An Exercise Intervention During Chemotherapy for Women With Recurrent Ovarian Cancer: A Feasibility Study.

ORIGINAL STUDY

An Exercise Intervention During Chemotherapy for Women With Recurrent Ovarian Cancer A Feasibility Study David Mizrahi, MSc,*Þ Carolyn Broderick, MBBS, PhD,* Michael Friedlander, FRACP, PhD,*þ Mary Ryan, PhD,þ Michelle Harrison, FRACP,§ Kate Pumpa, PhD,|| and Fiona Naumann, PhD¶ Objective: The aim of this study was to determine the feasibility of a combined supervised and home-based exercise intervention during chemotherapy for women with recurrent ovarian cancer. Secondary aims were to determine the impact of physical activity on physical and psychological outcomes and on chemotherapy completion rates. Methods: Women with recurrent ovarian cancer were recruited from 3 oncology outpatient clinics in Sydney and Canberra, Australia. All participants received an individualized exercise program that consisted of 90 minutes or more of low to moderate aerobic, resistance, core stability, and balance exercise per week, for 12 weeks. Feasibility was determined by recruitment rate, retention rate, intervention adherence, and adverse events. Aerobic capacity, muscular strength, fatigue, sleep quality, quality of life, depression, and chemotherapy completion rates were assessed at weeks 0, 12, and 24. Results: Thirty participants were recruited (recruitment rate, 63%), with a retention rate of 70%. Participants averaged 196 T 138 min I wk of low to moderate physical activity throughout the intervention, with adherence to the program at 81%. There were no adverse events resulting from the exercise intervention. Participants who completed the study displayed significant improvements in quality of life (P = 0.017), fatigue (P = 0.004), mental health (P = 0.007), muscular strength (P = 0.001), and balance (P = 0.003) after the intervention. Participants completing the intervention had a higher relative dose intensity than noncompleters (P = 0.03). Conclusions: A program consisting of low to moderate exercise of 90 min I wk was achieved by two-thirds of women with recurrent ovarian cancer in this study, with no adverse events reported. Randomized control studies are required to confirm the benefits of exercise reported in this study. Key Words: Cancer, Oncology, Exercise, Physical activity, Chemotherapy, Quality of life Received December 8, 2014, and in revised form March 12, 2015. Accepted for publication March 14, 2015. (Int J Gynecol Cancer 2015;25: 985Y992) cancer has the fifth highest rate of cancer-related O varian mortality among women and is the leading cause of death among gynecologic cancers.1 Most patients with ovarian

cancer are diagnosed as having advanced disease and present with nonspecific symptoms.2 Unlike other cancers such as breast and colon cancer, there is no effective screening for

*School of Medical Sciences, University of New South Wales Australia, Sydney, Australia; †Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia; ‡Gynaecological Oncology, Royal Hospital for Women, Sydney, Australia; §Royal Sydney Cancer Centre, Prince Alfred Hospital, Sydney, Australia; ||Research Institute for Sport and Exercise, University of Canberra, Canberra, Australia; ¶School of Copyright * 2015 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0000000000000460

Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Australia. Address correspondence and reprint requests to David Mizrahi, MSc, Kids Cancer Centre, Sydney Children’s Hospital, Level 1 South, High Street, Randwick, Sydney, Australia. E-mail: [email protected]. This study was funded by the University of New South Wales Start Up Grant. The authors declare no conflicts of interest.

International Journal of Gynecological Cancer

& Volume 25, Number 6, July 2015

Copyright © 2015 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.

