IMPORTANCE Cancer-related fatigue (CRF) remains one of the most prevalent and troublesome adverse events experienced by patients with cancer during and after therapy. OBJECTIVE To perform a meta-analysis to establish and compare the mean weighted effect sizes (WESs) of the 4 most commonly recommended treatments for CRF—exercise, psychological, combined exercise and psychological, and pharmaceutical—and to identify independent variables associated with treatment effectiveness. DATA SOURCES PubMed, PsycINFO, CINAHL, EMBASE, and the Cochrane Library were searched from the inception of each database to May 31, 2016. STUDY SELECTION Randomized clinical trials in adults with cancer were selected. Inclusion criteria consisted of CRF severity as an outcome and testing of exercise, psychological, exercise plus psychological, or pharmaceutical interventions. DATA EXTRACTION AND SYNTHESIS Studies were independently reviewed by 12 raters in 3 groups using a systematic and blinded process for reconciling disagreement. Effect sizes (Cohen d) were calculated and inversely weighted by SE. MAIN OUTCOMES AND MEASURES Severity of CRF was the primary outcome. Study quality was assessed using a modified 12-item version of the Physiotherapy Evidence-Based Database scale (range, 0–12, with 12 indicating best quality). RESULTS From 17 033 references, 113 unique studies articles (11525 unique participants; 78% female; mean age, 54 [range, 35–72] years) published from January 1, 1999, through May 31, 2016, had sufficient data. Studies were of good quality (mean Physiotherapy Evidence-Based Database scale score, 8.2; range, 5–12) with no evidence of publication bias. Exercise (WES, 0.30; 95% CI, 0.25–0.36; P < .001), psychological (WES, 0.27; 95% CI, 0.21–0.33; P < .001), and exercise plus psychological interventions (WES, 0.26; 95% CI, 0.13–0.38; P < .001) improved CRF during and after primary treatment, whereas pharmaceutical interventions did not (WES, 0.09; 95% CI, 0.00–0.19; P = .05). Results also suggest that CRF treatment effectiveness was associated with cancer stage, baseline treatment status, experimental treatment format, experimental treatment delivery mode, psychological mode, type of control condition, use of intention-to-treat analysis, and fatigue measures (WES range, −0.91 to 0.99). Results suggest that the effectiveness of behavioral interventions, specifically exercise and psychological interventions, is not attributable to time, attention, and education, and specific intervention modes may be more effective for treating CRF at different points in the cancer treatment trajectory (WES range, 0.09–0.22). CONCLUSIONS AND RELEVANCE Exercise and psychological interventions are effective for reducing CRF during and after cancer treatment, and they are significantly better than the available pharmaceutical options. Clinicians should prescribe exercise or psychological interventions as first-line treatments for CRF.

Cancer-related cognitive impairment is an important problem for patients with breast cancer, yet its trajectory is not fully understood. Some previous cancer-related cognitive impairment research is limited by heterogeneous populations, small samples, lack of prechemotherapy and longitudinal assessments, use of normative data, and lack of generalizability. We addressed these limitations in a large prospective, longitudinal, nationwide study. Patients and MethodsPatients with breast cancer from community oncology clinics and age-matched noncancer controls completed the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog) at prechemotherapy and postchemotherapy and at a 6-month follow-up as an a priori exploratory aim. Longitudinal models compared FACT-Cog scores between patients and controls at the three assessments and adjusted for age, education, race, menopausal status, and baseline reading ability, anxiety, and depressive symptoms. A minimal clinically important difference cutoff determined percentages of impairment over time. ResultsOf patients, 581 patients with breast cancer (mean age, 53 years; 48% anthracycline-based regimens) and 364 controls (mean age, 53 years) were assessed. Patients reported significantly greater cognitive difficulties on the FACT-Cog total score and four subscales from prechemotherapy to postchemotherapy compared with controls as well as from prechemotherapy to 6-month follow-up (all P , .001). Increased baseline anxiety, depression, and decreased cognitive reserve were significantly associated with lower FACT-Cog total scores. Treatment regimen, hormone, or radiation therapy was not significantly associated with FACT-Cog total scores in patients from postchemotherapy to 6-month follow-up. Patients were more likely to report a clinically significant decline in self-reported cognitive function than were controls from prechemotherapy to postchemotherapy (45.2% v 10.4%) and from prechemotherapy to 6-month follow-up (36.5% v 13.6%). ConclusionPatients with breast cancer who were treated in community oncology clinics report substantially more cognitive difficulties up to 6 months after treatment with chemotherapy than do age-matched noncancer controls.

