INTRODUCTION:

People use cancer as a metaphor for the worst things in life, but there are no metaphors dreadful enough to describe cancer. It's true that we've learned a lot more about cancer in the past 50 years, but mostly what we've learned is that cancer is a lot more complicated than we thought. "We truly grossly underestimated the cleverness of cancer," says Ralph deVere White, director of the U.C. Davis Cancer Center.

As a result of fast growing medical field, the life expectancy of people with cancer have become longer, having to deal with the long-term consequences of the disease and its treatment. Thus an increasing number of individuals need supportive care to enhance their quality of life (Lucia 2003), which increasing identification of the symptoms associated with cancer and relief of these symptoms emerging as an important dimension of cancer care.

Fatigue or tiredness is recognized as symptoms of cancer and its treatment. Cancer-related fatigue (CRF) is a subjective experience, affecting 70 to 100% of the cancer patient population (Mock 2001b). It has a profound effect on the whole person, physically, emotionally and mentally (Ahlberg 2003), and can persist for months or even years following completion of treatment. It can have a phenomenal impact on a patient's life, interfering with daily activities (Curt 2000) and also may potentially have devastating social and economic consequences (Fletchner 2002)

In the past people with cancer were encouraged to rest if they felt fatigued. It is important that individuals with cancer receive appropriate support and advice to help them cope with any side effects of the treatment or disease. Physical exercise has been suggested as helpful in reducing the fatigue that is associated with cancer.

Various studies have been done to examine the positive effects of exercise both during and after treatment. Fifty-six studies, involving a total of 4068 participants, were included in a review, the results of which suggest that physical exercise such as aerobic walking and aerobic cycling can help to reduce fatigue both during and after treatment for cancer.

NEED FOR THE STUDY:

The different approaches to Cancer treatments such as chemotherapy, radiation therapy, and biologic therapy can bring about fatigue in cancer patients. Fatigue is described as a common symptom of some types of cancer. Patients with cancer experiencing fatigue describe it as feeling tired, weak, worn-out, heavy, slow, or that they have no energy or get-up-and-go. Fatigue in cancer patients may be called cancer fatigue, cancer-related fatigue, and cancer treatment-related fatigue.

Cancer Fatigue can affect all areas of life by making the patient too tired to take part in daily activities, relationships, social events, and community activities. Patients may miss work or school, spend less time with friends and family, or spend more time sleeping. In some cases, physical fatigue leads to mental fatigue and mood changes. This can make it hard for the patient to pay attention, remember things, and think clearly. Money may become a problem if the patient needs to take leave from a job or stop working completely. Job loss can lead to the loss of health insurance. All these things can lessen the patient's quality of life and self-esteem.

When a healthy person is tired, they can relieve their fatigue by sleep and rest. Whereas Cancer-related fatigue is chalk and cheese. Cancer patients get tired after less activity than people who do not have cancer. Also, cancer-related fatigue is not completely relieved by sleep and rest and may last for a long time. Fatigue usually decreases after cancer treatment ends, but patients may still feel some fatigue for months or years.

In spite of the commonness and influence of CRF there is very less information available with regards to the exact cause, changing patterns and exacerbating and relieving factors (Fletchner 2002), thus complicating the development of effective management interventions (Dimeo 2002). The cause of CRF may also differ between individuals as well as according to the phase of the disease and the type of treatment received (Ryan 2007).

The National Comprehensive Cancer Network (NCCN 2005) has developed guidelines for the management of CRF. Initially any treatable factors that may cause fatigue should be identified and treated. The panel identified seven factors; pain, emotional distress, sleep disturbance, anaemia, nutrition, activity level and comorbidities. If the patient does not have any treatable contributing factors or CRF persists, then additional treatment is recommended depending on the patient's clinical status. This incorporates education and counseling, general strategies for the management of fatigue, pharmacological and non-pharmacological interventions. In line with these guidelines the role of non-pharmacological interventions in the management of CRF is supported by Mustian 2007 and colleagues who have identified psychosocial therapies, physical exercise, and a range of other interventions as potentially beneficial. The physical dimension of CRF is likely to have an organic aetiology (Dimeo 2001). The effect of treatment and a reduction in physical activity can lead to a reduction in physical performance (NCCN 2005). Thus, the patient requires an increased effort to accomplish normal everyday activities, which leads to the perception of fatigue. This is further exacerbated by impairment of skeletal muscle function intensified by a lack of activity (Lucia 2003).