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ovarian cancer.2 Primary treatment of ovarian cancer includes surgery and chemotherapy with carboplatin and paclitaxel; however, approximately 70% of patients with stage III or IV disease will experience recurrence and require further treatment.3 Ovarian cancer and its associated treatment often lead to physiological and psychological impairments.4 The combination of treatment adverse effects and poor prognosis can contribute to diminished quality of life (QOL).5 Interventions such as physical activity are emerging for patients with advanced cancers, and they report benefits in aerobic capacity, muscular strength, patient-reported outcomes, and overall survival.6,7 However, only a small number of randomized control exercise studies have included patients with advanced ovarian cancer and none with recurrent disease. In recent years, nonrandomized studies for patients with ovarian cancer have demonstrated the safety and feasibility of physical activity.8Y11 These studies demonstrate the benefits of physical activity for patients with ovarian cancer during first-line chemotherapy, including improvements in aerobic capacity, physical function, mental function, and QOL. It is common for patients with metastases to be excluded from such studies, so the effects of exercise on women with recurrent disease are unknown. Most patients with ovarian cancer reduce their physical activity after diagnosis and physical activity levels remain low during treatment, with only the minority reaching the recommended physical activity guidelines set by the American College of Sports Medicine of 150 minutes of moderate physical activity per week.12,13 A positive association between increased physical activity, QOL, and reduced fatigue and anxiety has been observed in patients with ovarian cancer.14,15 Women with ovarian cancer demonstrate interest in physical activity participation, with one study reporting that 87% of patients were either interested or maybe interested in participating, with 49% preferring a home-based program.14 Physical activity may improve multiple outcomes throughout treatment, including an increase in aerobic capacity and muscular strength, accompanied by an improved ability to complete activities of daily living.16 The cardiovascular response may assist in diminishing fatigue, positively affecting mood, sleep quality, and QOL.16 Patients with advanced breast cancer undergoing chemotherapy treatment who exercised more than 90 minutes per week improved their fatigue, distress, and QOL, compared with those who were less active.17 Based on the emerging evidence of the benefits of exercise interventions, the aim of this study was to assess the safety and feasibility of delivering a 90-min I wk exercise intervention for women with recurrent ovarian cancer who were undergoing chemotherapy. Furthermore, physical and psychological patient-reported outcomes during chemotherapy were investigated as well as chemotherapy completion.

METHODS Study Design This study was a prospective, single-arm trial designed to determine the feasibility and safety of implementing an exercise regime during second- or third-line chemotherapy for recurrent ovarian cancer treatment. Assessments were

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completed at 3 time points to determine the impact of physical activity on physical and psychological patient outcomes.

Setting and Participants Participants were recruited from oncology outpatient clinics at the Royal Hospital for Women and Royal Prince Alfred Hospital in Sydney and The Canberra Hospital, Canberra, Australia. The study received ethical approval from SESLHD (approval HREC 10/198) and ACT Health (approval ETH.5.13.118) Human Research Ethics Committees, whereas informed consent was obtained from each participant. Women were eligible for the study if they were 18 years or older, were diagnosed as having recurrent epithelial ovarian cancer, were receiving second- or third-line chemotherapy, were able to communicate in English to complete the questionnaires and interpret the exercise prescriptions, have clearance from their oncologist to partake in structured exercise, and had a Karnofsky Performance Status score at least 60. Participants who had cognitive impairment, were identified by their oncologist as too unwell, had existing musculoskeletal limitations that would inhibit exercising, or were already partaking in more than 150 min I wk of moderate exercise were excluded.

Procedure Eligible participants were identified by the medical oncologists or clinical nurse consultants and then approached by the study coordinator. After informed consent, participants underwent a baseline health and fitness assessment, conducted by an exercise physiologist. Participant age, treatment history, medical history, and date of diagnosis were obtained from hospital records.

Measures Feasibility Feasibility was measured by recruitment rate, retention rate, adherence to the 90-min I wk exercise target, and adverse events. Chemotherapy completion data was calculated using relative dose intensity (RDI).18

Questionnaires Self-report questionnaires were completed at all 3 time points (0, 12, and 24 weeks) using tools previously validated among patients with cancer. Psychological and physiological outcome questionnaires included the International Physical Activity QuestionnaireYShort form, used to quantify physical activity volume over the prior week19; the Pittsburgh Sleep Quality Index, used to measure sleep quality and quantity over the prior month in the domains of subjective sleep quality, sleep latency, duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction20; the Somatic Psychological Health Report (SPHERE), used to screen for clinically significant fatigue and psychological dimensions of distress21; the Short Form-36 (SF-36), used to measure physical and psychological health status and disease burden in the domains of vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental22; the Functional Assessment Cancer * 2015 IGCS and ESGO




TherapyYOvarian (FACT-O), used to measure QOL in the domains of physical, social, emotional, function, and ovarian cancerYspecific well-being23; and the FACT-Neurotoxicity, used to assess platinum-induced neurological symptoms of cancer treatment.24