Purpose Thirty percent to 90% of cancer survivors report impaired sleep quality post-treatment, which can be severe enough to increase morbidity and mortality. Lifestyle interventions, such as exercise, are recommended in conjunction with drugs and cognitive behavioral therapy for the treatment of impaired sleep. Preliminary evidence indicates that yoga—a mind-body practice and form of exercise—may improve sleep among cancer survivors. The primary aim of this randomized, controlled clinical trial was to determine the efficacy of a standardized yoga intervention compared with standard care for improving global sleep quality (primary outcome) among post-treatment cancer survivors. Patients and Methods In all, 410 survivors suffering from moderate or greater sleep disruption between 2 and 24 months after surgery, chemotherapy, and/or radiation therapy were randomly assigned to standard care or standard care plus the 4-week yoga intervention. The yoga intervention used the Yoga for Cancer Survivors (YOCAS) program consisting of pranayama (breathing exercises), 16 Gentle Hatha and Restorative yoga asanas (postures), and meditation. Participants attended two 75-minute sessions per week. Sleep quality was assessed by using the Pittsburgh Sleep Quality Index and actigraphy pre- and postintervention. Results In all, 410 survivors were accrued (96% female; mean age, 54 years; 75% had breast cancer). Yoga participants demonstrated greater improvements in global sleep quality and, secondarily, subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and medication use at postintervention (all P ≤ .05) compared with standard care participants. Conclusion Yoga, specifically the YOCAS program, is a useful treatment for improving sleep quality and reducing sleep medication use among cancer survivors.

Background Tai Chi Chuan (TCC) is an integrative medicine mind-body practice with a physical activity component that has positive effects on aerobic capacity, muscular strength, and quality of life among cancer survivors, similar to the effects elicited by other modes of moderate intensity exercise. Inflammatory cytokines, and insulin and insulin-related signaling molecules may contribute to weight gain and affect cancer recurrence rates and survival; exercise can curb cancer- and treatment-related weight gain, increase survival, and reduce levels of insulin and inflammatory cytokines. Despite knowing the beneficial effects of conventional exercise interventions on these mediators, little is known about the physiologic effects of TCC, a mind-body practice with a physical activity component, on these pathways in breast cancer survivors. Methods We assessed the effects of a 12-week, moderately intense, TCC intervention (n=9) compared to a non-physical activity control (n=10) consisting of psychosocial support therapy (PST) on levels of insulin, IGF-1, IGFBP-1, IGFBP-3 and cytokines IL-6, IL-2, and IFN-γ in breast cancer survivors. Results Levels of insulin are significantly different in TCC and PST groups; levels remained stable in the TCC group, but increased in the PST control group (p=0.099). Bivariate analysis revealed novel and significant correlations (all r >0.45, all p≤0.05) of both decreased fat mass and increased fat-free mass with increased IL-6 and decreased IL-2 levels. Conclusions This pilot study shows that TCC may be associated with maintenance of insulin levels and changes in cytokine levels that may be important for maintenance of lean body mass in breast cancer survivors.

