Lung cancer is one of the commonest cancers around the world. Sleep disturbances are commonly reported by lung cancer patients. Meanwhile, disturbed sleep is associated with several health problems, including shortened survival period. Thus, lung cancer imposes a substantial health burden on patients and society both locally and world widely. On top of the classical clinical therapies, additional approaches that could result in improved sleep are needed. Previous studies, including our own, have shown that physical exercise, such as aerobic walking, improves lung cancer patient's physical fitness particularly cardiovascular fitness, circadian rhythm and immune function. Another popular mode of exercise in Chinese population is tai-chi. With emphasis on breathing and concentration, tai-chi exhibits extra benefits for stress-relieving and psychological well-being. Those benefits of exercise have long been implicated for better sleep of cancer patients. The promising benefits of aerobic exercise or tai-chi, as non-pharmacological interventions, urge for need of rigorous evidence on the effectiveness of these interventions in improving sleep outcomes. However, to date, there has been no report from a randomized controlled trial (RCT) to study the effect of aerobic exercise or tai-chi on sleep of lung cancer patients. This proposed research is designed to conduct a three-arm RCT comparing aerobic exercise, tai-chi to usual care in non-small cell lung cancer patients. Recruited participants will be randomised into three groups: 1) a 16-week aerobic exercise group, 2) a 16-week tai-chi program group, and 3) a self-management control group. Aerobic exercise and tai-chi program will be conducted by certificated coaches. Life-long adherence to the practice in intervention groups is encouraged. Through this project, the investigators aim to evaluate if 1) aerobic exercise or 2) tai-chi intervention promote subjective sleep quality in lung cancer patients compared to control, as the primary outcome of this study. The investigators shall also examine if tai-chi practice can provide similar improvement in sleep quality compared with ordinary exercise. Using biomarkers including circadian rhythm, cardio-respiratory fitness, further provides objective measures for bio-physiological effectiveness of the interventions. The associations of those biological measures and psycho-social status with sleep outcomes will be further explored. Findings of this study will provide crucial information on the evidence-based practice by physical exercise or tai-chi to improve sleep of lung cancer patients. This study will also have far-reaching significance in providing important scientific evidence to policymakers to integrate physical activity into routine clinical management as an add-on treatment for lung cancer patients in Hong Kong.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
226
They are aerobic and mind-body exercise respectively.
Queen Mary Hospital
Hong Kong, Hong Kong
Quality of Sleep (Subjective)- Pittsburgh Sleep Quality Index
To assess the change of quality of sleep, the Chinese version of the Pittsburgh Sleep Quality Index, from baseline at 16-week and 1 year
Time frame: 1 year
Levels of physical activity
To measure compliance to exercise all participants will be measured for their level of physical activity in daily living. Physical activity will be quantified with a non-invasive small-size wrist-worn piezoelectric accelerometer (Actigraph; Ambulatory Monitoring Inc., New York). Actigraphy has been shown to provide valid assessments of physical activity. The user-defined time interval for the count of wrist accelerations is 1 min. Patients will be asked to wear the actigraph for at least 3 consecutive 24-hour spans. Each patient will keep a diary for times of rising and retiring.
Time frame: Baseline, 16-week, 1 year
Circadian rhythms- cortisol rhythms
We will measure circadian rhythms using biomarkers that have been linked to survival of cancer patients, cortisol rhythms will be measured using saliva samples collected before and after intervention. The cortisol levels will be measured using enzyme-linked immunosorbent assay (ELISA) kits. The saliva will be collected using Salivettes at following time points: 0.5 hour, 4 hour, 8 hour and 12 hour after habitual wake time (referred as circadian time).
Time frame: Baseline, and 1 year
Circadian rhythms- melatonin rhythms
We will measure circadian rhythms using biomarkers that have been linked to survival of cancer patients, melatonin rhythms will be measured using saliva samples collected before and after intervention. The melatonin levels will be measured using enzyme-linked immunosorbent assay (ELISA) kits. The saliva will be collected using Salivettes at following time points: 0.5 hour, 4 hour, 8 hour and 12 hour after habitual wake time (referred as circadian time).
