The relationship of fatigue in breast cancer survivors with quality of life and factors to address in psychological interventions: A systematic review

Hope and symptom burden of women with breast cancer undergoing chemotherapy: A cross-sectional study

AIM

This research aimed to explore the level of hope and symptom burden of breast cancer women undergoing chemotherapy, and predictive factors of hope were also investigated.

BACKGROUND

Chemotherapy brings physical and psychological stress to breast cancer patients. As an effective coping strategy, hope gives them the courage to overcome difficulties and improve prognosis and survival. Therefore, efforts are needed to raise hope.

DESIGN/METHODS

A total of 450 women who were undergoing breast cancer chemotherapy participated in this cross-sectional study. Sociodemographic data, disease characteristics, and measures of hope and symptom burden were collected using questionnaires. Hope was assessed using the validated Herth Hope Index, and the previously validated Memorial Symptom Assessment Scale was used to assess symptom burden. This paper adhered to the STROBE guidelines.

RESULTS

Chinese breast cancer chemotherapy women hope average scores of 30.15 ± 4.82 were in the medium range of the Hearth Hope Index as specified by Herth to be 24-35. Patients with age ≤45, religious beliefs and lighter symptom burden have a higher level of hope. These variables explained a total of 22.9% of the variation in hope.

CONCLUSIONS

The level of hope for women undergoing breast cancer chemotherapy still needs to be further improved. Symptom burden can negatively predict hope.

RELEVANCE TO CLINICAL PRACTICE

If nurses can decrease breast cancer chemotherapy women symptom burden, there is an impact on increasing levels of hope.

Relationship between social support, physical symptoms, and depression in women with breast cancer and pain

PURPOSE

Fatigue and pain are common among women with breast cancer, and often related to depressive symptoms. Social support may influence levels of fatigue, pain interference, and depressive symptoms. We tested a theory-based, structural model examining the relationship between social support (i.e., emotional and instrumental) and depressive symptoms via fatigue and pain interference in women with breast cancer.

METHODS

Women (N = 327) with stages I-III breast cancer were enrolled in a randomized trial investigating a behavioral pain intervention. Measures of social support, fatigue, pain interference, and depressive symptoms were completed at enrollment. Data were analyzed using structural equation modeling to test direct and indirect pathways relating social support, fatigue, pain interference, and depressive symptoms.

RESULTS

Our model evidenced good fit. Significant direct effects emerged linking higher levels of emotional support with lower levels of fatigue (β = -.30), pain interference (β = -.32), and depressive symptoms (β = -.31). More instrumental support was significantly associated with more depressive symptoms (β = .11), but not fatigue or pain interference. Higher levels of fatigue (β = .30) and pain interference (β = .34) were significantly related to higher levels of depressive symptoms. More emotional support related to less depressive symptoms via lower levels of fatigue (β = -.09) and pain interference (β = -.11).

CONCLUSION

Women reporting higher levels of emotional support endorsed fewer depressive symptoms, and that relationship was driven by lower levels of fatigue and pain interference. Our results highlight novel pathways that healthcare professionals can leverage to optimize social support topics in psychosocial interventions targeting breast cancer symptoms. This model should be replicated using longitudinal data.

Cancer and stress: NextGen strategies

Chronic stress is well-known to cause physiological distress that leads to body balance perturbations by altering signaling pathways in the neuroendocrine and sympathetic nervous systems. This increases allostatic load, which is the cost of physiological fluctuations that are required to cope with psychological challenges as well as changes in the physical environment. Recent studies have enriched our knowledge about the role of chronic stress in disease development, especially carcinogenesis. Stress stimulates the hypothalamic-pituitaryadrenal (HPA) axis and the sympathetic nervous system (SNS), resulting in an abnormal release of hormones. These activate signaling pathways that elevate expression of downstream oncogenes. This occurs by activation of specific receptors that promote numerous cancer biological processes, including proliferation, genomic instability, angiogenesis, metastasis, immune evasion and metabolic disorders. Moreover, accumulating evidence has revealed that β-adrenergic receptor (ADRB) antagonists and downstream target inhibitors exhibit remarkable anti-tumor effects. Psychosomatic behavioral interventions (PBI) and traditional Chinese medicine (TCM) also effectively relieve the impact of stress in cancer patients. In this review, we discuss recent advances in the underlying mechanisms that are responsible for stress in promoting malignancies. Collectively, these data provide approaches for NextGen pharmacological therapies, PBI and TCM to reduce the burden of tumorigenesis.

Sleep disturbance among Arabic breast cancer survivors

BACKGROUND

Sleep disturbance is the most common and distressing cancer symptom that negatively affects the quality of life (QoL). The main objective of this study is to determine the prevalence of sleep disturbance among Arabic women with breast cancer, post-treatment, and assess their sleep disturbance in relation to health-related QoL, demographics and treatment characteristics.

METHODS

In this study, cross-sectional data were collected using the Pittsburgh Sleep Quality Index (PSQI: 19-items) and the Functional Assessment of Cancer Therapy-General (FACT-G: 27 items). Demographic information and treatment characteristics were also collected.

RESULTS

A total of 133 women who had been diagnosed with breast cancer agreed to participate in the study. Approximately three-quarters (73.7%; n = 98) of the participants was reported as poor sleepers (PSQI ˃ 5). The worse mean score of the PSQI component was the sleep latency with the highest score (M = 1.71, SD = 0.93). There were significant relationships between poor sleep and treatment (patients receiving both chemotherapy and radiotherapy) and with comorbidities (asthma, anaemia, hypertension/heart failure, diabetes/heart diseases) (P < 0.05). Those experiencing poor sleep had the lowest QoL among the cancer patients.

