Key points
- Individuals with breast cancer frequently experience chronic fatigue.
- Current treatments are often insufficient.
- This study suggests that a newly developed multimodal therapy for cancer-related fatigue can improve sleep quality and reduce fatigue in breast cancer survivors.
- The results support the effectiveness of an integrative approach that combines conventional and complementary medicine in treating cancer-related fatigue.
Background
Many individuals with breast cancer experience severe fatigue. About one-third of breast cancer survivors continue to experience chronic fatigue, even five to ten years after successful treatment [1]. Common symptoms include low energy or, in some cases, extreme exhaustion, along with sleep disturbances that significantly affect an individual's quality of life. While both the illness and its treatments are thought to play a major role in the development of fatigue, the exact mechanisms are not yet fully understood [2].
Interestingly, despite patients’ subjective need for rest, a lack of physical activity can worsen fatigue symptoms. Physical exercise, such as aerobic training, is currently the standard treatment recommended for cancer-related fatigue [3]. A systematic review of 56 studies found that such physical activity helps to reduce fatigue both during and after cancer treatment [4]. Further, educational interventions that provide patients with information on mental well-being and sleep quality, have also shown clinical benefits [5].
Studies examining the use of only one of the above therapies suggest minimal to moderate symptom improvement. Based on this observation, research has begun to explore multimodal therapies for cancer-related fatigue [6], with the hypothesis that combining several therapeutic modalities may be more effective than individual therapies. Therefore, the authors of the current study have developed a multimodal therapy specifically tailored to breast cancer survivors [7].
Study objective
This study aimed to determine whether a novel multimodal therapy for breast cancer survivors, either alone or in combination with aerobic training, can reduce cancer-related fatigue and improve sleep quality as effectively as aerobic training alone.
Method
The study included 105 women (average age 58) who had been experiencing cancer-related fatigue for at least six months and who had completed their last cancer treatment no less than three years prior. The multimodal therapy that was tested consisted of psychoeducation and sleep education sessions, as well as eurythmy therapy and art therapy, both based on anthroposophic medicine. All participants were assigned either randomly or based on their preference to one of the following three study groups: multimodal therapy, combination therapy (multimodal and aerobic), or aerobic training. Each therapy lasted ten weeks and included both guided sessions and home exercises. All participants completed questionnaires assessing cancer-related fatigue and sleep quality before and immediately after the therapy, as well as six months later.
Main findings
- Overall, the multimodal therapy was as effective as the aerobic training alone in reducing cancer-related fatigue.
- When sleep and fatigue indicators were examined separately, participants in the multimodal therapy group showed significantly greater improvement in sleep quality than those in the aerobic group immediately after therapy. Moreover, six months after treatment, fatigue levels were significantly lower in the multimodal therapy group compared to the aerobic training group.
- The results for the combination therapy suggest that it was as effective as aerobic training alone in reducing fatigue, but led to better sleep quality six months after treatment.
Comment
In a follow-up study conducted four years later, the authors found that participants who had completed the multimodal therapy, as well as those in the combination therapy group, continued to show better sleep scores than those who had received aerobic training alone [8]. The authors explained the beneficial effects of the multimodal therapy to be linked to the interaction of several therapeutic modalities. For example, while psychoeducation supports self-regulation and stress management, sleep education teaches techniques to enhance sleep quality. Indeed, current research suggests that cancer-related fatigue is closely linked to sleep quality [9]. Chemotherapy may lead to fatigue indirectly due to its detrimental effects on sleep quality. Consequently, interventions that improve sleep quality during chemotherapy may also help alleviate fatigue.
Furthermore, this study suggests that therapies from anthroposophic medicine may be promising in treating cancer-related fatigue. According to this integrative medicine system, the multimodal therapies are believed to address fatigue on multiple levels, including the physical (e.g., by promoting vitality), the emotional (e.g., recognizing one’s emotions), as well as the spiritual (e.g., finding meaning). For instance, eurythmy therapy aims to promote self-awareness through mindful movements, while art therapy is believed to balance emotions and encourage self-reflection.