Exercise has been demonstrated to be effective in reducing fatigue and improving the exercise tolerance of healthy and chronically diseased individuals (Mock 2005). It has been suggested that changes brought about by physical activity may counteract the negative effects the tumour and toxic therapy have on the capacity of physical performance (Dimeo 2002). Activity could reduce CRF by improving functional capacity, resulting in a reduced effort and improvement in the perception of CRF (NCCN 2005). Rest, the preferred recommendation for CRF in the past, is likely to be counterproductive as inactivity leads to muscle wasting and a loss of cardiorespiratory fitness, leading to increased fatigue (Dimeo 2001). Winningham 1992 developed a theoretical framework for CRF (Winningham's Psychobiological-Entropy model) which proposes that a balance between rest and activity can reduce CRF, whereas an imbalance can lead to deterioration suggesting that too little or too much exercise may exacerbate CRF.

The benefit of exercise may not be limited to the improvement of the physical dimension of CRF. It could also relieve the emotional and mental dimensions. Exercise has been demonstrated to improve mood and reduce anxiety and fear in patients (Dimeo 2001).

STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of Exercise on cancer-related fatigue among women with Breast cancer admitted in Erode Cancer Centre, Erode

OBJECTIVES:

1. To assess the level of Cancer related Fatigue before and after exercise among the women with Breast cancer in control and experimental group.

2. To evaluate the effectiveness of Exercise on cancer-related fatigue among women with Breast cancer in control and experimental group

3. To find out the association between post test scores of cancer-related fatigue among women with Breast cancer in control and experimental group and the selected demographic variables such as age of the women, educational status, religion, occupation, monthly family income ,marital status, stage of illness and duration of hospitalization

HYPOTHESES:

H₁ The post test cancer-related fatigue score of women with Breast cancer who had exercise will be significantly lesser than their pretest fatigue score.

H₂The post test cancer-related fatigue score of experimental group women with Breast cancer who had exercise will be significantly lesser than their posttest score of the control group.

H₃There will be a significant association between cancer-related fatigue and the selected demographic variables.

DESCRIPTION OF THE INTERVENTION:

Exercise [Walking]:

The current NCCN (National Comprehensive Cancer Network) recommendation is to begin with low intensity exercise and then to progress slowly and modify the exercise plan as conditions change.

The Experimental group maintained an individualized, self paced, home based walking exercise program throughout the treatment and after treatment. The duration of walking might be 20 to 30 minutes sessions, 5 times per week. The control groups receive routine care.

METHODOLOGY:

Research Approach:

The research Approach selected to accomplish the objective of the study was an evaluative approach

Research Design:

The Research design of this study was Non- equivalent pre-test, post test control group design to determine the effectiveness of intervention strategy. The Non-equivalent control group design is similar to the pretest posttest control group design except that there is no random assignment of subjects to the experimental and comparison group.

Study setting:

The study was conducted in Erode cancer centre at Erode.

Population:

The Target populations of this study were patients with Breast Cancer receiving chemotherapy and radiation Therapy.

Sample:

The samples of this study were patient with Breast Cancer receiving chemotherapy and radiation Therapy in Erode Cancer Centre, Erode

Sample size:

The sample size consisted of 50 patients with Breast Cancer of which 25 Samples in experimental Group and 25 in control group.

Sampling Technique:

The sample for the study was selected through purposive sampling Technique.

Criteria for sample selection:

The sample for the study was selected based on the following criteria.

Inclusion criteria:

1. The patient with Breast Cancer receiving chemotherapy and or radiation therapy.

2. The patient with the age group from 30 years and above.

3. The patient with early stages (I, II and III) of Breast Cancer.

4. The patient who reside in Erode.

5. The patient can able to provide verbal and written consent.

6. The patient who can speak Tamil and English.

7. Those who were willing to participate.

Exclusion criteria:

The patient with hemodynamically stable and critically ill

1. The patient with cardiovascular problem

2. The patient with metastasis and or advanced stage of Breast Cancer.

Description of the Tool:

The instruments comprised of two arts

Part I Demographic data of the patient with breast cancer

Part II Fatigue was assessed by piper fatigue scale.

Section A: Baseline Proforma:

It contained items for obtaining information regarding Age, Educational status, Religion, Occupation, Monthly family Income, Marital status, Stages of Illness and Duration of Hospitalization.