CONCLUSION

Sleep disturbance is a significant problem for Arabic patients diagnosed with breast cancer. The result suggests that sleep disturbance should be routinely assessed in clinical settings. Further research should develop an intervention for management to reduce sleep disturbance and improve sleep quality in cancer patients.

Enhancing Self-Esteem and Body Image of Breast Cancer Women through Interventions: A Systematic Review

Breast Cancer (BC) is the most common neoplasm in women worldwide, considered a global public health problem. Among BC women, some of the most common psychological symptoms in the adaptation to the disease are reduction in self-esteem and distorted body image (BI). Although there are numerous studies with the goal of promoting different psychological variables, BI and self-esteem are often separately observed despite their relationship and their importance in the process of the illness. Moreover, there have been no reviews that have synthesized the findings related to interventions aimed at enhancing both self-esteem and BI in BC women. Therefore, the objective of this review was to identify and examine the implemented interventions aimed at boosting both variables in this population. For this purpose, a systematic review was implemented following the PRISMA statement. A thorough search was performed on the following databases: Web of Science, PubMed, PsychInfo, PsychArticles, and Scopus. Among 287 records, only eight articles met the eligibility criteria. Interventions were grouped into three types according to their characteristics: Group therapies, Physical activity therapies, and Cosmetic and beauty treatments. The levels of effectiveness of the different interventions varied between them, and within each, in their impact on self-esteem and BI. More interventions focused on developing BI and self-esteem in this population are needed due to their ability to predict psychological functioning and quality of life of women with breast cancer.

Pathophysiological implications of neuroinflammation mediated HPA axis dysregulation in the prognosis of cancer and depression

Cancer patients are more likely to develop depressive symptoms and show a poor prognosis compared to the normal healthy individuals. Cancer occurrence and the anticancer treatments result in the pro-inflammatory cytokines-mediated inflammation, which dysregulates the HPA-axis activity that may result in depression-like behaviour. Conversely, depression causes the activation of the HPA-axis that results in the downstream release of endogenous glucocorticoids which may result in depressive signs and symptoms in some cancer patients. Depression may also result in non-adherence to treatment and increased mortality in cancer patients. In this review, we have focused on the role of neuroimmune axis and hyperactive HPA-axis in case of both cancer and depression. Therefore, therapeutics targeting the HPA-axis dysregulation could be effective in ameliorating symptoms of depression in cancer patients.

Effects of Qigong, Tai Chi, acupuncture, and Tuina on cancer-related fatigue for breast cancer patients: A protocol of systematic review and meta-analysis

BACKGROUNDS

Cancer-related fatigue (CRF) is one of the most common and disabling outcomes in patients with breast cancer (BC). Traditional Chinese medicine (TCM) nonpharmacological interventions are becoming increasingly popular for cancer treatment and rehabilitation interventions. However, their efficacy and safety remain unclear and there is no systematic review or meta-analysis focusing fully on this issue. We aim to evaluate the effects of representative TCM nonpharmacological interventions, including Qigong, Tai Chi, acupuncture, and Tuina, on CRF in BC patients.

METHODS

Published randomized controlled trials (RCTs) that assessed the efficacy of these interventions on CRF for BC patients will be included. We will search from the following electronic databases: PubMed, Cochrane Library, EMBASE, MEDLINE, Web of Science, Scopus, PsycINFO, PSYINDEX, CINAHL, China National Knowledge Infrastructure (CNKI), WanFang Database, and Chinese Biomedical Literature Database (CBM). The primary outcomes are the improvement of CRF, which will be evaluated by the Piper Fatigue Scale (PFS), the Functional Assessment of Cancer Therapy (FACT)-Fatigue Scale, Schwartz Cancer Fatigue Scale (SCFS), the Multidimensional Fatigue Inventory (MFI). The secondary outcomes are quality of life and safety. The meta-analysis will be performed using RevMan ver 5.3(Cochrane) statistical software.

RESULTS

We will provide more practical results investigating the efficacy of Qigong, Tai Chi, acupuncture, Tuina for BC patients with CRF from several respects including the improvement of fatigue, quality of life, and safety.

CONCLUSIONS

This review will generate more stronger evidence in BC patients for TCM nonpharmacological interventions, including Qigong, Tai Chi, acupuncture, Tuina, in the treatment of CRF and help to inform clinicians and policymakers.

ETHICS DISSEMINATION

Ethical approval is not necessary because all of the study base in our review will be based on published research. We will submit our results to a peer-reviewed journal.

STUDY REGISTRATION NUMBER

The study is priorly registered through International Platform of Registered Systematic Review and Meta-analysis Protocol on October 2, 2020 (INPLASY 2020100003).

Health-related quality of life in breast cancer patients: review of reviews from 2008 to 2018

BACKGROUND

Breast cancer still is a topic. This overview of the literature aimed to update the current knowledge on quality of life in breast cancer patients.

METHODS

A review of literature in MEDLINE, Cochrane Database of Systematic Reviews and Google Scholar were carried out to identify review papers on health-related quality of life in breast cancer during the 2008 to 2018. All publications were screened using the PRISMA guideline. The methodological quality of reviews was assessed using the AMSTAR. The findings were summarized and tabulated accordingly.

