Effects of Aerobic Exercise, Tai Chi on Sleep in Advanced Lung Cancer

Individuals with advanced lung cancer experience chronic sleep disturbances that affect them physically and psychologically, contributing to decreased quality of life (QOL) and survival. Physical exercise has garnered considerable interest for improving the well-being of patients with cancer because of its safety, affordability, and diverse benefits. Aerobic exercise (AE) and mind-body exercises (MBEs) have shown improved sleep in patients with early-stage cancer. It is thought that AE and MBEs improve sleep through different underlying mechanisms. AE promotes thermoregulation, body restoration, and energy conservation, while MBEs strengthen mental awareness and elicit relaxation.

However, the literature is limited on the effects of exercise on sleep in patients with advanced cancer who experience a greater symptom burden compared with other patients with cancer. Given the potential of both AE and MBEs in promoting sleep, the comparative effect of these different modalities warrants further research. Naomi Takemura, PhD, and colleagues evaluated both AE and tai chi (TC) and their impact on subjective sleep quality, physical and psychological outcomes, and survival in patients with advanced lung cancer. Their findings were reported in JAMA Oncology [published online December 7, 2023; doi:10.1001/jamaoncol.2023.5248].

The assessor-blinded, multicenter, three-arm, randomized, controlled trial compared AE and TC with a self-managed control group. A total of 226 participants were recruited between December 19, 2018, and September 7, 2021, from the oncology and medical outpatient clinics of three major public hospitals in Hong Kong. Patients who were diagnosed with stage IIIB or IV non-small cell lung cancer, were aged 18 years or older, had an Eastern Cooperative Oncology Group performance status of 0 to 2 in medical records, had no other cancer diagnoses in the previous year, did not exercise regularly, and were not actively participating in classes for AE and MBEs were included. Patients with active neurologic, substance abuse, or psychiatric disorders were excluded.

Patients were randomized 1:1:1 to AE (n=75), TC (n=76), and a control group (n=75) for the 16-week study. Randomization was stratified by treatment modality (targeted therapy or nontargeted therapy). All three groups had similar sociodemographic and clinical variables at baseline.

The mean age of participants was 61.41 years, and 54% were women. The AE arm received group exercise sessions and home-based exercises twice monthly, with each group session lasting an hour. Home exercises were encouraged for 150 minutes each week for moderate intensity and two to three resistance exercises every other day. The TC group took a 60-minute group session twice weekly. The TC group also performed the Yang style of TC at the end of 16 weeks for evaluation. The control group performed physical activity based on the World Health Organization’s recommended level of physical activity (ie, ³150 minutes of moderate-intensity AE per week).

The mean attendance rates in AE and TC were 8.50 and 27.30, respectively. The mean self-practice durations during the intervention period varied among the three cohorts, with 147.50 minutes in the AE group, 127.83 in the TC group, and 71.02 in the control group.

The study’s primary end point was subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI). Secondary end points included objective sleep measures, anxiety, depression, fatigue, QOL, circadian rhythm, and 1-year survival. Data were collected at baseline, 16 weeks, and 8 months after the intervention was completed.

At 16 weeks, a statistically significant reduction in PSQI was found in both the AE (difference between groups, −2.72; 95% CI, −3.97 to −1.46; P<.001) and TC (difference between groups, −4.21; 95% CI, −5.58 to −2.94; P<.001) groups compared with the control group. These differences continued at 8 months after the intervention for both AE (difference between groups, −1.75; 95% CI, −3.24 to −0.26; P<.001) and TC (difference between groups, −3.95; 95% CI, −5.41 to −2.49; P<.001). Of interest, the TC group showed a statistically greater reduction in PSQI compared with the AE group at both 16 weeks (difference, −1.49; 95% CI, −2.77 to −0.22; P=.02) and postintervention (difference, −2.20; 95% CI, −3.57 to −0.83; P<.001). The researchers suggested reasons for this difference could be the breathing regulation in TC and the mindfulness meditation component of MBEs.

Additionally, both AE and TC improved anxiety, depression, physical function, and circadian rhythm. The researchers noted that AE enhanced agility, whereas TC improved balance ability, fatigue, and survival. The median 1-year survival was higher in the AE group compared with the control group (47.76 and 44.20 weeks, respectively), but the TC group had the highest (49.18 weeks). After adjustment for the primary treatment modality, the TC group demonstrated a statistically significant lower hazard ratio (HR, 0.35; 95% CI, 0.17-0.75; P=.004), but not the AE group (HR, 0.55; 95% CI, 0.29-1.03; P=.06).

The authors cited limitations to the study. Participants were aware of group assignment, which could have led to expectation bias. The dosage of AE was lower than the dosage of TC. There may have been some participants with greater determination or less symptom burden who had a higher tendency to participate, which may limit study generalizability. The self-practice being self-reported could have led to an overestimation of physical activity. Secondary end point results should be interpreted as exploratory due to comparisons. Among patients with advanced lung cancer, both exercises, particularly TC, can be incorporated into survivorship care.

“AE and TC resulted in statistically significant improvements in sleep disturbances, anxiety, depression, physical function, and circadian rhythm. Notably, participants in the TC group showed greater improvement in sleep than those in the AE group, as well as in survival compared with [the control group],” concluded the researchers. “Given the safe nature of the exercises, both, but particularly TC, could be considered as a complementary therapeutic option to enhance the holistic well-being of patients with advanced lung cancer.”