van Waart, H., Stuiver, M.M., van Harten, W.H., Geleijn, E., Kieffer, J.M., Buffart, L.M., . . . Aaronson, N.K. (2015). Effect of low-intensity physical activity and moderate- to high-intensity physical exercise during adjuvant chemotherapy on physical fitness, fatigue, and chemotherapy completion rates: Results of the PACES randomized clinical trial. Journal of Clinical Oncology, 33, 1918–1927.

DOI Link

Study Purpose

To evaluate the effects of low and moderate to high intensity exercise on fatigue, fitness, and treatment completion rates

Intervention Characteristics/Basic Study Process

Patients were randomized to usual care control, low-intensity, or moderate- to high-intensity exercise groups. Those in the low-intensity group did home-based self-managed activity for at least 30 minutes for five days a week. Those in the moderate- to high-intensity group participated in 50 minute sessions two times per week and were encouraged to also be physically active for 30 minutes per day for five days per week. Study measures were obtained at baseline, at completion of chemotherapy, and six months later. Exercise programs began with initiation of chemotherapy and continued until three weeks after completion of chemotherapy.

Sample Characteristics

  • N = 197
  • MEAN AGE = 50.7 (SD = 9.1)
  • FEMALES:  100%
  • KEY DISEASE CHARACTERISTICS:  Breast cancer;  the majority were stage II or III; 78% had radiation therapy as well as chemotherapy
  • OTHER KEY SAMPLE CHARACTERISTICS: 70% were working full or part time


  • SITE: Multi-site  
  • SETTING TYPE: Outpatient  
  • LOCATION: Netherlands

Study Design

Randomized, controlled trial

Measurement Instruments/Methods

  • Fatigue Quality List
  • Multidimensional Fatigue Inventory
  • EORTC-QLQ –C30
  • Hospital Anxiety and Depression Scale
  • Sleep Quality Inventory
  • Physical Activity Scale for the Elderly
  • Grip strength with dynamometer
  • Exercise diary
  • Steep ramp test fitness and endurance testing


Participants attended 71% of exercise sessions, and 55% of those on the low-intensity program followed recommendations at least 75% of the time. Those in the moderate- to high-intensity group had the best endurance and muscle strength results at the end of chemotherapy. Those in the higher-intensity exercise group also had the lowest physical fatigue levels at the end of chemotherapy (p < 0.001).  Those in the low-intensity group had slightly lower fatigue levels than controls. There were no significant differences between groups at three months. There were no significant differences between groups in anxiety or depression scores.


Results of this study showed the lowest physical fatigue scores during chemotherapy among those participating in moderate- to high-intensity sessions. It is unclear if this difference between exercise groups was related to exercise intensity or the overall difference in the amount of exercise done. Effects on fatigue were not maintained at three months postchemotherapy and there were no effects on measures of anxiety or depression


  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)


Nursing Implications

This study adds to the already extensive body of evidence showing the benefits of exercise in managing fatigue during cancer treatment. It is unclear if the amount, duration, or intensity of exercise are most important for deriving benefit from exercise. Group differences seen at the end of chemotherapy were not maintained three months later, and it is unclear what amount of physical activity was done between the end of treatment and final study measurements.