RESULTS

Within over a decade, a total of 974 review papers were identified which according to the study selection criteria finally we have evaluated 82 reviews. Of these about 85% had a reasonable methodological quality. The findings were mainly summarized on several headings including instruments used to measure quality of life, treatment, supportive care, psychological distress, and symptoms. Questionnaires had a good performance to quantify quality of life in breast cancer patients. Most reviews were focused on the impact of treatment including endocrine therapy as well as integrating complementary and alternative medicine into the current practice. According to the reviews, yoga was the most recommended exercise to improve quality of life in breast cancer patients.

CONCLUSION

Overall, the findings from this overview indicated that quality of life in breast cancer patients enhanced during the last decade. Several simple but effective interventions such as physical activity and psychosocial interventions proved to be effective in improving quality of life in this population. However, management of symptoms such as pain, and lymphedema, issues related to worry, sexual function especially for young patients, and the future outlooks all are among topics that deserve further consideration. Also, this overview indicated that methodological issues in measuring quality of life in breast cancer patients improved greatly, but still there is a long way to go to understand what really matter to patients.

Fatigue-Related Cognitive-Behavioral Factors in Survivors of Childhood Cancer: Comparison with Chronic Fatigue Syndrome and Survivors of Adult-Onset Cancer

Purpose: Cancer-related fatigue is a burdensome late effect of cancer treatment. A pilot study showed the effectiveness of cognitive-behavioral therapy (CBT) in fatigued survivors of childhood cancer (CCS). The aim of this study is to investigate whether the six cognitive-behavioral factors that are addressed during CBT differ in CCS compared with patients with chronic fatigue syndrome (CFS) and survivors of adult-onset cancer (ACS). Levels of self-esteem, optimism, and depressive symptoms, variables that are also related to fatigue, were also compared between groups. Methods: Retrospective analyses were performed on 34 CCS (ages 11-42 years), 102 patients with CFS, and 95 ACS who were referred for evaluation of severe fatigue. Fatigue severity, possible cognitive-behavioral fatigue maintaining factors, depressive symptoms, self-esteem, and optimism were assessed using questionnaires and actigraphy. Results: No significant differences were found in the factors coping with the experience of having had cancer, fear of cancer recurrence, physical activity, and in levels of self-esteem and optimism. CCS attributed their fatigue significantly more often to psychosocial causes and reported fewer problems in sleep/rest compared with patients with CFS. Compared with ACS, CCS reported significantly more social support, more problems in sleep/rest, and more depressive symptoms. Conclusions: There is substantial overlap in cognitive-behavioral factors that can maintain fatigue between CCS and CFS patients or ACS. Also differences were found regarding attribution of fatigue, the sleep/rest pattern, social support, and depressive symptoms that might have clinical implications when CBT for fatigue is provided to CCS.

Impact of Psycho-Social Factors on Fatigue among Breast Cancer Patients Who Are Currently Undergoing Radiotherapy

Fatigue in breast cancer patients undergoing radiotherapy has been studied less comprehensively than fatigue from chemotherapy. The aim of this study was to test the impact of psycho-social factors on the fatigue among breast cancer patients undergoing radiotherapy. This was a cross-sectional correlational study and participants were 210 breast cancer patients currently undergoing radiotherapy in an outpatient setting in Korea. Data collection was carried out from 22 July to 30 September 2019. The results of this study showed that symptom assessment, anxiety and depression, uncertainty, and perceived stress had a direct effect on the fatigue of breast cancer patients receiving radiotherapy, while social support had an indirect effect. These factors explained 67.2% of the fatigue among the participants. This study confirmed that various interventions for symptom assessment, anxiety and depression, uncertainty, and stress reduction need to be developed to reduce fatigue of breast cancer patients receiving radiotherapy. The present results form the basis for developing such interventions.

Cancer-related Fatigue in Breast Cancer Survivors: A Review

Fatigue has been the most distressing and frequent symptom in breast cancer (BC) survivors after treatment. Although fatigue can occur in other cancer survivors, women with a history of BC might share some distinctive features. The present study aimed to recapitulate the knowledge about risk factors and correlates of cancer-related fatigue (CRF) in BC survivors after oncologic therapy. An electronic data search was conducted in PubMed using the terms "fatigue," "breast," "cancer," and "survivors." Records were included if they were original articles, available in English, had used a quantitative scale, had > 100 participants, and had excluded women with BC relapse. BC survivors were required to have finished their treatments ≥ 2 months before, except for hormonal therapy. The physiopathology and other interventions were considered beyond the scope of our review. The correlates were subsequently classified into 7 main categories: (1) sociodemographic data, (2) physical variables, (3) tumor- and treatment-related variables, (4) comorbidities, (5) other symptoms, (6) psychological issues, and (7) lifestyle factors. Fatigue was consistently greater in younger, obese, and diabetic women. Women reporting fatigue often communicated symptoms such as pain, depression, insomnia, and cognitive dysfunction. Coping strategies such as catastrophizing could play an important role in the persistence of fatigue. However, tumor characteristics, previous treatments received, and physical activity were not consistently reported. CRF was a strong predictor of the quality of life of BC survivors after treatment. In conclusion, we found CRF was a frequent and serious symptom that severely affects the quality of life of BC survivors after treatment. Health practitioners require more awareness and information about CRF.

