en door vergelijkende ervaringen, verbale overtuigingen en het fysiologische arousal niveau. Ten aanzien van de relatie tussen de persoonlijke kenmerken en de kwaliteit van leven werd verwacht dat zij een positief effect zouden hebben op het fysieke, psychische en sociale functioneren van de deelnemers. Uit de resultaten bleek dat de verwezen patiënten meer negatieve sociale steun ervoeren dan een referentiegroep van recent gediagnosticeerde patiënten en de normale bevolking. De verwezen populatie ervoer tevens meer positieve sociale steun dan de normale bevolking maar minder dan de referentie groep van pas gediagnosticeerde patiënten. Verder bleek na afloop van het programma een significante afname van positieve sociale steun te zijn opgetreden terwijl er geen veranderingen in negatieve sociale steun en zelfeffectiviteit werden gevonden. Mensen met meer negatieve sociale steun rapporteerden een slechter sociaal functioneren voor, en slechter fysiek, sociaal en psychisch functioneren na afloop van het programma. Negatieve steun zoals ervaren voor het programma had ook een negatief effect op mentaal functioneren na afloop van het programma. Mensen met een hoge mate van zelfeffectiviteit rapporteerden een beter mentaal functioneren voor, en een beter fysiek en mentaal functioneren na afloop van het programma. Verder bleek de kwaliteit van leven voor het revalidatieprogramma de belangrijkste voospeller voor de kwaliteit van leven na afloop van het programma te zijn. Ten slotte bleek een afname van negatieve sociale steun en een verbetering van zelfeffectiviteit samen te hangen met verbetering van de kwaliteit van leven. Op basis van de resultaten kan geconcludeerd worden dat het revalidatieprogramma weinig effect heeft op de persoonlijke kenmerken van de deelnemers, hoewel een vraagteken geplaatst kan worden bij de sensitiviteit van de vragenlijst om zelfeffectiviteit te meten. Verder blijken negatieve sociale steun en zelfeffectiviteit meer consistente voorspellers voor de kwaliteit van leven te zijn dan positieve sociale steun. Ten slotte kan geconcludeerd worden dat hoewel het programma niet leidt tot verbetering van de zelfeffectiviteit en tot afname van negatieve sociale steun op groepsniveau, verbetering van de kwaliteit van leven op individueel niveau wel samen hangt met toegenomen zelfeffectiviteit en afgenomen negatieve sociale steun. Aanbevolen wordt dan ook om toekomstige programma’s in te richten op verbetering van zelfeffectiviteit en afname van negatieve sociale steun. Een praktische implicatie van de studie is tevens dat

Samenvatting


��

kankerpatiënten die veel negatieve sociale steun ervaren een risicogroep vormen voor slechter functioneren en daarom meer aandacht verdienen. Aangezien vermoeidheid een van de meest gerapporteerde klachten na kanker is, wordt in Hoofdstuk 5 een studie gepresenteerd naar vermoeidheid van patiënten die verwezen zijn voor revalidatie. Vermoeidheid wordt gezien als een multidimensioneel construct en het eerste doel van de studie is het onderzoeken van het effect van diverse variabelen op vermoeidheid voorafgaand aan revalidatie. Een tweede doel is het onderzoeken van het effect van het multidimensionele revalidatieprogramma op vermoeidheid, en na te gaan of en in welke mate verandering van vermoeidheid na de interventie samenhangt met veranderingen van voorspellers die voorafgaand aan revalidatie worden geïdentificeerd. Bij 72 patiënten werd voor de interventie gekeken naar de relatie tussen verschillende variabelen en de vijf verschillende dimensies van vermoeidheid. Het effect van demografische variabelen, ziekte en behandelingsgerelateerde variabelen, anthropometrische gegevens, fysiologische variabelen, fysieke en psychische stress symptomen en ervaren functioneren op vermoeidheid werd onderzocht. Analyses lieten zien dat verschillende dimensies van vermoeidheid samenhingen met verschillende fysieke en psychosociale parameters, hetgeen het multidimensionele karakter van vermoeidheid onderstreept. Verdere analyses lieten zien dat maximale workload, fysieke symptomen, ervaren fysiek functioneren, mentaal functioneren, rol beperkingen op basis van fysiek functioneren en zelfeffectiviteit de belangrijkste voorspellers van vermoeidheid op baseline waren. De resultaten bij de 56 deelnemers die het programma hadden afgemaakt, lieten verder zien dat het revalidatieprogramma positieve en, belangijker, klinisch relevante effecten had op alle dimensies van vermoeidheid. De meeste afname van vermoeidheid werd gevonden in de fysieke dimensie. Verder bleek dat vermoeidheid voor het revalidatieprogramma de belangrijkste voorspeller voor vermoeidheid na de interventie was. Ten slotte werd gevonden dat een afname van vermoeidheid vooral samenhing met verbetering van fysieke parameters. De patiënten die na de revalidatie minder fysieke symptoomstress, een beter fysiek functioneren en minder beperkingen op basis van fysiek functioneren rapporteerden, hadden ook minder last van vermoeidheid. Ondanks het feit dat het niet mogelijk was het effect van de verschillende componenten van het programma te onderzoeken wordt op basis van de gevonden resultaten aanbevolen om in toekomstige interventies in elk geval een fysieke trainingscomponent op te nemen.

