Yan-Qiu Huang, Guo-Zhi Yang, Chang-De Jin, Sheng Gao

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Non-drug interventions for cancer-related fatigue: an updated review

Yan-Qiu Huang1, Guo-Zhi Yang2, Chang-De Jin3, *, Sheng Gao4

1Graduate School of Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.2Graduate School of Jiangxi University of Traditional Chinese Medicine, Jiangxi, 330004, China.3Nursing School of Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China.4Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Jiangxi, 330004, China.

Non-drug interventions are easy operation, no damage and with significant therapeutic effects for cancer-related fatigue (CRF), which also can reduce the economic burden of cancer patients and improve the quality of life. This paper reviews the effects of non-drug interventions on CRF including exercise intervention, long distance healthy education, cognitive behavior intervention, traditional Chinese medicine intervention and emotional intervention to provide reference for clinical medical staff and relevant scholars. These non-drug intervention can enhance the therapeutic effects of conventional medicine, improve life quality and reduce the financial burden of patients with CRF. However, non-drug intervention for patients with CRF is only an adjuvant treatment method, and it can not completely replace conventional medicine treatment. The combination of conventional medicine treatment and non-drug intervention should be used to help patients with CRF to obtain the best therapeutic effects.

Cancer-related fatigue, Non-drug interventions, Research progress, Review

With the characters of easy operation, no damage and significant therapeutic effects, non-drug intervention for cancer-related fatigue can enhance drug therapeutic effects, improve life quality, reduce the financial burden of patients as well. Non-drug interventions are recommended for treating cancer related-fatigue.

This paper reviews the effects of some non-drug interventions on cancer-induced fatigue. Non-drug interventions can improve the physical condition of patients, establish the confidence to overcome the disease, thereby reducing the severity of fatigue in cancer patients. The combination of drug treatment and non-drug intervention should be used to help patients to obtain the best therapeutic effects.

CRF, Cancer-related fatigue; TCM, Traditional Chinese medicine.

The authors declare that there is no conflict of interests regarding the publication of this paper.

Chang Liu

Introduction

Cancer has become one of the world's most serious public health problems threatening human life and the leading cause of death for urban residents [1]. There are about 14.1 million new cancer patients and 8.2 million deaths worldwide every year [2]. The aim of cancer treatment is not just to prolong the life span, and how to improve the quality of life has become a concern of scholars [3]. According to the US National Comprehensive Cancer Network, cancer-related fatigue (CRF) is: "a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning" [4]. The incidence of CRF is over 60 %. About 74 % of patients with advanced cancer experience painful fatigue, which seriously affects the treatment and quality of life of patients [5-6]. However, due to the complexity of the pathogenesis of CRF, there is no effective treatments at present, and the combination of drug and non-drug intervention is often used for treatment [7]. This article reviews the non-drug intervention methods for cancer-related fatigue in recent years.

Exercise intervention

The Oncology Nursing Society recommends exercise intervention as a clinical treatment for CRF, proper exercise can increase the pulmonary ventilation and perfusion, enhance body's resistance, and reduce the degree of fatigue [8]. A 162 patients’ study of the University of Sydney evaluated the effects of Qi gong [a traditional practice to cultivate and balance Qi with roots in Chinese medicine, philosophy, and martial arts, https://en.wikipedia.org/wiki/Qigong] treatment for CRF as half patients performed 10 weeks of Qi gong in the base of routine care. The fatigue level of the Qi gong group was reduced, and the overall quality of life was improved [9]. The exercise of yoga also showed benefits for patients with cancer in the treatment of CRF. Vadirajaset up a "comprehensive Yoga course" in patients with metastatic breast cancer, instructing patients in breathing exercises, breathing adjustment and yoga relaxation techniques for 60 minutes each time [10]. After 3 months of intervention, the level of perceived stress, the frequency of fatigue and the severity of fatigue in the experimental group were significantly reduced. Compared with Qi gong and Yoga, fast walking does not require systematic learning, and is not subject to the limitations of the venue and environment, so it is more easily accepted by patients and more popular. The research of Zhouhas proved the effects of fast walking by randomly divided 144 ovarian cancer survivors into the experimental group and the control group (conventional nursing) [11]. The experimental group was given fast walking intervention 7 times a week for 150 minutes. After six months of intervention, the fatigue score and quality of life of the patients in the experimental group were significantly improved. Peng WPalso conducted personalized aerobic exercise intervention for CRF patients with ovarian cancer during the intermittent period of chemotherapy, such as jogging, walking, cycling, staircase climbing, aerobics and social dance [14]. After the intervention, the fatigue relief degree of the experimental group was better than that of the control group (< 0.05), and the quality of life and patient satisfaction were significantly higher than that of the control group (< 0.05), the difference was statistically significant. In China, traditional exercises such as Ba Duan Jin (one of the most common used Chinese Qigong for exercise. https://en.wikipedia.org /wiki/Baduanjin_qigong) and Tai Chi [The term Taiji and its other spelling T'ai chi are most commonly used in the West to refer to Taijiquan [or T'ai chi ch'uan, an internal martial art, Chinese meditation system and health practice. https://en.wikipedia.org/wiki/Taiji_(philosophy)] also could improve the life quality of CRP patients. The research of He GJshowed reduced the postoperative fatigue symptoms and delayed the symptoms during chemotherapy by guiding the patients with breast cancer to perform the Ba Duan Jin [12]. By exercising the Tai Chi 5 times a week for 15 weeks, the scores of multidimensional fatigue symptom inventory short form, and three negative sub-scale (general, physical, and emotional fatigue) were lower compared with patients who only received routine treatment in a 114 nasopharyngeal cancer patients research [13].

