Wanchai, A., Armer, J. M., & Stewart, B. R. (2011). Nonpharmacologic supportive strategies to promote quality of life in patients experiencing cancer-related fatigue: a systematic review. Clinical Journal of Oncology Nursing, 15, 203–214.

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To review the literature on nonpharmacologic supportive strategies to enhance quality of life (QOL) among patients with breast cancer experiencing cancer-related fatigue.

Search Strategy

Databases searched were MEDLINE and CINAHL (2000–2010).

Search keywords were breast cancer patient, oncology patient, fatigue, cancer-related fatigue, quality of life, health-related quality of life, physical activity, and exercise.

Studies were included in the review if they 

  • Were randomized, controlled trials or quasiexperimental designs
  • Investigated nonpharmacological supportive strategies
  • Had cancer-related fatigue and/or QOL as an outcome measure.

Literature Evaluated

Eighty-nine articles were identified, of which 28 met the inclusion criteria. No method of quality rating of the studies was described.

Sample Characteristics

  • Twenty-eight studies including 2,164 patients were included.
  • Sample sizes among studies ranged from 11 to 377 patients.
  • All studies were performed in patients with breast cancer at various phases of care and receiving various types of treatment or after treatment.


Supervised exercise was used in eight studies.  Four of these showed that exercise significantly improved QOL and reduced fatigue.  Two studies showed that supervised exercise improved QOL but not fatigue; they had noted study limitations and intervention contamination. One large multi-site study showed that supervised aerobic exercise improved self-esteem, fitness, etc., but had no significant effect on QOL, depression, anxiety, or fatigue

Home-based exercise was used in six studies.  All of these confirmed a positive effect of participation in exercise on fatigue.  Fatigue levels either decreased, or those who exercised had significantly less increase in fatigue over time.

Telephone-based encouragement in activity was used in one study (25 patients).  At 12 weeks, there were significant increases in activity, QOL, and fatigue.

One study used print materials and step pedometers along with physical activity recommendations.  Those who received all three of these strategies had improved QOL and fatigue.

Education and counseling was used in five studies. Mixed results were seen across studies, with a positive effect on fatigue that was significant in three of these studies. 

Sleep therapy was examined in three studies.  Two of these demonstrated a significant positive effect on fatigue with cognitive behavioral therapy and insomnia treatment.  One large study using cognitive behavioral therapy showed improvement in sleep quality but no effect on fatigue.

Other interventions were yoga in one study, tai chi in one study, and physical therapy in one study.  Yoga was associated with an improvement in fatigue, and physical therapy was also associated with improvement, although this was only studied in 11 patients.


This review generally showed that supervised exercise and supervised exercise and other strategies to promote exercise can reduce cancer-related fatigue and improve QOL in women with breast cancer.  Findings were limited by several studies with small sample sizes and variations in the phases of care in which the interventions were provided. There was insufficient evidence to draw conclusions about the complementary therapies included.


  • Studies of supervised education demonstrated mixed results.
  • Several studies had small samples or other limitations.
  • Application should be used cautiously.

Nursing Implications

Based on current evidence, exercise, educational counseling, and sleep therapy appear to be helpful methods to improve QOL and reduce fatigue. Because of methodological limitations of many of these previous studies, further well-designed research is needed to confirm these conclusions.

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