In Hoofdstuk 6 wordt de ontwikkeling van een fysiek zelfmanagement trainingen-programma beschreven. Dit programma is ontwikkeld ten behoeve van een landelijke gerandomiseerde multi-center trial (de Onco-Rev studie) die tussen 2003 en 2007 de effecten van een multidimensioneel revalidatieprogramma op de kwaliteit van leven onderzoekt en vergelijkt met fysieke training en met een (wachtlijst) controle groep. Het doel van de studie in deze thesis is het ontwikkelen van een fysiek trainingsprogramma waarvan de inhoud en de wijze van afleveren gebaseerd zijn op de hoogst beschikbare bewijskracht. Voor de inhoud van het programma werden vier veel voorkomende, gerelateerde, maar conceptueel en empirische verschillende fysieke problemen van kankerpatiënten onderscheiden, namelijk een afgenomen aëroob inspanningsvermogen, verminderde spierkracht, vermoeidheid en rolbeperkingen op basis van fysieke problemen. Literatuuronderzoek werd verricht naar de evidentie van het effect van bewegingsprogramma’s op aërobe capaciteit, spierkracht, vermoeidheid en beperkt fysieke (rol) functioneren. Voor de wijze van afleveren werd gekeken naar verschillen

Samenvatting


��

in evidentie van het effect van individuele versus groepsprogramma’s, van locale fitnessoefeningen versus sportprogramma’s en van zelfmanagement of zelfeffectiviteit verhogende programma’s versus traditionele interventies. Voor het effect van bewegen werd evidentie gevonden die varieerde van evidentie op rct (randomized controlled trial) niveau voor spierkracht naar evidentie op meta-analyse niveau voor vermoeidheid, fysiek (rol) functioneren en aëroob inspanningsvermogen. Voor de wijze van afleveren werd geen evidentie gevonden voor verschillen in het effect tussen individuele en groepsbenaderingen, of tussen locale fitness oefeningen en sport. Er was evidentie op het niveau van meta-analyses dat zelfmanagement programma’s en programma’s met zelfeffectiviteit verhogende technieken positieve effecten hebben op gezondheidsgerelateerde uitkomstmaten bij diverse chronische ziektes, op de kwaliteit van leven bij kanker patiënten en op therapietrouw (aan bewegingsprogramma’s) en het aannemen van fysiek actief gedrag. Het revalidatie programma werd ontwikkeld op basis van het best beschikbare bewijs met betrekking tot de inhoud en de wijze van afleveren. Mogelijke voordelen van het programma zijn:1) een op maat gemaakte fysieke training die gericht is op het vastgestelde probleem van de

patiënt;2) de training wordt als een zelfmanagement programma afgeleverd en kan daardoor

positieve effecten hebben op gezondheidsgerelateerde uitkomsten, kwaliteit van leven, therapietrouw (aan beweegprogramma’s) en een fysiek actieve leefstijl op de lange termijn.

In hoofdstuk 7 worden de resultaten van de studie in een grotere context geplaatst. Aandacht wordt besteed aan de belangrijke bevindingen, methodologische beschouwingen, de klinische implicaties en aan toekomstig onderzoek.