The Effect of Art Therapy and Music Therapy on Breast Cancer Patients: What We Know and What We Need to Find Out—A Systematic Review

Objective. To systematically review the evidence available on the effects of art therapy and music therapy interventions in patients with breast cancer.Design. Systematic search was conducted in PubMed, EBSCO, and Cochrane Central databases. Articles were scanned using the following keywords: “art therapy” or “music therapy” and “breast cancer” or “breast neoplasms,” “breast carcinoma,” “breast tumor,” and “mammary cancer.” Only RCTs published in English, with a control group and experimental group, and presenting pre-/post-therapy results were included. PRISMA guidelines for this systematic review were followed.Results. Twenty randomized controlled trials matched the eligibility criteria. Nine studies evaluated the effect of art therapy, and eleven evaluated the effect of music therapy. Improvements were measured in stress, anxiety, depression reduction, pain, fatigue, or other cancer-related somatic symptoms’ management. Overall, the results show that art therapy was oriented towards the effects on quality of life and emotional symptoms while music therapy is the most often applied for anxiety reduction purposes during or before surgeries or chemotherapy sessions.Conclusion. Art and music therapies show effective opportunities for breast cancer patients to reduce negative emotional state and improve the quality of life and seem to be promising nonmedicated treatment options in breast oncology. However, more detailed and highly descriptive single therapy and primary mental health outcome measuring RCTs are necessary to draw an evidence-based advise for the use of art and music therapies.

[Effect of activities profile variations on health-related quality of life among breast cancer patients: Secondary exploratory analysis from PASAPAS study data]

INTRODUCTION

Lifestyle changes in breast cancer patients, by physical activity increasing, are becoming a main objective in supportive care. The objective of this study was to explore the impact of the daily activity profile evolution on the quality of life among this public.

METHODS

Sixty patients (18 to 75 years) with non-metastatic breast cancer were randomized to a 2:1 ratio (physical activity intervention; control) in the PASAPAS randomized clinical trial. Multiple linear regression analyzes were computed to explain quality of life scores 6 months after the start of adjuvant therapy. Variables retained were the baseline quality of life scores, the anxiety trait, the randomization arm, the variations of time spent in different physical activity classes ([3-4 [MET, [4-6 [MET, ≥6 MET) and in sedentary behaviors.

RESULTS

Only the decrease in time spent in sedentary behaviors really appeared as a predictor of the quality of physical life. Participation in the intervention group appeared as a predictor of quality of mental life.

DISCUSSION

Results plead in favor of sedentary life style decrease as part of the objectives of care program for women with breast cancer. It also highlights the need of collective supervised sessions implemented by competent staff. This research also suggests that the dynamics of daily activity profile variations should be studied further in association to quality of life.

A randomized placebo-controlled trial of bupropion for Cancer-related fatigue: Study design and procedures

BACKGROUND

Cancer-related fatigue is a significant problem and is associated with poor quality of life. Behavioral interventions include exercise and cognitive-behavioral therapy, which survivors may be unwilling or unable to adopt. Pharmacologic interventions (e.g., selective serotonin reuptake inhibitors) have been disappointing. One potential therapy is the antidepressant bupropion, a norepinephrine-dopamine reuptake inhibitor that targets both inflammation and the hypothalamic-pituitary-adrenal axis. The current study is intended to provide a rigorous test of the efficacy and tolerability of bupropion for cancer-related fatigue.

METHODS

A randomized, double-blind, placebo-controlled trial will examine the effects of bupropion on cancer-related fatigue. The trial will be conducted nationwide through the University of Rochester Medical Center (URMC) National Cancer Institute Community Oncology Research Program (NCORP). Disease-free breast cancer survivors (n = 422) who completed chemotherapy and/or radiotherapy 12-60 months previously and report significant fatigue will be randomized 1:1 to receive bupropion (300 mg/day) or placebo. Outcomes will be assessed at baseline and the 12-week follow-up. The primary outcome, fatigue, will be measured with the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F). Secondary outcomes include quality of life, depression, and drug tolerability. Exploratory outcomes include cognition and symptomatology. Potential biological mechanisms and genetic moderators of cancer-related fatigue will also be explored.

DISCUSSION

This study is the first placebo-controlled trial to our knowledge to evaluate bupropion for cancer-related fatigue. Positive results could revolutionize the treatment of cancer-related fatigue, as bupropion is safe, inexpensive, widely-available, and may be more tolerable and acceptable for many patients than current, limited treatment options.

Severe fatigue after treatment for childhood cancer

BACKGROUND

Treatment strategies for childhood cancer are improving, resulting in higher survival rates. However, the consequences of childhood cancer do not end with the successful completion of cancer treatment. Most patients will develop late effects after cessation of treatment. Severe fatigue is seen as a common and debilitating late effect in cancer survivors. Although most research on fatigue has been performed in patients after adult-onset cancer, our review focuses on fatigue after childhood cancer.

OBJECTIVES

To estimate the prevalence of severe fatigue after treatment for childhood cancer. Secondary objectives are to describe the course of severe fatigue following cancer treatment and to examine risk factors for fatigue, or factors associated with it.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019; issue 8 March 2019), MEDLINE/PubMed (from 1945 to 8 March 2019), Embase/Ovid (from 1947 to 8 March 2019), reference lists of included articles and several conference proceedings from 2011 to 2018.

SELECTION CRITERIA

Observational studies, randomised controlled trials and controlled clinical trials reporting on fatigue in participants after treatment for childhood cancer. Case series and case reports were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risks of bias. If the publication did not present the prevalence of severe fatigue, we contacted study authors for additional information.