Introduction Breast cancer survivors experience diminished health-related quality of life (HRQOL). We report on the influence of tai chi chuan exercise (TCC) on HRQOL and explore associations between changes in HRQOL and biomarkers. Methods Breast cancer survivors (N=21) were randomly assigned to TCC or standard support therapy (SST) for 12 weeks (three times/week; 60 min/session). Interleukin-6, interleukin-8 (IL-8), insulin-like growth factor-1 (IGF-1), insulin-like growth factor-binding protein (IBFBP)-1, IGFBP-3, glucose, insulin, and cortisol were measured pre- and postintervention. Overall HRQOL and subdomains were assessed at preintervention (T1), midintervention (T2) and postintervention (T3) and biomarkers at T1 and T3. Results The TCC group improved in total HRQOL (T1–T2: CS=8.54, P=0.045), physical functioning (T1–T2:CS=1.89, P=0.030), physical role limitations (T1–T2 CS=1.55, P=0.023), social functioning (T1–T3:CS=1.50, P=0.020), and general mental health (T1–-T2:CS=2.67, P=0.014; T1–T3: CS=2.44, P=0.019). The SST improved in social functioning (T1–T2:CS=0.64, P=0.043) and vitality (T1–T2:CS=0.90, P=0.01). There were relationships between changes in IGF-1 and overall HRQOL (r=−0.56; P<0.05), physical role limitation (r=−0.68; P<0.05), and social functioning (r=−0.56; P<0.05). IGFBP-1 changes were associated with physical role limitation changes (r=0.60; P<0.05). IGFBP-3 changes were associated with physical functioning changes (r=0.46; P≤0.05). Cortisol changes were associated with changes in physical role limitations (r=0.74; P<0.05) and health perceptions (r=0.46; P<0.05). Glucose changes were associated with emotional role limitation changes (r=−0.70; P<0.001). IL-8 changes were associated with emotional role limitation changes (r=0.59; P<0.05). Discussion/conclusions TCC may improve HRQOL by regulating inflammatory responses and other biomarkers associated with side effects from cancer and its treatments. Implications for cancer survivors TCC may be an intervention capable of improving HRQOL in breast cancer survivors.

Objective: To examine cigarette purchasing patterns of current smokers and to determine the effects of cigarette price on use of cheaper sources, discount/generic cigarettes, and coupons. Background: Higher cigarette prices result in decreased cigarette consumption, but price sensitive smokers may seek lower priced or tax-free cigarette sources, especially if they are readily available. This price avoidance behaviour costs states excise tax money and dampens the health impact of higher cigarette prices. Methods: Telephone survey data from 3602 US smokers who were originally in the COMMIT (community intervention trial for smoking cessation) study were analysed to assess cigarette purchase patterns, use of discount/generic cigarettes, and use of coupons. Results: 59% reported engaging in a high price avoidance strategy, including 34% who regularly purchase from a low or untaxed venue, 28% who smoke a discount/generic cigarette brand, and 18% who report using cigarette coupons more frequently that they did five years ago. The report of engaging in a price avoidance strategy was associated with living within 40 miles of a state or Indian reservation with lower cigarette excise taxes, higher average cigarette consumption, white, non-Hispanic race/ethnicity, and female sex. Conclusion: Data from this study indicate that most smokers are price sensitive and seek out measures to purchase less expensive cigarettes, which may decrease future cessation efforts.

Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.

A B S T R A C T PurposeTo identify whether a history of cancer is associated with specific geriatric syndromes in older patients. Patients and MethodsUsing the 2003 Medicare Current Beneficiary Survey, we analyzed a national sample of 12,480 community-based elders. Differences in prevalence of geriatric syndromes between those with and without cancer were estimated. Multivariable logistic regressions were used to evaluate whether cancer was independently associated with geriatric syndromes. ResultsTwo thousand three hundred forty-nine (18%) reported a history of cancer. Among those with cancer, 60.3% reported one or more geriatric syndromes as compared with 53.2% of those without cancer (P Ͻ .001). Those with cancer overall had a statistically significantly higher prevalence of hearing trouble, urinary incontinence, falls, depression, and osteoporosis than those without cancer. Adjusting for possible confounders, those with a history of cancer were more likely to experience depression (adjusted odds ratio [OR], 1.15; 95% CI, 1.02 to 1.30; P ϭ .023), falls (adjusted OR, 1.17; 95% CI, 1.04 to 1.32; P ϭ .010), osteoporosis (adjusted OR, 1.21; 95% CI, 1.06 to 1.38; P ϭ .004), hearing trouble (adjusted OR, 1.28; 95% CI, 1.08 to 1.52; P ϭ .005), and urinary incontinence (adjusted OR, 1.42; 95% CI, 1.20 to 1.69; P Ͻ .001). Analysis of specific cancer subtypes showed that lung cancer was associated with vision, hearing, and eating trouble; prostate cancer was associated with incontinence and falls; cervical/uterine cancer was associated with falls and osteoporosis; and colon cancer was associated with depression and osteoporosis. ConclusionElderly patients with cancer experience a higher prevalence of geriatric syndromes than those without cancer. Prospective studies that establish the causal relationships between cancer and geriatric syndromes are necessary.