Long distance healthy education

Distance education refers to the medical care service provided by medical staff through internet or other distance education technologies. With the development of the internet and communication devices, network-based long distance intervenes for patients with CRF has showed its popularity. Youngrandomly divided 273 patients with moderate and severe CRF into two groups, and the experimental group received 12 weeks of internet-based and personalized CRF education program [15]. According to the guide book, participants complete seven online courses, including personally tailored sections based on the transtheoretic model (physical activity, sleep hygiene, and pain control) and education sections based on the cognitive behavioral therapy model (general introduction, energy conservation, nutrition, and distress management). Researchers reminded participants of the assessment points. Results showed that the scores of the simple fatigue scale (= 0.001) and the fatigue severity scale (= 0.001) of participants were significantly reduced, their anxiety level was also reduced (= 0.004). Dai SJ. conducted an outpatient extended care intervention based on the WeChat nurse communication platform in young and middle-aged breast cancer patients undergoing modified radical mastectomy and adjuvant chemotherapy [16]. Research team constructed a breast cancer nursing knowledge database, and established a WeChat public account. The responsible nurse draw up personalized nursing measures and pushed daily plan at 8:00 am every day. After 6 months of intervention, the simple fatigue scale scores of participants were assessed, and that of the observation group were significantly lower than the control group (< 0.01). The distance education model has the advantages of low cost, simple operation, and wide application range. However, patients who lack knowledge of network equipment and network cannot perform this intervention, and the patient's personal privacy and network security issues also cannot be ignored.

Cognitive behavior intervention

Cognitive behavior intervention is an intervention method to eliminate patients' negative emotions and change their bad coping styles by changing patients' irrational thinking, wrong cognition and abnormal behavior. It can significantly reduce the various stress reactions of cancer patients [17]. Wu YLrandomly divided 82 CRF patients into experimental group and control group[18]. On the basis of routine nursing, the control group also received cognitive behavior intervention. At first, researchers explained the relevant knowledge of the disease to help the patients and their families correctly understand the cancer, CRF and the chemotherapy response. Secondly, the intervention nurses instructed the patients to conduct progressive relaxation training twice a day for 30 minutes each time. Finally, sleep hygiene education, stimulus-control therapy, sleep restriction therapy and cognitive therapy intervention were conducted to help participants improve their sleep quality. The results showed that the total number of CRF patients in the experimental group was significantly reduced, and the difference was statistically significant compared with the control group. Eichlerconducted cognitive behavioral intervention in 23 breast cancer CRF patients by treating patients according to cognitive behavioral therapy manual eight times a week, 90 minutes each time [19]. After 8 weeks, the scores of multidimensional fatigue inventory of patients decreased significantly, and the level of anxiety and depression also decreased significantly.