MAIN RESULTS

We included 30 studies (18,682 participants in total). Eighteen studies contributed to the main objective and 22 studies contributed to the secondary objectives. We found substantial differences between studies in cancer diagnosis, cancer treatment, age of participants, questionnaires used to assess fatigue, and sample size. All included studies scored at least one 'Risk of bias' item as unclear or high risk. We identified both clinical and statistical heterogeneity and therefore could not pool results, so we present them descriptively. Eighteen studies (describing 14,573 survivors) reported the prevalence of severe fatigue, which ranged from 0% to 61.7%. In a subgroup of three studies including children aged up to 18 years at fatigue assessment (268 survivors), prevalence rates ranged from 6.7% to 12.5%. In comparison, in a subgroup of 12 studies including participants aged 16 and over (13,952 survivors), prevalence rates ranged from 4.4% to 61.7%. The prevalence of severe fatigue in a subgroup of survivors of haematological cancer was presented in seven studies and ranged from 1.8% to 35.9% (1907 survivors). Prevalence of severe fatigue in brain cancer survivors was presented in two studies (252 survivors) and was 14.6% and 21.1% respectively. One study presented a prevalence for bone cancer survivors of 0.0% (17 survivors). Four studies provided prevalence rates of severe fatigue in control groups of siblings or population-based controls, which ranged from 3.1% to 10.3%. In these four studies, survivors were more often fatigued than controls, but this difference was statistically significant in only two studies. Studies assessing risk and associated factors for fatigue were heterogeneous, and definitions of the factors under study were often inconsistent, with results therefore presented descriptively. They found that depression might be associated with fatigue. In contrast, age at diagnosis and education level did not seem to be associated with fatigue. We were unable to calculate any overall risk estimate for any of the reported risks and associated factors, because we could not conduct meta-analysis. One study provided information about the course of fatigue over time, and found that over the course of 2.7 years, 32 of the 102 participants (31.4%) reported persistent severe fatigue.

AUTHORS' CONCLUSIONS

It is unclear how many childhood cancer survivors suffer from severe fatigue. This review encountered several difficulties. We found statistical and clinical heterogeneity and great variation in the reporting of possible risk and associated factors. The evidence in this review is therefore weak, and the exact prevalence of severe fatigue after treatment for childhood cancer remains to be determined. This is also the case for the course of severe fatigue following treatment and the strength of the relationship between fatigue and associated and risk factors. Despite these limitations, our review does provide a comprehensive overview of the existing literature about severe fatigue after treatment for childhood cancer.

Feasibility and Preliminary Efficacy of a Bright Light Intervention in Ovarian and Endometrial Cancer Survivors

BACKGROUND

Cancer-related sleep disturbance is common and can adversely affect physical and mental health. Bright light (BL) therapy is a novel intervention that targets sleep by promoting circadian regulation. Emerging evidence suggests BL can improve sleep disturbance, symptom burden, and health-related quality of life in cancer and other populations; however, this research is limited. The present two-phase pilot study assessed the feasibility and preliminary intended effects of BL therapy on sleep in ovarian and endometrial cancer survivors, and explored biologic and chronobiologic factors that may underlie intervention effects.

METHODS

In phase I, focus groups were conducted with 12 survivors and 9 gynecologic oncology clinicians to evaluate and gather feedback about the proposed study. In phase II, a pilot randomized controlled trial was conducted with 18 ovarian or endometrial cancer survivors who were randomized 1:1 to receive 45 min of BL or dim light (DL) for 4 weeks. Participants wore wrist actigraphs; completed sleep diaries and self-report questionnaires; and provided blood, saliva, and urine samples at baseline (T1), post-intervention (T2), and 3-month follow-up (T3).

RESULTS

Study procedures were modified according to focus group results. Enrollment, retention, and adherence were all ≥ 80%. Mixed-model ANOVAs demonstrated that the number of nighttime awakenings per actigraphy, and sleep quality and depression per self-report, trended toward improvements in the BL condition compared to the DL condition. These variables improved from T1 to T2 before returning to baseline at T3. Effect sizes were generally medium to large.

CONCLUSIONS

Study findings suggest that BL therapy is feasible among ovarian and endometrial cancer survivors. It may be an effective, non-pharmacological approach to reduce sleep disturbance and symptom burden in this population.

The relation between mindfulness and the fatigue of women with breast cancer: path analysis

Background

Although fatigue is a common and distressing symptom in cancer survivors, the mechanism of fatigue is not fully understood. Therefore, this study aims to investigate the relation between the fatigue and mindfulness of breast cancer survivors using anxiety, depression, pain, loneliness, and sleep disturbance as mediators.

Methods

Path analysis was performed to examine direct and indirect associations between mindfulness and fatigue. Participants were breast cancer survivors who visited a breast surgery department at a university hospital in Japan for hormonal therapy or regular check-ups after treatment. The questionnaire measured cancer-related-fatigue, mindfulness, anxiety, depression, pain, loneliness, and sleep disturbance. Demographic and clinical characteristics were collected from medical records.

Results

Two-hundred and seventy-nine breast cancer survivors were registered, of which 259 answered the questionnaire. Ten respondents with incomplete questionnaire data were excluded, resulting in 249 participants for the analyses. Our final model fit the data well (goodness of fit index = .993; adjusted goodness of fit index = .966; comparative fit index = .999; root mean square error of approximation = .016). Mindfulness, anxiety, depression, pain, loneliness, and sleep disturbance were related to fatigue, and mindfulness had the most influence on fatigue (β = − .52). Mindfulness affected fatigue not only directly but also indirectly through anxiety, depression, pain, loneliness, and sleep disturbance.