Samenvatting



��

Dankwoord

Als ik terugkijk op de periode waarin ik mijn proefschrift heb geschreven dan is dat een periode waarin veel gebeurd is, privé en werk gerelateerd. Voor mij was het een leuke en drukke periode, waarin ook af en toe een beroep gedaan werd op mijn stressbestendigheid en doorzettingsvermogen. Gelukkig heb ik met de nodige humor en relativeringsvermogen een aantal hobbels goed kunnen nemen.

Het schrijven van een proefschrift doe je niet alleen. Veel mensen hebben het mogelijk gemaakt dat ik een dergelijk traject kon doorlopen en hen ben ik dank verschuldigd.

Allereerst wil ik de deelnemers aan het onderzoek bedanken voor het invullen van de vragenlijsten en hun bijdrage aan de ontwikkeling van het revalidatieprogramma. Zonder hun medewerking en hun feedback was dit proefschrift er niet geweest.

Een aantal mensen wil ik hartelijk bedanken voor hun bijdrage aan de opzet van het onderzoek, het analyseren van de resultaten en het schrijven van de artikelen.

Als eerste wil ik mijn beide co-promotoren, dr. C.P. van der Schans en dr. J.E.H.M. Hoekstra-Weebers bedanken voor de bijdrage die zij elk op hun eigen manier hebben geleverd. Cees, jij hebt mij in het onderzoekswereldje betrokken, wat voor mij een openbaring was. Ik wil je bedanken voor je deskundige, inhoudelijke begeleiding en de wijze waarop je mij in dit traject tegemoet getreden bent: open, eerlijk en vol vertrouwen in een goede afloop. Als steun en toeverlaat kon ik op de lastige momenten altijd een beroep op je doen, wat ik erg gewaardeerd heb. Het is prettig met je te mogen samen werken. Josette, je bent later in dit traject gestapt en ik denk dat ik mijn promotie niet had kunnen afronden zonder jouw hulp. Je hebt ontzettend veel tijd en energie in mijn proefschrift gestoken en daarvoor ben ik je erg dankbaar. Ik heb veel van je geleerd op het gebied van schrijven en analyseren en ik herinner me de leuke gesprekken over de interpretatie van de data en de verwoording daarvan. Verder heb ik je leren kennen als een betrokken en gezellig mens, wat ook onze gezamenlijke congresbezoeken in Banff en Venetie extra leuk maakte. Cees en Josette, als dagelijkse begeleiders waren jullie de sleutelfiguren voor mij: heel veel dank.

Mijn eerste promotor, Prof. dr. K. Postema. Beste Klaas, als hoofd van de afdeling Revalidatie van het UMCG heb je de rol van Prof. Eisma overgenomen, ook binnen dit promotietraject. Op geheel eigen wijze heb je invulling aan deze rol gegeven en ik wil je bedanken voor het vertrouwen dat je mij hebt gegeven omtrent de afronding van mijn proefschrift. Daarnaast heb je zorggedragen voor regelmatige overlegmomenten, die de inhoud van het proefschrift en de samenwerking ten goede kwamen. Ik heb vertrouwen in onze toekomstige samenwerking met betrekking tot onderzoek en ben benieuwd wat we op dat gebied samen kunnen doen.

Mijn tweede promotor, Prof. dr. R. Sanderman. Robbert, jou bedank ik voor je altijd positieve attitude ten aanzien van mijn proefschrift. Je hebt me altijd het gevoel gegeven dat het wel goed kwam met dat proefschrift en je weet niet half hoe belangrijk dit is. Ook waardeer ik je brede wetenschappelijke belangstelling en je hulp tijdens de diverse fasen van het onderzoek. Je vermogen om in grote lijnen te denken en je professionele opstelling hebben me goed geholpen tijdens dit traject.


��

Mijn derde copromoter, dr. R.Otter. Renee, als directeur van het ikn heb jij de voor-waarden gecreëerd om dit proefschrift überhaupt mogelijk te maken. Dank zij jouw inspanningen is een samenwerkingsverband met het - toen nog Revalidatiecentrum Beatrixoord en het azg - tot stand gekomen. Verder kreeg ik, via een detachering vanuit het ziekenhuis naar het ikn, de mogelijkheid het revalidatieprogramma te implementeren en het onderzoek naar de effecten ervan uit te voeren. Tot het eind toe heb je mij gesteund in de realisatie van een proefschrift dat van belang is voor de oncologische zorg. Dank daarvoor.