Physical Assessment Participants were fitted with a polar heart rate (HR) monitor before the submaximal aerobic capacity test to measure HRrest. The YMCA cycle ergometer protocol was used (Vision Fitness, HRT E3800, Cottage Grove, WI), with participants completing 3-minute workloads of 25, 50, 75, and 100 W at 50 revolutions/min.25 A 10-repetition-max (RM) upper and lower body strength test was conducted using a seated supported-row and supine leg press machine (Maxim Fitness, Kidman Park, SA). The test ceased when participants reported 16 or 17 of 20 (very hard) using the Borg Rating of Perceived Exertion (RPE) scale, which corresponded to approximately 85% 1 RM, or if correct technique was unable to be sustained.26,27 A single-leg balance test was conducted to measure balance ability. A 30-second sit to stand test was performed as a measure of lower body functional capacity.

Exercise Intervention The 12-week time frame and 90-minute weekly target informed our study design based on previous exercise oncology research during chemotherapy.8,17 Participants were initially prescribed individualized low-moderate intensity exercise for 90 min I wk based on their physical capacity and exercise history assessed at baseline. Aerobic, resistance, core stability, and balance exercise sessions were of 10 to 40 minutes in duration, were 3 to 4 times a week, and were home based, with up to 1 session a week supervised. Participants were informed of Borg RPE scale and were prescribed an intensity of 11 to 14, correlating with 55% to 70% HRmax for aerobic exercise and 50% to 70% 1 RM for resistance training.27 Aerobic exercise consisted of walking, cycling, and swimming. Home-based resistance training consisted of the use of resistance bands and body weight exercises for 3 sets of 10 repetitions. Core stability exercise including floor and stability ball exercises was prescribed between an RPE of 11 and 14. Balance exercises were prescribed for those experiencing debilitating neuropathy and were at risk for having a fall. Participants completed a self-report physical activity diary and received a weekly telephone call to monitor adherence and progress, and discuss program progression. These sessions also included behavioral change strategies relating to time management, goal setting, overcoming barriers, and progressively overloading training components when goals were achieved.

Statistical Analysis Secondary outcomes were analysed using SPSS version 20.0. Wilcoxon signed rank tests compared preintervention and postintervention data, with statistical significance set at P G 0.05. An independent t test determined baseline differences between study completers and noncompleters.

Exercise for Women With Ovarian Cancer

RESULTS Participant Characteristics and Feasibility Fifty-four women were invited to participate in the study between September 2011 and July 2014, with 6 deemed ineligible (Table 1). Thirty participants provided consent (recruitment rate, 64%) with the reasons for nonrecruitment listed in Figure 1. Twenty-one participants completed the intervention and the 12-week assessment (retention rate, 70%). Twelve participants completed the 24-week follow-up assessment. There were significant baseline differences between study completers and dropouts in performance status (P = 0.02), QOL (P = 0.02), physical function (P = 0.03), and neurotoxicity (P = 0.05). Study completers averaged 196 T 138 min I wk of physical activity, adhering to the 90-min I wk target on 81% of the occasion (participants reporting physical activity Q90 min I wk on 190/236 weeks). There were no adverse events from the intervention (Fig. 2). The mean age of the participants was 58.6 T 10.9 years, with an average of 41.4 T 26 months since initial diagnosis and 5.3 T 8.7 months since the most recent disease recurrence. Eighty percent of participants were diagnosed as having advanced disease. Twenty percent were employed and continued to work during chemotherapy, with the remainder either retired or ceasing employment. The mean body mass index of participants was 25.3 T 7.1 kg/m2, with approximately one-third of participants being overweight or obese. Fifty-three percent of participants had a Karnofsky Performance Status score of 70 or higher, with a mean score of 74.5 T 10.1 of 100. Most TABLE 1. Participant (n = 30) demographic and clinical data at baseline

Age, y 30Y49 50Y69 70+ Body mass index Underweight/healthy Overweight/obese Employment status Employed Unemployed/retired Karnofsky Performance Status 970 e70 Disease stage at diagnosis I/II III/IV Chemotherapy regime Carboplatin + caelyx, every 28 d Paclitaxel, weekly Other

* 2015 IGCS and ESGO


n

%

5 21 4

17 70 13

21 9

70 30

6 24

20 80

14 16

47 53

6 24

20 80

9 9 12

30 30 40

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FIGURE 1. Consort diagram of participant recruitment pathway. participants were not sufficiently active at baseline, meaning that they were either completely sedentary or physically active but not reaching the 150-min I wk American College of Sports

Medicine guidelines. The most common chemotherapy regimens during the exercise intervention were combination carboplatin and caelyx (30%) and weekly paclitaxel (30%).