Section B: Piper fatigue scale:

Fatigue was assessed by piper fatigue scale. This scale consisted of 27 questions, composed of 22 numerically scaled, "0" to "10"items that measure four dimensions of subjective fatigue: behavioral/severity, affective meaning, sensory and cognitive/mood. These 22 items are used to calculate the four sub-scale/dimensional scores and the total fatigue scores. To calculate the total fatigue score, add the 22-item scores together and divide by 22 in order to keep the score on the same numeric "0" to "10" scale. For each questions fill in the space provided for that response that best describes the fatigue the client experiencing now or today.

Scoring procedure

Level of Fatigue	Actual scores
No	0
Mild Fatigue	1-3
Moderate Fatigue	4-6
Severe Fatigue	7-10

Plan for data analysis:

The data were analysed by using both descriptive and inferential statistics

· Baseline proforma of the samples were described by frequency and percentage distribution

· Frequency and percentage was used to assess the level of Cancer-related fatigue among women with breast cancer of experimental and control group

· Unpaired ‘t’ test was used for Compare the effectiveness of exercise on Cancer-related fatigue among experimental and control group,

· Chi square test was used to find out the association between Cancer-related fatigue scores and selected variables of women with breast cancer in experimental and control group.

RESULTS:

Section A:

1. As per the demographic characteristics in control group 40% of the women were in the age group of 41 -50 years. However 60% of them were illiterate, all of them were Hindus, 38% them were sedentary worker and 32% above Rs. 4500 income group, 96% of them were married, 64% were stage II and 44% were hospitalized for 4-5weeks.

2. Where as in experimental group 48% of the women were in the age group of 41 -50 years ,48% of them were illiterate, 68% of them were Hindus, 44% them were unemployed and 72% above 4500 income group, 96% of them were married, and 64% were stage II and 60% were hospitalized for less than 1week.

Section B:

In pre-test Cancer-related fatigue score of control group 52% had moderate fatigue, 32%had mild fatigue and 16%had severe fatigue, whereas in post-test 64% had moderate fatigue, 28%had severe fatigue and 8%had mild fatigue.

In pre-test Cancer-related fatigue score of experimental group 72% had moderate fatigue and 28%had severe fatigue, whereas in post-test 84% had mild fatigue, and 16%had moderate fatigue.

Section C:

In experimental group mean post-test score of cancer-related fatigue 55.5 was less than the mean post-test score of cancer-related fatigue 121.8 of control group. The obtained Unpaired ‘t’ value at df (48) was 10.74, which is significant at 0.05 level. The findings shows exercise has a significant effect in reducing Cancer-related fatigue of experimental group than. So the researcher concluded that exercise has played a significant role in reducing Cancer-related fatigue

Section D:

There was a significant association between the post-test Cancer-related fatigue scores of control group and variables like Religion ( Fisher Exact Test=0.026 , P< 0.05) and Monthly income ( Fisher Exact Test²= 0.008, p < 0.05). But there was no significant association with other variables like age, education, occupation, marital status, stage of illness and duration of hospitalization.

There was a significant association between the post-test Cancer-related fatigue scores of experimental group and variables like occupation (Fisher Exact Test=0.041, P< 0.05) and Monthly income ( Fisher Exact Test²= 0.031 , p < 0.05). But there was no significant association with other variables like age, education, religion, marital status, stage of illness and duration of hospitalization.

CONCLUSION:

The findings imply the need for educating women on effective management of cancer-related fatigue. Exercise has played a significant role in reducing Cancer-related fatigue among breast cancer women

RECOMMENDATION:

On the basis of the findings of the study it is recommended that,

· An experimental study could be undertaken without the control group

· A large scale study can be carried out to generalize the findings.

· A similar study can be conducted to women with other type of cancer.

· A similar study can be conducted by using other alternative therapies like acupressure, acupuncture and yoga.

· A comparative study can be conducted to evaluate the effectiveness of two different teaching methods.

REFERENCES:

1. Cancer-related fatigue. Fort Washington, Pa.: National Comprehensive Cancer Network. http://www.nccn. Org /professionals/ physician_gls/f_guidelines.asp. Accessed May 10, 2011.

2. Fatigue (PDQ). National Cancer Institute. Accessed May 10, 2011.http://www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/Patient/page1.

Received on 23.05.2014 Modified on 28.07.2014

Int. J. Adv. Nur. Management 2(3): July-Sept.,2014; Page 134-138