Een aantal mensen heeft zich in de aanvangsfase van het project ingespannen om het revalidatieprogramma zo goed mogelijk van de grond te tillen. Prof. W. H. Eisma en drs. H. Piersma, beste Willem en Henk, dank voor jullie hulp bij de PR en het realiseren van de financiering, die uiteindelijk tot stand kwam via een gezamenlijk jubileum van de Rotary en KWF kankerbestrijding. Prof. dr. J.H. Arendzen en drs. B. Grol, beste Hans en Brigit, dank voor het delen van jullie inhoudelijke kennis en organisatorische ondersteuning bij het ontwikkelen en implementeren van het revalidatieprogramma. Ik heb jullie hulp als waardevol, plezierig en leerzaam ervaren.

Vele mensen waren betrokken bij de opzet en uitvoering van het multidisciplinaire revalidatieprogramma, de onderzoeksmetingen en de ontwikkel/implementatie fase van het fysieke zelfmanagement programma. Zonder compleet te kunnen zijn wil ik de volgende mensen bedanken: Rob Bertram, Marjon Houwerzijl, Marijn Favejee, Diana Vos, Majorie Klein-Herenbrink, Ellis Wilts, Tineke Terpstra, Grieteke Jonker-Pool, Henk Hummel, Truus van der Werf, Pim Meijler, Berend Meijerink, Marielle van der Zee, Ria Bakker, Inge Boonstra, Marleen Schönherr, Dirkje Stoltenborgh, Fredrike Heuvel, Marcel ten Wolde, Anke Kooistra, Hanneke Wasser, Riemie Kalsbeek, Mieke Oosterwijk, Therese van Hoogdalem, assistenten van de hart/longfunctieafdeling van het UMCG en het Centrum voor Revalidatie, medische specialisten en huisartsen die patiënten naar het programma hebben verwezen, en alle anderen die op enige wijze bij het programma betrokken waren. Allen dank voor jullie inzet.

Ook wil ik drs. R. Stewart bedanken. Roy, tijdens mijn promotietraject ben ik een aantal keren bij je geweest voor statistische problemen. In plaats van me dan een kant en klare oplossing te bieden – waar ik stiekem op hoopte – liet je me vaak zelf nadenken. Hierdoor heb ik heb veel van je geleerd en bovendien heb ik van jou als persoon genoten!

Naar mijn paranimfen wil ik ook een woord van dank uitspreken. Boukje, dank je voor je vriendschap die al bijna 20 jaar bestaat. We hebben samen al vele ‘life events’ meegemaakt, en ik vind het fijn dat je ook bij dit ‘event’ als paranimf betrokken wilt zijn.

Marrit, volgens mij ben je al een aantal keren mijn kamergenoot geweest, en het wordt elke keer leuker! Jou gezelligheid, humor en relativeringsvermogen hebben mijn promotietraject een stuk leuker gemaakt. Ik ben dan ook erg blij dat je nu als mijn paranimf wilt optreden en ik hoop dat we nog lang bij elkaar betrokken blijven.

De leden van de leescommissie, Prof. dr. J.A. Langendijk, Prof. dr. J.H.B. Geerzten en Prof. dr. H.B.M. van de Wiel, wil ik bedanken voor de vlotte en zorgvuldige beoordeling van het manuscript.

Dankwoord


��

Een aantal mensen is betrokken bij de Oncorev-studie, de landelijke multi-centre vervolgstudie waarin het effect van multidisciplinaire oncologische revalidatie op de kwaliteit van leven wordt vergeleken met fysieke training en een (wachtlijst)controle groep. Anne en Irene, mede-onderzoekers, ik wil jullie bedanken voor de fijne samenwerking. Ik heb het als erg leuk ervaren en ik heb veel van jullie geleerd. De gesprekken die we hebben gevoerd over de verschillen tussen multidisciplinaire revalidatie en fysieke training, de problemen rondom het te hanteren design en het analyseren van de data zullen me nog lang bij blijven. Dr. W. Ros en Prof. dr. B. van de Borne, beste Wynand en Bart, dank voor het delen van jullie expertise op het gebied van psychosociale ondersteuning van kankerpatiënten en het onderzoek hiernaar. Prof. dr. Wim Trijsburg wil ik postuum bedanken voor zijn begeleiding en zijn altijd positieve inbreng tijdens de Oncorev- projectgroepvergaderingen. Helaas kan hij de eindproducten van deze studie niet meer meemaken, maar hij blijft tot het einde toe ‘aanwezig’.

