1. Scruth, Elizabeth PhD, MPH, RN, CCRN-K, CCNS, FCCM, FCNS, CPHQ

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Aromatase inhibitors (AIs) are a hormonal therapy used to treat hormone-sensitive breast cancers in women who have undergone menopause. Adverse effects of AIs include joint and muscle pain, referred to as AI-induced musculoskeletal symptoms or AIMSSs.1 Aromatase inhibitor medications improve 5-year survival rates compared with other hormonal therapy in early breast cancer, so it is important that women continue to take the medication.2


The adverse effects of AIs can affect the adherence rate to the medication and strategies to options to manage AI-induced symptoms to enable them to have meaningful dialogue with the patient on improving their quality of life.



The reduced adverse effects need to be explored. Exercise is encouraged in all cancer survivors to maintain physical health and its role in preventing or managing AIMSSs is the subject of a recent Cochrane review.


The aim of the systematic review was to assess the effects of exercise therapies on the prevention or management of AIMSSs in women with stages I to III hormone receptor-positive breast cancer.3


It is important for nurses to understand the effects of AI treatment and be aware of the aim of the Cochrane Review involved exploring interventions in the published literature aimed at assessing the effects of exercise interventions on the management and prevention of AIMSSs in women with stages I to III hormone receptor-positive breast cancer.1 The 2 primary outcomes of the review looked at the effect of exercise therapies on the prevention and treatment of symptoms of AIMSSs (pain, stiffness, and grip strength) from baseline and the safety of the intervention, including adverse effects such as injuries. Six secondary outcomes included incidence of AIMSSs, persistence and compliance of women taking their medication due to the intervention, health-related quality of life, participant cancer-specific quality of life, breast cancer-specific survival, and overall survival.



The review considered randomized controlled trials (RCTs) in all languages, both published and unpublished. The trials included compared exercise versus a comparator arm that was unrestricted. Included in the trials were women 18 years and older, with stages I to III estrogen receptor-positive or progesterone receptor-positive breast cancer or both, and being treated adjuvantly with AIs. Exercise therapies included were unrestricted in type including walking, aerobic exercise combined with resistance training, calisthenics, and weak exercise-walking up stairs and walking with handheld poles. Control arm groups varied including waiting list, unsupervised moderate physical activity, and a no-exercise instruction until the end of the study group. Exercise therapies ranged in length from 6 weeks to 12 months with a mixture of both supervised and unsupervised. Intensity of the exercise therapy varied between the studies.



The databases searched were the Cochrane Breast Cancer's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL, 2018, issue 1), MEDLINE (1946 to December 2018), EMBASE (1947 to December 2018), CINAHL (1937 to present), World Health Organization search portal for registered and ongoing trials, and



The review included 7 individually RCTs inclusive of 400 participants. One study explored the prevention of AIMSSs, and 6 studies looked at the treatment of AIMSSs.


For the primary outcome of preventing pain, stiffness, grip strength, and compliance to taking AI medications, 1 study reported no difference in the exercise group compared with the comparator group. The study did not provide data values and did not compare any other outcomes.


For the 6 studies that explored managing AIMSSs, the overall change in worst pain scores in 4 studies (standardized mean difference [MD], -0.23; confidence interval [CI], -0.78 to 0.32; 284 women, very low certainty evidence) was very uncertain. One study of 53 women suggested that exercise therapies result in little to no difference in overall change in stiffness scores (MD, -0.76; 95% CI, -1.67 to 0.15) and visual analogue scale stiffness score (MD, -0.42; 95% CI, -2.10 to 1.26; low certainty evidence). For the overall change in grip strength, 1 study of 83 women resulted in the evidence being very uncertain (MD, 0.30; 95% CI, -0.55 to 1.15). For the second primary outcome of safety of the intervention including adverse effects, there were no adverse events identified across 4 studies in either arm inclusive of 331 women. The evidence was of low certainty.



The 7 studies included only a small number of participants leading to uncertainty of evidence for all outcomes. Because of the low certainty of the evidence, the overall effect of exercise on pain, grip strength, and adherence to AIs in the treatment of AIMSSs is inconclusive. Further RCTs of high quality and adequately powered (large sample sizes) are needed to be published to improve precision of results. Although the results of the systematic review did not result in conclusive evidence that exercise can prevent or manage AIMSSs, exercise still needs to be a part of every woman's daily routine. Current guidelines for exercise recommend all women engage in exercise at least 3 to 4 times a week and every day preferably.



Nurses spend time with patients both in the hospital and community setting. There are opportunities during interactions with women experiencing breast cancer to discuss overall well-being both physically and mentally. Exploring exercise routines prior to the cancer diagnosis may open the dialogue to recommendations for exercise strategies during and after breast cancer treatment. Reminding women that exercise can be easily incorporated into daily routines inexpensively is an essential part of holistic caring for patients. Further research is needed on this topic.




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3. Roberts KE, Ricket K, Feng S, Vagenas D, Woodward NE. Exercise therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer. Cochrane Database Syst Rev. 2020;(1):art. no. CD012988. doi:. [Context Link]