Ask an answerable question (PICO)：
Lung cancer is the leading cause of death among cancer patients. The discomfort of late-stage cancer symptoms and the physical burden caused by chemotherapy are significant risk factors for developing depression symptoms. This is particularly prevalent among those diagnosed with lung cancer compared to other types of cancer, leading to decreased quality of life, prolonged hospital stays, increased treatment costs, and higher mortality risk. Therefore, this paper aims to improve clinical care quality through a review and appraisal of the literature. Thus, the research question is formulated as follows: "Does engaging in walking exercise (Intervention) alleviate depression symptoms during chemotherapy (Outcome) in patients with lung cancer (Population)?"
The Method and Analysis of Literature Review：
A comprehensive literature search was performed using databases (PubMed, CINAHL, Cochrane Library, Embase, and Airiti Library) covering 2019 to 2024. Only systematic reviews and randomized controlled trials (RCTs) were included. There was also a language restriction: only articles in English and Chinese were considered. A total of six articles were included in this study: five systematic reviews and one RCT.
Critical Appraisal：
The risk of bias in the included studies was evaluated using the ROBIS Tool (2016) for appraising systematic reviews and the Cochrane Risk of Bias 2.0 (2019) for randomized trials. The Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence was used to rank the evidence level. The certainty of the evidence was assessed by GRADE. The search results indicate that engaging in walking exercise for 30-60 minutes, 2-5 times a week, over an 8-12 week period may significantly reduce depression symptoms in patients with lung cancer undergoing chemotherapy.
Clinical Application of Evidence：
Based on the integrated findings from the literature, this study proposes a clinical implementation plan following the steps of evidence-based knowledge translation. The intervention targets patients with lung cancer undergoing chemotherapy in the respiratory department of a medical center in Taipei. Upon consenting to participate, each patient will complete a pre-intervention assessment using the Hospital Anxiety and Depression Scale-Depression subscale (HADS-D). Subsequently, project personnel will provide one-on-one nursing guidance using leaflets and videos to explain the program's details, exercise procedure, and criteria for discontinuation. During the intervention period, participants will perform walking exercises for 30 minutes five times a week over an 8-week period and maintain exercise logs. Follow-up assessments of depression symptoms using the HADS-D will be conducted in the fourth and eighth weeks after the intervention.
Evaluation of Effectiveness：
From April to June 2024, a total of 22 patients with lung cancer undergoing chemotherapy were enrolled in this study. Among them, 16 participants ultimately complete the whole study. The results showed that the mean score of the HADS-D was statistically significantly decreased from 5.82 ± 4.32 to 3.56 ± 2.42 (Wald Chi-Square = 7.386, 95% CI -2.44 to -0.40, p = .007). It indicated that walking exercise was effective in improving depression symptoms among patients with lung cancer undergoing chemotherapy. A subgroup analysis revealed that patients with lung cancer who had depression symptoms at baseline (HADS-D score ≥ 8) showed significant improvement to no depression symptoms (HADS-D score < 8) after engaging in walking exercise. Furthermore, the extent of depression symptoms improvement in these patients was greater than the average improvement observed in patients who had no depression symptoms at baseline.
Conclusions and Recommendations：
This study demonstrates that a walking exercise program can effectively alleviate depression symptoms in patients with lung cancer undergoing chemotherapy. Clinically, early instruction in walking exercises for patients with lung cancer can prevent psychological imbalance, thereby enhancing patient adherence to treatment and improving therapeutic outcomes. Ultimately, this approach will enhance the quality of care.
蕭韜文 蘇瑞源 