Een aantal mensen op het umcg ben ik veel dank verschuldigd. Ook al waren zij niet direct inhoudelijk bij het project betrokken, zonder hen had ik niet de mogelijkheid gehad mijn promotietraject te starten en het naar behoren af te ronden. Paul Nijkrake, beste Paul, ik heb het al vaker tegen je gezegd: in het umcg zijn vele mogelijkheden, maar je moet ze wel zien en benutten. Jij hebt, als direct leidinggevende, mij deze mogelijkheden letterlijk en figuurlijk aangereikt. Je hebt mij altijd aangemoedigd om me inhoudelijk en persoonlijk te ontwikkelen en dit blijf je maar doen. Je hebt me zelfs de gelegenheid geven een eigen onderzoekslijn voor de discipline Fysiotherapie neer te zetten en deze uit te bouwen, wat ik een geweldige uitdaging vind. Ik heb op procesmatig gebied zeer veel van jou geleerd en waardeer je als mens enorm. Dank je voor de samenwerking tot nu toe.

Dr. P.U. Dijkstra, beste Pieter, collega fysiotherapeut en epidemioloog: de jaren die ik als kamergenoot met jou heb doorgebracht, waren zeer waardevol. We hebben vele gesprekken gevoerd over methodologische en statistische onderwerpen, wat voor mij altijd leerzaam is geweest. Dit samen met je verzorgende karakter en je humor, maakt dat ik me thuis voel op onze kamer.

Drs. S. Meijer, beste Stella, al jaren werk ik met jou samen om het onderzoek van de discipline Fysiotherapie op een hoger niveau te brengen. Ongemerkt deed ik daarbij kennis op die ik weer voor mijn eigen onderzoek gebruikte en vice versa. Bedankt voor de tot nu inspirerende samenwerking. De andere collega´s van het umcg wil ik heel hartelijk bedanken voor hun collegialiteit en loyaliteit. Hierdoor wordt een promotietraject een stuk aangenamer.

Ook de collega’s van het ikn wil ik bedanken: de Marrits, Ali, Lucienne, Christa, Ellen, Marjan, Carolina, Michael en alle anderen: bedankt voor jullie collegialiteit, jullie ondersteuning en je belangstelling tijdens mijn promotietraject. Gery, jou wil ik speciaal bedanken voor het ontwerpen van het herkenbare logo. En Stacey: bedankt voor de gezelligheid als kamergenoot en je hulp bij vertaalkwesties.

Mijn collega’s van de Verenigde Integrale Kanker Centra wil ik bedanken voor de samenwerking rondom de landelijke implementatie van het revalidatieprogramma Herstel en Balans. In de afgelopen jaren hebben we, al was het niet altijd even gemakkelijk, het revalidatieprogramma in diverse centra met succes geïmplementeerd. Toch valt er nog veel te doen in de oncologische revalidatie en ik wil jullie daar veel succes bij wensen.

Dankwoord


��8

Andere collega onderzoekers, Joke, Gea Annemieke, dank voor jullie gezelligheid in Banff en voor jullie inhoudelijke input tijdens onze artikelbesprekingen en presentaties. Barbara, ook jij bedankt voor je hulp bij het vertalen.

Lieve vrienden en familie, jullie wil ik bedanken voor de steun die jullie me elk op je eigen manier hebben gegeven. Jullie betrokkenheid en gezelligheid buiten het werk hebben me door de soms lastige tijden heen geholpen: dank je wel allemaal!

Nico, heel hartelijk bedankt voor de wijze waarop jij mijn proefschrift hebt vormgegeven. Volgens mij is dit niet alleen reclame voor mij, maar ook voor jezelf.