FIGURE 2. Mean, interquartile range, and maximum and minimum values of individual weekly physical activity data collected from self-report diaries.

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Fifteen participants achieved the 90-min I wk physical activity goal on at least 75% of occasions. Of the 9 participants in this study who did not commence or withdrew, 5 did not participate in any exercise due to experiencing severe symptoms such as fatigue, pain, and anxiety, whereas 3 participants were able to achieve the study goal on 50% of occasions before withdrawing from the study due to diseaseprogression and advanced symptom severity. One participant was unable to return the completed exercise diary after completing the intervention and was lost to follow-up.

Impact of Exercise Intervention Twenty-one participants completed baseline and 12week assessments, with 12 participants completing follow-up testing 24 weeks after the initial assessment. Their results are presented in Table 2 later. Participants who completed the study significantly increased their physical activity participation from baseline at both the 12- and 24-week time points (P G 0.01 for both). There were significant improvements in global QOL (P = 0.017), physical well-being (P = 0.006),


and functional well-being (P = 0.009). Participants reported improvements in fatigue (P = 0.004), sleep quality (P = 0.050), and physical function (P = 0.027). The physical assessment demonstrated that increased physical activity was associated with improved upper body (P = 0.001) and lower body strength (P = 0.003), 30-second sit to stand (P = 0.004), and single-leg balance (P =0.003). There were no significant differences in aerobic capacity, neurotoxicity, HRrest, blood pressure, body mass index, and waist-to-hip ratio; however, there was a significant decrease in hip circumference from 101.47 T 11.08 to 100.32 T 10.40 cm (P = 0.009). Participants who completed all 3 time points (n = 12) completed the final assessment 12 weeks after the conclusion of the intervention. Significant improvements were displayed from baseline to 24-week follow-up in physical activity volume (P = 0.003), balance (P = 0.02), upper body strength (P = 0.002), lower body strength (P = 0.001), mental function (P G 0.001), sleep quality (P = 0.04), emotional wellbeing (P = 0.04), functional well-being (P = 0.005), physical well-being (P = 0.01), and global QOL (P = 0.004).

TABLE 2. Physical and psychological variables assessed before and after an exercise intervention for intervention completers, assessed at weeks 0, 12, and 24

QOL (FACT-O) Physical Social Emotional Functional Ovarian specific Global QOL Symptom scales Fatigue (SPHERE) Sleep (PSQI) Mood disturbance (SPHERE) Mental function (SF-36) Physical function (SF-36) Neurotoxicity (FACT-Ntx) Physical activity (MET-h I wk, IPAQ) Physical assessment Upper body strength, kg Lower body strength, kg Aerobic capacity, mL kgj1 minj1 30-s sit to stand Single-leg balance, s

Pre Post Follow-Up (Week 0; n = 21) (Week 12; n = 21) (Week 24; n = 12)

Significance (P Value)

Mean (SD)

Weeks 0Y12 Weeks 0Y24

18.1 20.6 15.2 16.3 31.2 101.3

(7.0) (5.4) (6.0) (6.1) (6.3) (22.1)

21.6 19.8 17.1 18.9 32.9 109.9

(5.9) (6.2) (4.3) (4.5) (5.2) (21.0)

24.7 19.3 18.4 20.6 33.7 116.6

(2.3) (6.2) (3.8) (6.0) (3.7) (16.5)

0.006* 0.368 0.067 0.009* 0.447 0.017†

0.001* 0.610 0.040† 0.006* 0.210 0.004*

3.1 8.1 1.7 42.5 41.6 45.0 9.8

(2.7) (4.1) (2.4) (11.5) (9.8) (5.9) (8.4)

1.2 6.5 1.2 47.6 46.3 44.3 18.1

(1.4) (3.9) (2.0) (8.6) (6.1) (7.2) (10.6)

1.3 5.8 0.83 54.6 46.0 45.4 18.6

(1.6) (4.1) (1.3) (6.6) (6.7) (6.2) (7.8)