Conclusions

The study model helps to explain the process by which mindfulness affects fatigue. Our results suggest that mindfulness has both direct and indirect effects on the fatigue of breast cancer survivors and that mindfulness can be used to more effectively reduce their fatigue. It also suggests that health care professionals should be aware of factors such as anxiety, depression, pain, loneliness, and sleep disturbance in their care for fatigue of breast cancer survivors.

Trial registration

This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN number. 000027720) on June 12, 2017.

Graded activity is an important component in cognitive behavioral therapy to reduce severe fatigue: results of a pragmatic crossover trial in cancer survivors

Background: Fatigue is one of the most common and distressing long-term effects of cancer treatment. Cognitive behavioral therapy (CBT) is an evidence-based intervention for patients with severe post-cancer fatigue. CBT for fatigue is a complex intervention consisting of multiple elements like a graded activity program, regulation of the sleep-wake rhythm and reformulation of fatigue-related cognitions. The contribution of the separate elements to the positive effect of CBT on fatigue is unclear. The main objective of this pragmatic crossover trial was comparing the efficacy of graded activity with the other elements of CBT in reducing post-cancer fatigue.Material and methods: Severely fatigued cancer survivors were randomized to (i) graded activity followed by the other elements of CBT after crossover (n = 41), or (ii) the two components in reverse order (n = 48). Fatigue severity was measured at baseline, before crossover and after CBT (Checklist Individual Strength (CIS), Fatigue Severity subscale). Differences in effects on fatigue were examined with a linear regression analysis. Objective physical activity, perceived activity and self-efficacy were explored as mediators of the effect of graded activity.Results: Before crossover, the reduction in fatigue was significantly larger after graded activity than after the other elements (β = 4.75, 95% confidence interval (95% CI) = -9.19; -0.32). An increase in perceived activity mediated this effect (β = -4.17, 95% CI = -7.37; -1.37).Conclusions: Graded activity is an important component of CBT for post-cancer fatigue as it resulted in a larger reduction in fatigue compared with the other elements, mediated by an increased level of perceived activity. Results indicated that the other elements of CBT are of added value in reducing fatigue.

Fear of progression and its role in the relationship of cancer-related fatigue with physical functioning and global quality of life - A register-based study among hematological cancer survivors

OBJECTIVE

Fear of progression (FoP) is a frequent symptom among cancer patients, but data among hematological cancer survivors are scarce. Furthermore, theory assumes that FoP serves as link between bodily symptoms and different aspects of quality of life. However, this model has not been tested with the bodily symptom cancer-related fatigue (CRF) so far. Therefore, we investigated (i) levels of FoP stratified by type of and time since diagnosis and (ii) whether FoP mediates relationships of CRF with physical functioning (PF) and global quality of life (QoL).

METHODS

This cross-sectional study recruited long-term survivors of hematological malignancies (mean time since diagnosis: 9 years) via two regional cancer registries. We applied analyses of (co-)variance and mediation analyses to identify indirect effects.

RESULTS

922 survivors participated. There was no overall effect of type of diagnosis on FoP (F_conditional = 1.6, p = .15). However, we found an overall effect of time since diagnosis on FoP (F_conditional = 8.5, p < .001), with FoP being significantly elevated in the group closest to diagnosis. As hypothesized, we found an indirect (mediating) effect of FoP in the associations of CRF with QoL (β = -0.13, 97.5 %-CI = [-0.17; -0.09]) and PF (β = -0.12, 97.5 %-CI = [-0.17; -0.08]).

CONCLUSION

Among long-term survivors of hematological malignancies, a shorter time since diagnosis seems to be associated with elevated levels of FoP. Addressing FoP in psycho-oncological interventions may help to buffer the detrimental effects of CRF. However, longitudinal data is needed to validate our findings.

Mindfulness based stress reduction provides psychological benefit and restores immune function of women newly diagnosed with breast cancer: A randomized trial with active control

BACKGROUND

Women newly diagnosed with breast cancer experience psychological distress, accompanied by reduced Natural Killer Cell Activity (NKCA) and altered levels of cytokines, which may compromise cancer control. Few studies have evaluated psycho-immune outcomes of mindfulness-based stress reduction (MBSR) for women newly diagnosed with breast cancer in comparison to an active control condition.

OBJECTIVE

The purpose of this study was to determine whether MBSR benefits psychological, behavioral, and immunological function in women recently diagnosed with breast cancer.

DESIGN

After confirmation of breast cancer staging, women diagnosed with early-stage breast cancer (n = 192) were randomized to an 8-week MBSR program or an 8-week active control condition (ACC). The ACC consisted of a series of cancer recovery and health education classes. Both MBSR and the ACC were administered in group format.

METHODS

Women completed psychometric instruments and provided blood for NKCA and cytokine levels at pre-, mid-, and completion of program, as well as at 1- and 6-months post-program. One hundred and twenty four women completed all five-assessments (MBSR, n = 63; ACC, n = 61). Hierarchical linear modeling was used to analyze trajectories of outcomes over time and between groups.

RESULTS

Compared to the ACC group, women randomized to MBSR exhibited decreasing trajectories of perceived stress, fatigue, sleep disturbance, and depressive symptoms. Further, compared to women randomized to ACC, MBSR women exhibited trajectories demonstrating significantly more rapid restoration of NKCA, accompanied by lower circulating TNF-alpha levels, lower IL-6 production, and greater IFN-gamma production.

