Wu, H., Dodd, M. J., & Cho, M. H. (2008). Patterns of fatigue and effect of exercise in patients receiving chemotherapy for breast cancer. Oncology Nursing Forum, 35, E90-E99.

DOI Link

Study Purpose

To examine daily fatigue patterns during the third cycle of chemotherapy in women with breast cancer and predict whether fatigue trajectories differ by exercise or chemotherapy regimens.

Intervention Characteristics/Basic Study Process

Patients completed a daily fatigue diary that included a fatigue rating and items to determine whether they were exercisers or nonexercisers. Patients were asked to complete the diary daily. Weekly telephone calls from an exercise physiologist were used to determine exercise adherence.  Adherence was determined as either a yes or no based on whether the patient exercised at least three days per week for 20 minutes per session and at a “somewhat hard” intensity. Measures obtained during the third course of chemotherapy were used in this analysis.

Sample Characteristics

  • Ninety-eight patients (all female) were included.
  • Mean age was 49.5 years (standard deviation = 9.3; range 28–72).
  • Patients had breast cancer stage III and less.
  • Of the patients, 72% were married/partnered, 28% were single, 74% were Caucasian, and 89% were educated more than 12 years.
  • Patients were undergoing chemotherapy, with the majority (79%) receiving chemotherapy.


  • Multisite  
  • Outpatient
  • Five cancer centers in the San Fransisco Bay area

Phase of Care and Clinical Applications

Patients were undergoing the active treatment phase of care.

Study Design

This was a prospective, longitudinal, repeated-measure design primary study; a secondary analysis of these data was performed.

Measurement Instruments/Methods

  • The fatigue diary had two standard questions, each measured on an 11-point rating scale ranging from 0 (no fatigue/tiredness) to 10 (overwhelming fatigue/tiredness). 
  • Determination of exerciser versus nonexerciser status, the Surgeon General’s Guideline for Physical Activity, was used (described as at least three days a week for 20 minutes per session at an intensity of “somewhat hard”).


Average levels of fatigue reported were moderate for the first eight days and mild for the rest of the cycle. Highest levels of fatigue were observed on days 1 to 3 for average and worst fatigue. Five distinct trajectory patterns of cancer-related fatigue (CRF) were identified:  immediate and sharp increase followed by a gradual decline; early peak, a decline, and a sharp increase toward the end of the cycle; small variations among daily scores; chaotic pattern; and step-up evaluation followed by a gradual decline. Nonexercisers had higher average and worst fatigue (p < 0.01). In exercisers and nonexercisers, fatigue declined in severity over time, and the rate of decline was not significantly different between the two groups; however, fatigue levels were consistently higher among nonexercisers.


CRF peaked in the days immediately after intravenous chemotherapy and declined gradually over time. Fatigue tended to be lower in those who exercised as described.


  • The study had a small sample size, with less than 100 patients.
  • The sample consisted of female outpatients with breast cancer.
  • Fatigue was not measured at different times during the day.
  • No baseline of fatigue was established prior to chemotherapy.
  • The length of the chemotherapy cycle varied depending on the regime.

Nursing Implications

Nurses should provide anticipatory guidance to patients so that they can plan for the days when they are at most risk for fatigue. Continued exercise during the course of chemotherapy may be helpful in mitigating the severity of fatigue.