Time frame: Baseline, and 1 year
Cardio-respiratory fitness- 6-minute walking test
Cardio-respiratory fitness shall be evaluated using the 6-minute walking test (6MWT). The 6MWT has been widely used to assess cardio-respiratory fitness in lung cancer patients \[28-30\]. The 6MWT requires participants to walk on an even and flat surface between two cones set 30m apart, with the object being the participant walking as far as possible within the 6 minutes period (if participant cannot continue for the 6 minutes, the test will end). The walking test is measured in units of meters walked at the end of the 6 minutes.
Time frame: Baseline, 16-week, 1 year
Physical functioning- Get Active Questionnaire
Physical fitness will a be assessed using the Get Active Questionnaire (GAQ). The GAQ assesses if participants are safe to participate in the interventions and ensures if participants can perform the exercises within the intervention.
Time frame: Baseline, 16-week, 1 year
Physical functioning- timed up and go test
This test evaluates participants' agility.
Time frame: Baseline, 16-week, 1 year
Physical functioning-sit to stand test
This test evaluates participants' muscle strength.
Time frame: Baseline, 16-week, 1 year
Physical functioning- single leg standing test
This test evaluates participants' balance.
Time frame: Baseline, 16-week, 1 year
Immune functions- cytotoxic activity of natural killer (NK) cells, and spontaneous or phytohemagglutinin (PHA)-stimulated T-lymphocyte proliferation
For each participant, 10 ml of peripheral blood will be collected before and after intervention in intervention groups, as well as in control group at the same time points, for some immune functional studies. The peripheral blood mononuclear cells are isolated for measurements of immune functions. Immune functions will be analyzed by cytotoxic activity of natural killer (NK) cells, and spontaneous or phytohemagglutinin (PHA)-stimulated T-lymphocyte proliferation.
Time frame: Baseline, 1 year
Health-related quality of Life- European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire
Health related QoL is an important outcome for lung cancer patients and plays an important impact on prognosis. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30). It will be evaluated by three parts, global score, symptom score and functional score with the range of 0-100. Higher score in global and functional aspects denote better quality of life while lower score in symptom aspects denotes better quality of life.
Time frame: Baseline, 16-week, 1 year
Health-related quality of Life- European Organization for Research and Treatment of Cancer Quality of Life Core corresponding lung cancer-specific module
Health related QoL is an important outcome for lung cancer patients and plays an important impact on prognosis. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire corresponding lung cancer-specific module (QLQ-LC13) shall be used as measurements of QoL. Lower score denotes better quality of life. The range of score is 0-100.
Time frame: Baseline, 16-week, 1 year
Psychological Distress- Hospital Anxiety and Depression Score
To evaluate psychological distress the Hospital Anxiety and Depression Score (HADS) will be used. The HADS comprises seven items each for anxiety and depression. Each item of the anxiety subscale and the depression subscale was scored on a 4-point scale. This scale is a reliable tool, and is widely used to assess patients with cancer.
Time frame: Baseline, 16-week, 1 year
Fatigue- Brief Fatigue Inventory
Fatigue will be measured by the Chinese version of the Brief Fatigue Inventory (BFI). The BFI was developed to measure fatigue in cancer patients. It consists of 9 items with each item scored on a 0-10 scale. The BFI measures patients' fatigue when symptoms are at their worst, least, usual and currently during the normal waking hours, with 0 indicating no fatigue, and 10 being fatigue as bad as one can imagine. Other items include fatigues interaction with patients' general activity, mood, waking ability, normal work (includes both work outside the home and housework), relations with other people, ability to think clearly, and enjoyment of life. The interference is measured with 0 being does not interfere, and 10 being completely interferes.
Time frame: Baseline, 16-week, 1 year
Quality of Sleep (Objective)- Actigraph
Actigraph will serve as an objective measure for assessing sleep parameters, such as sleep efficiency, total sleep time.
Time frame: Baseline, 16-week, 1 year
Fried frailty Criteria
Frailty will be measured by weight loss, exhaustion, low physical activity, slowness and weakness.
Time frame: Baseline, 16-week, 1 year
One-year survival rate
One-year relative survival rate will be retrieved from patients' medical record.
Time frame: 1 year
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