0.004* 0.050† 0.205 0.007* 0.027* 0.628 0.007*

0.090 0.040† 0.110 0.001* 0.210 0.830 0.003*

22.4 28.1 24.4 14.3 30.4

(5.0) (7.5) (5.9) (4.5) (28.6)

25.8 35.9 24.9 17.8 47.1

(5.5) (11.8) (6.8) (4.7) (28.6)

27.1 45.0 27.6 19.0 40.1

(4.9) (14.2) (7.5) (5.4) (19.9)

0.001* 0.003* 0.500 0.004* 0.003*

0.002* 0.001* 0.090 0.100 0.020†

*Indicates significance at P e 0.01. †Indicates significance at P e 0.05. Higher FACT-Ntx, less neuropathy severity; higher FACT-O, better quality of life; higher PSQI, worse sleep quality; higher SF-36, better physical and mental function; higher SPHERE, worse somatic and psychological symptoms; IPAQ, International Physical Activity Questionnaire; PSQI, Pittsburgh Sleep Quality Index.



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Chemotherapy Data The mean (range) RDI for study completers was 94.6% (75%-100%) and 79.8% (50%Y100%) for noncompleters, which was significant (P = 0.03).

DISCUSSION This study was the first to examine whether a combined supervised and home-based exercise intervention was feasible, safe, and beneficial for women with recurrent ovarian cancer. Our study reported 2 main findings. First, we demonstrated that it was feasible and safe for women with recurrent ovarian cancer to participate in an exercise regime, with approximately two-thirds completing the intervention. Second, women completing the program had improvements in fatigue, sleep quality, functional capacity, mental function, muscular strength, balance, and QOL.

Feasibility The 30 women who were recruited were generally representative of the wider ovarian cancer patient population in terms of age and disease diagnosis stage.1 Because the women in the study all had advanced-staged disease, it was anticipated that the recruitment rate would be low, particularly as the women were undergoing chemotherapy during the recruitment phase. The most common reason for nonrecruitment was not being interested (39%), raising the possibility of response bias as those interested in physical activity are likely to be more willing to participate and change physical activity behaviors. Twenty-one participants completed the intervention and were assessed postintervention, indicating a retention rate of 70%. This was lower than the retention rate of 87% (range, 80%Y96%) for mixed cancer patients28; however, this was not unexpected because more participants in our study had advanced disease, poorer prognosis, and lower performance status. A large cohort of the participants adhered to the 90-min I wk physical activity target, achieving this goal 81% of the time. The adherence rate was relatively high considering many were receiving ongoing chemotherapy throughout the exercise intervention. The weekly physical activity mean of 196 T 138 minutes for program compliers was more than double the program target. Finally, safety was confirmed as there were no adverse events occurring as a result of the exercise intervention. Physical activity participation was not feasible for all participants with recurrent ovarian cancer throughout this study. For the 9 participants who dropped out or did not commence, there were significant baseline differences in performance status, QOL, physical function, and physical activity. Red flags were raised with Karnofsky Performance Status e 70, QOL e 75, and physical function (SF-36) G35, suggesting that a certain baseline level may be required to participate in a lifestyle intervention during treatment. The most common mode of physical activity completed throughout this intervention was aerobic exercise, which consisted predominately of walking. Home-based exercise and walking have recently been reported as physical activity preferences for ovarian cancer survivors, which may be a reason for high adherence rates.14 Walking has been shown to be safe and

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feasible for women with ovarian cancer undergoing chemotherapy treatment.10

Preliminary Benefits of Exercise The physiological and psychological benefits observed during the intervention are particularly important considering the usual decline expected during treatment.5 Significant improvements were observed postintervention in physical well-being, functional well-being, global QOL, fatigue, sleep quality, mental function, upper and lower muscular strength, balance, and functional capacity. This is the only study to date displaying significant improvements in muscular strength and balance for patients with ovarian cancer. These improvements are likely to be important to postmenopausal patients who often experience a reduction in bone mineral density induced by treatment, as they may assist in reducing falls risk.29 Our study displayed significant improvements in psychological health, as well as positive trends nearing significance using the SPHERE and FACT-O emotional well-being scale. These psychological benefits attained were similar to mixed advanced and advanced lung cancer patients, suggesting that psychological health may still be improved despite a generally poor prognosis.30,31 The documented benefits associated with physical activity suggest that exercise programs should be offered to patients undergoing chemotherapy to maximise health outcomes. There was no significant change in VO2peak in this study unlike a cohort of patients with stage IYIII ovarian cancer.9 This may be due to the aerobic exercise component in our study being too low in volume to facilitate improvements in aerobic capacity.32 A minimum VO2peak of 14.5 mL I kg I min is an independent predictor of survival in metastatic disease and is the aerobic capacity required to maintain functional independence in healthy older women.33 Our findings displayed that only 1 participant fell below this threshold at baseline, although this result must be interpreted with caution due to the differences in cardiopulmonary function due to the prevalence of comorbidities between patients and healthy controls.