Hans en Tineke, ik bof natuurlijk ontzettend met Richard, maar jullie als schoonouders doen het ook niet slecht: dank voor de gezelligheid en het vele lekkere eten van de afgelopen jaren: het lijkt me goed dat we dit gewoon continueren.

Pap, jouw eeuwige ‘waar een wil is, is een weg’, riep vroeger regelmatig weerstand bij me op, maar blijkt ook nu weer de waarheid. Inmiddels ben ik het dus met je eens. Dank dat je er altijd voor me bent.

Mam, jammer dat je er niet meer bij kon zijn, ik denk dat je had genoten.

Lieve Richard, een proefschrift schrijven kun je leren. Wat ik voor jou voel, kan ik echter nog steeds met geen pen beschrijven. Fijn dat je jouw leven met mij wilt delen!

Lauren, lieverd, jij hebt me laten zien dat er meer is dan promoveren; namelijk al het andere…

Dankwoord


��

NorthernCentreforHealthcareResearch(NCH)

This thesis is published within the research program Rehabilitation Programs Research of the Northern Centre for Healthcare Research (nch). More information regarding the institute and its research can be obtained from our internet site: www.med.rug.nl/nch.

Previous dissertations Rehabilitation Programs Research ( from 1998 onwards) Kuijer W (2006) Measuring disability in patients with chronic low back pain; the usefulness of different instruments.

promotores: prof dr JHB Geertzen, prof dr JW Groothoffcopromotor: dr PU Dijkstra

Leur JP van de (2005) Clearance of bronchial secretions after major surgery. promotores: prof dr JH Zwaveling, prof dr JHB Geertzencopromotor: dr CP van der Schans

Rietman JS (2005) Treatment related morbidity in breast cancer patients promotores: prof WH Eisma, prof dr HJ Hoekstra, prof dr JHB Geertzen,

prof dr JW Groothoffcopromotor: dr PU Dijkstra

Brouwer S (2004) Disability in chronic low back pain: psychometric properties of ADL- and work-related instruments

promotores: prof dr JHB Geertzen, prof dr JW Groothoff, prof dr LNH Göekencopromotor: dr PU Dijkstra

Dekker R (2004) Long-term outcomes of sports injuries. promotores: prof dr HJ ten Duis, prof WH Eisma, prof dr JW Groothoffcopromotor: dr CK van der Sluis

Schegget -Slaterus MJ ter (2004) The quality of expert advice in relation to the act on facilities for the handicapped.

promotores: prof dr JW Groothoff, prof WH Eisma Schönherr MC (2003) Functional Outcome after Spinal Cord Injury: Participation and Activities.

promotores: prof WH Eisma, prof dr JW Groothoff Sturms LM (2003) Pediatric traffic injuries: Consequences for the child and the parents.

promotores: prof WH Eisma, prof dr HJ ten Duis, prof dr JW Groothoffcopromotor: dr CK van der Sluis

Meijer JWG (2002) The diabetic foot syndrome: diagnosis and consequences. promotores: prof WH Eisma, prof dr JW Groothoffcopromotores: dr TP Links, dr AJ Smit

Schoppen T (2002) Functional outcome after a lower limb amputation. promotores: prof WH Eisma, prof dr JW Groothoff, prof dr LHN Göekenreferenten: dr AM Boonstra, dr J de Vries

Rommers GM (2000) The elderly amputee: rehabilitation and functional outcome. promotor: prof WH Eismacopromotor: dr JW Groothoff

Halbertsma JPK (1999) Short hamstrings & stretching: a study of muscle elasticity. promotores: prof WH Eisma, prof dr LNH Göekencopromotor: dr JW Groothoffreferent: dr ir AL Hof


��0

Geertzen JHB (1998) Reflex sympathetic dystrophy: a study in the perspective of rehabilitation medicine.

promotores: prof WH Eisma, prof dr HJ ten Duiscopromotor: dr JW Groothoffreferent: dr PU Dijkstra

Sluis CK van der (1998) Outcomes of major trauma. promotores: prof dr HJ ten Duis, prof WH Eisma

Previous dissertations Rehabilitation Programs Research




Documents

The development of an evidence-based physical self-management