Kangas, M., Bovbjerg, D.H., & Montgomery, G.H. (2008). Cancer-related fatigue: A systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychological Bulletin, 134, 700–741.

DOI Link


STUDY PURPOSE: To conduct a systematic review and meta-analysis on nonpharmacologic interventions (psychosocial and exercise) for cancer-related fatigue (CRF)

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy

INCLUSION CRITERIA: Published trials that met the following criteria: (a) published in a scientific peer-reviewed journal in full manuscript form; (b) written in the English language; (c) included a nonpharmacological intervention as one treatment arm of the study; (d) evaluated participants who were aged at least 18 years, had been diagnosed with cancer (any type or stage), and were at any phase of treatment or recovery; and (e) included a specific quantitative measure of fatigue or related symptom (comprising tiredness, lethargy, vigor, vitality or energy) as a primary or secondary outcome measure, in which the measure was administered minimally at preintervention (baseline) and postintervention. Randomized, controlled trial (RCTs) or non-RCTs (clinical trials without randomization) and single group design with baseline and post-intervention measures; only RCTs with sufficient statistical data to compute effect size were included in the meta-analysis.
EXCLUSION CRITERIA: Case reports and single case designs

Literature Evaluated

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Criteria adapted from CONSORT guidelines and Delphi criteria list as well as four additional criteria: (a) whether the participant inclusion criteria for each identified study required individuals to be suffering from fatigue and/or related symptoms (e.g., low energy, vigor) prior to randomization; (b) whether the study was based on a specific CRF aim and/or CRF-related hypothesis (including predictions for effect of intervention[s] on fatigue, vigor and/or vitality); (c) whether the intervention was based on a specific fatigue-related theory, which the researchers made explicit in the publication; and (d) type of fatigue outcome measure used (i.e., unidimensional versus multidimensional). These four criteria were included in the moderator analyses. Two evaluators reviewed abstracts and articles. Duplicate studies were excluded from the analysis.

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 57 RCTs included in the meta-analysis, 116 published articles for systematic review
  • TOTAL PATIENTS INCLUDED IN REVIEW = 4,621 in meta-analysis
  • KEY SAMPLE CHARACTERISTICS: Of the patients, 33%–45% had breast cancer and were in a mix of stages and treatment statuses.

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care


Both psychosocial interventions and exercise showed benefit in CRF. Psychosocial interventions had a small to moderate effect on fatigue; exercise had a moderate effect. No significant differences existed in the effect of exercise on CRF between psychosocial interventions and exercise. Exercise showed a stronger effect during treatment than post-treatment, whereas psychosocial interventions showed a stronger effect post-treatment.


Both psychosocial interventions and exercise are beneficial in ameliorating CRF. A multimodal approach across all phases of treatment is best.


  • Limited search
  • High heterogeneity
  • Somewhat dated review; latest published article included was 2006

Nursing Implications

Provides additional support for psychosocial interventions and exercise for CRF. Because of the heterogeneity of interventions, supporting one type of psychosocial intervention or exercise regime over another is difficult. Nurses can incorporate interventions acceptable to patients.

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