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Last Updated: 05/09/13

Review of Integrative Nonpharmacologic Interventions and Fatigue


A review article from by Karen M. Mustian, Ph.D., et al., summarized research pertaining to integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue (CRF), a common symptom that leads to impaired quality of life for cancer patients and survivors. The authors were recipients of two National Cancer Institute grants (1R25-CA102618; 2U10CA37420-20).

Mustian noted that the National Comprehensive Cancer Network issues a set of guidelines for the treatment of cancer-related fatigue, which suggests screening of possible contributing factors such as anemia or nutritional deficiencies. The guidelines also suggest pharmacologic means of treatment for contributing factors, including antidepressants, steroids, and other drugs. Conservation of energy by patients is also suggested, although research has shown that CRF is not always alleviated with periods of rest, like other types of fatigue. The guidelines do suggest some behavioral integrative nonpharmocologic interventions such as exercise and psychosocial interventions, and the article provides information on the scientific evidence of some interventions.

A brief overview of several interventions will be listed below and more in-depth interpretation of the science can be found in the article at

Exercise interventions from 12 randomized controlled trials (RCT) showed preliminary evidence that exercise was well tolerated by cancer survivors. Studies showed that exercise interventions involving moderately intense aerobic exercise (e.g., walking and cycling) ranging from 10-90 minutes in duration, 3-7 days/week were consistently effective at either reducing or halting the progression of CRF in cancer patients during and after treatment. Additionally, one study showed that resistance training three times per week with progressively increasing weight and number of repetitions was effective in reducing CRF in patients receiving hormone therapy.

Psychosocial interventions such as support groups, stress management education, and coping strategy training have also grown in popularity and interest in relation to the treatment of CRF. These interventions may also act as an alternative for patients who cannot tolerate exercise interventions. Mustian and colleagues looked at 15 randomized controlled trials examining a variety of psychosocial interventions in cancer survivors during and after treatment, such as group and individual support groups including health education and stress management skills, and nurse-administered cognitive behavioral programs, among others. As a whole, these studies suggest that psychosocial support therapy can lead to lower levels of CRF among patients. One study that used a structured psycho-educational intervention involved health education, stress management, and coping skills weekly for 6 weeks, and showed a significantly larger decrease in fatigue for the intervention group compared to the control. Interestingly, participants in sessions delivered both in a group and individually, orally or through writing, or by a licensed professional or a trained nonprofessional showed benefit. Further research is needed, however, to understand what the optimal mode of delivery is, as well as the optimal content.

Other interventions, such as yoga, were investigated. In one study 39 patients with lymphoma who were receiving active cancer treatment participated in a Tibetan yoga stress reduction program, once a week for 7 weeks, and showed no increase in CRF at study completion, or 12 months post treatment. Participants in the wait-listed control group did demonstrate increases in CRF. The yoga program included yoga postures, visualization, breathing, and mindfulness.

Along similar lines of mindfulness, Speca and colleagues found that 109 early- or late-stage cancer patients  taking part in a mindfulness-based stress reduction (MBSR) program demonstrated greater reductions in fatigue than participants in a wait-list control group. Another study showed similar CRF improvements in a group of 59 patients with breast or prostate cancer. Both studies are preliminary, and while promising, do show the need for studies with a larger participant base in a randomized controlled trial format with CRF as a primary outcome, in order for results to be used as a basis of clinical care.

Further research into integrative nonpharmacologic treatments for CRF such as nutritional therapy (in one study individualized dietary counseling and a protein supplement group reported lower CRF as compared to a control group that ate according to their own desires) and sleep therapy (trials in which patients are counseled on proper sleep hygiene, wake/sleep patterns, and sleep management techniques such as limiting overall time spent in bed) are preliminary but promising for the development of future larger trials.

Mustian and colleagues stated that “physical exercise and psychosocial therapeutic interventions currently have the strongest scientific evidence base to support their use. Unfortunately, the most effective exercise prescription or psychosocial therapy remains unclear and the effect sizes are small.” They also noted that oncologists should encourage their patients to exercise and participate in psychosocial programs, but the research has yet to show that there is an identified “dose” or type that can be prescribed. While the effect size of improvements in CRF may be small, exercise and psychosocial programs are generally well tolerated and safe.