CONCLUSIONS

These results demonstrate early provision of MBSR for women newly diagnosed with breast cancer provides not only psychological benefit, but also optimizes immune function supportive of cancer control.

Patient-reported fatigue in breast cancer patients receiving radiation therapy

PURPOSE

Fatigue or tiredness is one of the most commonly reported symptoms in breast cancer patients treated with radiation therapy (RT). This study aimed to identify characteristics associated with fatigue in breast cancer patients receiving adjuvant RT.

METHODS

Patients with non-metastatic breast cancer receiving RT at the Odette Cancer Centre from 2011 to 2017 were included in our study if they completed at least one ESAS pre- and post-RT. Information regarding patient, disease and treatment characteristics was retrieved from chart review. To identify variables associated with fatigue scores pre-RT, post-RT and changes in fatigue scores, a univariate and multivariate general linear regression analysis was conducted; p < 0.05 was considered statistically significant.

RESULTS

Our study included 1223 female patients (mean age 59 years old) who completed ESAS on average 28 days before, and 142 days after RT. In multivariate analysis, higher baseline fatigue scores were found in women with higher disease stages (p = 0.001), and those who receive locoregional radiation (p < 0.001). No variables were significantly associated with post-RT fatigue scores. While adjuvant chemotherapy and locoregional RT were associated with higher baseline scores in univariate analysis, in multivariate analysis, they were associated with significant reduction in fatigue post-RT (p = 0.01, p = 0.007 respectively).

CONCLUSIONS

Fatigue is associated with higher disease stage and receipt of locoregional radiation. While the relationship between anxiety or depressive symptoms and fatigue is well-established, a major gap exists in our understanding of its etiology and treatment; further investigation to address this can better improve patient quality of life.

The effect of a 12-week home-based walking program on reducing fatigue in women with breast cancer undergoing chemotherapy: A randomized controlled study

BACKGROUND

Fatigue is the most common symptom experienced by cancer patients during treatment and can last long after completing treatment. Fatigue in cancer patients who have completed treatment is well known to be reduced by exercise, but the effect of exercise on reducing fatigue in patients under treatment has been inconsistent.

OBJECTIVES

The purposes of this study were to examine short-term and long-term effects of an individually tailored, home-based brisk walking program on reducing fatigue in breast cancer patients under chemotherapy.

DESIGN, SETTING, PARTICIPANTS

For this randomized controlled trial, women were recruited from a medical center in northern Taiwan if they were diagnosed with stages I-III breast cancer and experienced insomnia, fatigue, pain, or depressive symptoms after their first cycle of chemotherapy. Consenting participants (N = 159) were randomly assigned to either an exercise (12-week home-based walking program) group (n = 81) or an attention-control group (n = 78).

METHODS

The 12-week, home-based brisk walking program started on the first day of the third chemotherapy cycle. Fatigue was measured by the Brief Fatigue Inventory. Covariates, i.e., functional performance, sleep disturbance, anxiety, depression, and exercise-related variables, were also measured. Data were collected at baseline, two times during the exercise intervention, and five times after the exercise intervention (eight times in total). The effects of time-varying and time-invariant predictors on fatigue were analyzed by multilevel modeling.

RESULTS

Fatigue levels increased over time for both groups, even after completing treatment. At the end of the 12-week exercise program, the exercise group had less fatigue than the attention-control group, and this group difference was maintained for the whole study period. At the end of exercise program, women who had spent more time exercising before diagnosis had less fatigue than those who had exercised less often. In addition, patients' fatigue levels at various time points fluctuated along with their functional performance, sleep disturbance, and depression.

CONCLUSIONS

Our tailored, home-based brisk walking program effectively reduced fatigue in breast cancer patients under chemotherapy, and this effect lasted after completing treatment.

Sleep disturbance and cancer-related fatigue symptom cluster in breast cancer patients undergoing chemotherapy

PURPOSE

Sleep disturbance and cancer-related fatigue (CRF) are among the most commonly reported symptoms associated with breast cancer and its treatment. This study identified symptom cluster groups of breast cancer patients based on multidimensional assessment of sleep disturbance and CRF prior to and during chemotherapy.

METHODS

Participants were 152 women with stage I-IIIA breast cancer. Data were collected before chemotherapy (T1) and during the final week of the fourth chemotherapy cycle (T2). Latent profile analysis was used to derive groups of patients at each timepoint who scored similarly on percent of the day/night asleep per actigraphy, the Pittsburgh Sleep Quality Index global score, and the five subscales of the Multidimensional Fatigue Symptom Inventory-Short Form. Bivariate logistic regression evaluated if sociodemographic/medical characteristics at T1 were associated with group membership at each timepoint.

RESULTS

Three groups (Fatigued with sleep complaints, Average, Minimal symptoms) were identified at T1, and five groups (Severely fatigued with poor sleep, Emotionally fatigued with average sleep, Physically fatigued with average sleep, Average, Minimal symptoms) at T2. The majority of individuals in a group characterized by more severe symptoms at T1 were also in a more severe symptom group at T2. Sociodemographic/medical variables at T1 were significantly associated with group membership at T1 and T2.

CONCLUSIONS

This study identified groups of breast cancer patients with differentially severe sleep disturbance and CRF symptom profiles prior to and during chemotherapy. Identifying groups with different symptom management needs and distinguishing groups by baseline sociodemographic/medical variables can identify patients at risk for greater symptom burden.