Traditional Chinese medicine (TCM) intervention

A large number of studies have shown that TCM has unique advantages and significant curative effect in the treatment of CRF, among which acupuncture, moxibustion and acupoint pressure have been widely used in the field of CRF due to their unique advantages such as simple treatment and few adverse reactions [20, 21]. Cheng. randomly divided 28 patients with CRF into acupuncture group and placebo acupuncture group [22]. According to the theory of TCM, the experimental group was selected Qihai (CV6), Zusanli (ST36), Taixi (KI3), Sanyinjiao (SP6) acupoints for acupuncture. Both groups received 4 weeks and 8 courses of treatment, 45 minutes each time, twice a week, and follow-up of patients for 2 weeks. The results showed that compared with placebo group, the Chinese version of fatigue scale score of the experimental group was significantly lower (< 0.01), lung cancer symptoms and the quality of life was also improved. Liu XRdivided 80 elderly patients with advanced CRF into the experimental group and the control group [23]. The control group received routine treatment, and the observation group received moxibustion at Shenque (CV8) point on the abdomen as the main point, Guanyuan (CV4), Qihai (CV6) and Zhongwan (CV12) as the matching points for Ginger-separated Moxibustion treatment, once a day, 28 days/treatment. The Piper fatigue scale score of the observation group after 1 course of treatment was significantly lower than the control group, and the quality of life score was significantly higher than that of the control group, which improved the patient's fatigue status, quality of life and immune function. With the consent of patients and their parents, Bastani. randomly divided 120 pediatric CRF patients into two groups (acupressure group and placebo group) [24]. On the second day after the end of chemotherapy, the experimental group was pressed ST36 (Joksamly) and the placebo group was pressed LI12 (Zohoulia) for 3 minutes. After 1 hour of compression, the fatigue strength of the children decreased, and the difference was statistically significant (< 0.001). However, the results after 24 hours of intervention showed that there was no significant difference in the fatigue degree between the two groups. Therefore, in the follow-up study, we still need to carry out large-scale, long-term longitudinal studies to verify the effectiveness of non-drug interventions in TCM.

Emotional intervention

Mindfulness based cognitive therapy is a psychological therapy that combines Mindfulness with cognitive behavioral therapy concept, which is mainly used to prevent the recurrence of depressive disorder [25]. Leeapplied mindfulness based cognitive therapy to CRF patients, and found that not only CRF was alleviated in the intervention group, but also the score of happiness scale was significantly improved [26]. Chinese scholar Zhu CHperformed a touch-therapy intervention on patients with CRF in breast cancer chemotherapy [27]. Participants received a touch therapy once every day before going to sleep, 20-30 min/time, the fatigue of the participants was significantly reduced, and the quality of life and physical strength were also improved. Zeng Junestablished a spiritual care group, and conducted four stages of spiritual care intervention for patients with CRF after bladder cancer surgery, in order to reduce the degree of fatigue of patients [28]. Burnsrandomly divided 104 breast cancer CRF patients into experimental group (52 cases) and control group (52 cases) [29]. The control group received routine nursing, while the intervention group received gratitude intervention for four weeks. The content includes encouraging the writing of a Thanksgiving Diary, encouraging patients to bravely express their gratitude in daily life and organizing participants to watch the Thanksgiving video. After the intervention, the patients in the intervention group had lower cancer-causing scores, anxiety scores and depression scores than the control group. Yu H. gave music therapy intervention to patients with terminal cancer, which not only significantly reduced the level of cancer-induced fatigue, but also provided some reference for the dying care of cancer patients [30].

Discussion

Non-drug intervention can not only improve the therapeutic effects of patients with CRF, but also reduce the financial burden of patients. Exercise intervention, long distance interval, cognitive behavior intervention and emotional intervention from the physical and psychological level improve the physical condition of patients, establish the confidence to overcome the disease, thereby reducing the severity of fatigue in cancer patients. TCM intervention such as acupuncture, moxibustion, acupoint pressing and other methods to achieve dredge meridians, promoting Qi and blood circulation, so as to reduce the CRF symptoms of patients. However, it should be noted that non-drug intervention for CRF patients is only an adjuvant treatment method, and it cannot completely replace conventional medicine treatment. The combination of drug treatment and non-drug intervention should be used to help patients obtain the best therapeutic effect.

Conclusion

This paper reviews the effects of non-drug interventions on CRF to provide reference for clinical medical staff and relevant scholars. Though these non-drug intervention can enhance the therapeutic effects of conventional medicine and improve life quality, they can not completely replace conventional medicine treatment. Both conventional medicine application and non-drug intervention should be used in combination to help patients with CRF to obtain the best therapeutic effects.

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10.12032/TMRND201902009

Huang YQ, Yang GZ, Jin CD,Non-drug interventions for cancer-related fatigue: an updated review. TMR Non-Drug Therapy 2019, 2(2): 42-47.

17 April 2019,

Submitted: 8 March 2019,

Online:16 May 2019.

*Corresponding to:Chang-De Jin, Nursing School of Tianjin University of Traditional Chinese Medicine, 10 Poyanghu Road, Weat Area, Tuanbo New City, Jinghai District, Tianjin, 301617, China. E-mail: jcd1886@sina.cn.