Since the treatment of chronic health conditions is often based on multimodal approaches [10], the investigation of their efficacy and effectiveness beyond the contribution of individual therapy components is essential. Further research on multimodal therapies is warranted.
Study strenghts and limitations
This is the first study to investigate the effectiveness of this novel multimodal therapy, which combines conventional therapies with treatments from traditional, complementary and integrative medicine. The authors designed and assessed a comprehensive therapy program within an integrative oncology framework, used standardized questionnaires to measure cancer-related fatigue and sleep quality, and documented the study’s procedures and methodology in detail and with transparency.
A limitation of the study is the relatively small sample size and the disproportionate distribution of participants among the different experimental groups. Overall, there was a dropout rate of 20%, and many of the dropouts were in the aerobic therapy group. Finally, about half of the participants were allocated to the therapy group based on their own preference, which may have resulted in selection bias and influenced the results.
Conclusion
A new multimodal therapy, which includes psychoeducation, sleep education, as well as eurythmy and art therapy from anthroposophic medicine, effectively reduced cancer-related fatigue in breast cancer survivors. The results highlight the benefits of an integrative therapeutic approach in oncology.
Study reference: Kröz M, et al. Impact of a combined multimodal-aerobic and multimodal intervention compared to standard aerobic treatment in breast cancer survivors with chronic cancer-related fatigue - results of a three-armed pragmatic trial in a comprehensive cohort design. BMC Cancer 2017;17(166):1-13.
Link to the study: https://doi.org/10.1186/s12885-017-3142-7
Referenzen
- Bower JE, Ganz PA, Desmond KA, et al. Fatigue in long‐term breast carcinoma survivors: A longitudinal investigation. Cancer 2006;106(4):751-8.
- Bower JE. Cancer-related fatigue - mechanisms, risk factors, and treatments. Nature Reviews Clinical Oncology 2014;11(10):597-609.
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF): S3-Leitlinie Komplementärmedizin in der Behandlung von onkologischen PatientInnen (Kurzversion 1.1). AWMF; 2021 (Zugriff: 25.07.2024). https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Komplement%C3%A4r/Version_1/LL_Komplement%C3%A4r_Kurzversion_1.1.pdfCramp F, Byron-Daniel J. Exercise for the management of cancer‐related fatigue in adults. Cochrane Database of Systematic Reviews 2012;11:CD006145.
- Duijts SF, Faber MM, Oldenburg HS, et al. Effectiveness of behavioral techniques and physical exercise on psychosocial functioning and health‐related quality of life in breast cancer patients and survivors - a meta‐analysis. Psychooncology 2011;20(2):115-26.
- Berger AM, Kuhn BR, Farr LA, et al. Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. Psychooncology 2009;18(6):634-46.
- Spahn G, Choi KE, Kennemann C, et al. Can a multimodal mind-body program enhance the treatment effects of physical activity in breast cancer survivors with chronic tumor-associated fatigue? A randomized controlled trial. Integrative Cancer Therapies 2013;12(4):291-300.
- Kröz M, Fink M, Reif M, et al. Multimodal therapy concept and aerobic training in breast cancer patients with chronic cancer-related fatigue. Integrative Cancer Therapies 2013;12(4):301-11.
- Kröz M, Quittel F, Reif M, et al. Four-year follow-up on fatigue and sleep quality of a three-armed partly randomized controlled study in breast cancer survivors with cancer-related fatigue. Scientific Reports 2023;13(1):2705-18.
- Medysky ME, Temesi J, Culos-Reed SN, Millet GY. Exercise, sleep and cancer-related fatigue: are they related? Clinical Neurophysiology 2017;47(2):111-22.
- Lee C, Crawford C, Swann S. Multimodal, integrative therapies for the self-management of chronic pain symptoms. Pain Medicine 2014;15(S1):76-85.