Behavioral Modification Participants maintained their physical activity levels at the 24-week follow-up, suggesting that a lifestyle change had been successfully adopted. To complement the maintained physical activity levels, nearly all physiological and psychological outcomes measured did not decline. These findings would suggest that behavior change strategies may be effective beyond the life of the 12-week intervention, which is an essential component of health promotion.

Chemotherapy Completion This study was the first to document chemotherapy completion rates during an exercise intervention for women with recurrent ovarian cancer and found that exercise did not detract from chemotherapy compliance. There was a significant difference in chemotherapy completion between study completers and noncompleters with an RDI of 94.6% and 79.8%, respectively. Emerging evidence supports the safety of exercise during chemotherapy in patients with breast cancer * 2015 IGCS and ESGO




performing either resistance or aerobic exercise during adjuvant chemotherapy, displaying a higher RDI compared with nonexercising controls (78%, 74%, and 66%, respectively).34 The sample size and the study design of our study limit a conclusion on the impact of exercise on chemotherapy completion; however, this preliminary finding warrants further investigation. However, it is possible that women who are healthier and have a higher RDI may be more inclined to participate in regular exercise.

Strengths, Limitations, and Challenges This study, to our knowledge, is the first combined home-based and supervised exercise intervention for women with recurrent ovarian cancer. The recruitment rate demonstrated significant support and interest among patients and clinicians to participate in an exercise program. This was a feasibility study and therefore had no control group. It was not powered to make inferences regarding the effect of exercise on physiological and psychological patient outcomes. Adequately powered randomized controlled trials are required to confirm the true effect of exercise in this population, including a nonexercising or wait-list control for comparisons. The addition of a midintervention assessment would also be useful in monitoring physiological and psychological benefits in a randomized study. The home-based nature of the study relied heavily on participants accurately reporting their physical activity sessions in the self-report exercise diaries. It might not have been uncommon for participants to overestimate their physical activity sessions. Furthermore, the reported physical activity was nearly double that of patients with early breast cancer who had completed treatment,35 highlighting that overreporting physical activity may have occurred.

CLINICAL IMPLICATIONS AND CONCLUSIONS This study found that approximately two-thirds of women with recurrent ovarian cancer were able to engage safely in exercise during chemotherapy. It is feasible to implement an exercise program during a chemotherapy regime in a time where physiological and psychological decline is expected. It is essential that the program is individualized and prescribed based on the limitations and physical needs of the patient. Although this study suggests that an exercise intervention is both safe and, further research in the form of an exercise randomized controlled trial is required to determine its efficacy.

ACKNOWLEDGMENT The authors thank all participants, nursing staff, and investigators involved in this study.

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Nausea as a sentinel symptom for cytotoxic chemotherapy effects on the gut-brain axis among women receiving treatment for recurrent ovarian cancer: an exploratory analysis.

Feasibility and efficacy of a 12-week supervised exercise intervention for colorectal cancer survivors.

Bleomycin cardiotoxicity during chemotherapy for an ovarian germ cell tumor.

Effect of an exercise training intervention with resistance bands on blood cell counts during chemotherapy for lung cancer: a pilot randomized controlled trial.

Feasibility of an exercise intervention for fatigued breast cancer patients at a community-based cardiac rehabilitation program.

Incidence of chemotherapy-induced ovarian failure in premenopausal women undergoing chemotherapy for breast cancer.

Recurrent Pseudomembranous Colitis in an Ovarian Cancer Patient Undergoing Carboplatin Chemotherapy.

Effects of exercise on biobehavioral outcomes of fatigue during cancer treatment: results of a feasibility study.

Feasibility of laparoscopic cytoreduction in patients with localized recurrent epithelial ovarian cancer.