Breast Cancer Quality of Life and Health-state Utility at a Brazilian Reference Public Cancer Center

Objectives: To evaluate health-related-quality-of-life and derive health-state-utility (HSU) from breast cancer patients, before and after routine therapy at a Brazilian reference public cancer center.Methods: In a prospective cohort study, a consecutive sample of outpatients newly diagnosed with breast cancer was submitted to two interviews (baseline, 6-month) to complete EQ-5D-3L/VAS and EORTC-QLQ-C30/BR23 questionnaires. Demographic and clinical information was reviewed from medical records.Results: For 196 patients, EQ-5D domains of pain/discomfort and anxiety/depression were mainly affected, but partially improved overtime, while mobility/usual activities/self-care worsened after therapy. EORTC-QLQ-C30/BR23 scales mostly affected were emotional functioning, insomnia, pain, sexual enjoyment and future self-health perspective at baseline, while financial difficulties, insomnia, fatigue and therapy side-effects at follow-up. Overtime mean scores were 71.4 (_95%CI68.5-74.4) and 76.1 (_95%CI73.3-78.8) for EQ-5D-VAS, and 0.712 (_95%CI0.686-0.737) and 0.732 (_95%CI0.707-0.757) for HSU. HSU was 0.689 (_95%CI0.648-0.730) in stages III-IV, and 0.692 (_95%CI0.652-0.731) under two/three chemotherapy regimens.Conclusion: In a context of impairments in emotional functioning, sexual enjoyment, symptoms burden, and poor future self-health perspective, breast cancer produced a mean HSU of 0.712. After routine care, there was a small improvement in quality of life, with lower HSU particularly in advanced disease and multiple chemotherapy regimens.

Cognitive Behavior Therapy for Persistent Severe Fatigue in Childhood Cancer Survivors: A Pilot Study

OBJECTIVES

Fatigue is a common and disabling late effect in childhood cancer survivors (CCS). In this pilot study, the effectiveness of cognitive behavior therapy (CBT) in CCS with persistent and severe fatigue was retrospectively evaluated.

MATERIALS AND METHODS

In total, 33 consecutively referred CCS with persistent severe fatigue were offered CBT. The primary outcome was fatigue severity (Checklist Individual Strength, Fatigue Severity Subscale). Secondary outcomes were functional impairment, psychologic distress, and quality of life (QoL).

RESULTS

In total, 25 CCS completed CBT (76%). The mean age of CCS was 23.1 years (range, 11 to 42 y), mean age at primary cancer diagnosis was 9.7 years (range, 0 to 17 y), and mean time since primary cancer diagnosis was 13 years (range, 5 to 34 y). Fatigue severity ([INCREMENT] 17.4; confidence interval (CI)=12.7-22.1; P<0.001), functional impairment (SIP8 [INCREMENT] 470.3; CI=312.3-628.4; P<0.001/SF36 [INCREMENT] 11.7; CI=17.2-6.3; P<0.001), and psychologic distress ([INCREMENT] 26.4; CI=15.6-34.9; P<0.001) were significantly decreased at second assessment. QoL ([INCREMENT] 13.5; CI=22.0-4.3; P=0.005) was significantly improved. A total of 23 CCS of the 33 CCS (70%) met the criteria for clinically significant improvement of fatigue.

CONCLUSIONS

In this pilot study, the majority of severely fatigued CCS showed a clinically significant reduction in fatigue following CBT. Moreover, daily function and QoL improved, and psychologic distress decreased.

Psychometric Properties of the Short Form of the Fear of Cancer Recurrence Inventory (FCRI) in Chinese Breast Cancer Survivors

Objective: Currently, fear of cancer recurrence (FCR) is emerging as an important issue for long-term breast cancer survivors and is associated with lower quality of life and functional impairment. Given that there is a dearth of research regarding the FCR of Chinese breast cancer survivors, this study investigated whether the short form of the Fear of Cancer Recurrence Inventory (FCRI) could detect high FCR and explored the level and characteristics of FCR in breast cancer survivors. Methods: Two hundred forty patients who had undergone successful breast cancer surgery in China submitted their survey through a website. The participants' demographic and medical data, level of FCR, anxiety, depression, and quality of life were assessed. Results: Two hundred seven patients with ages ranging from 19 to 60 years completed the questionnaires. The mean FCR score of the total sample was 18.39. A cutoff score of 12 or higher on the short form of the FCRI was optimal for the detection of high FCR with a sensitivity of 98.6% and a specificity of 35%, and the PPV (positive predictive values) and NPV (negative predictive values) were 44% and 98%, respectively. The area under the curve of the receiver operating characteristics (ROC) analysis was 83%. A total of 159 breast cancer survivors (76.81%) experienced high FCR levels (FCR score > 12), characterized by lower functional and overall health than survivors with a low FCR (P < 0.01). Conclusions: The short form of the FCRI is capable of detecting high FCR and is therefore able to assist Chinese breast cancer survivors in receiving appropriate care for reducing FCR.

Predictive value of soluble ST-2 for changes of cardiac function and structure in breast cancer patients receiving chemotherapy

The current study was to evaluate soluble ST-2 level and left ventricular ejection fraction (LVEF) in patients with breast cancer receiving doxorubicin or trastuzumab treatment for 6 months and determine whether soluble ST-2 level can be used to predictive left ventricular function impairment.Patients who were diagnosed as having breast cancer receiving doxorubicin or trastuzumab or combined therapy were enrolled. Demographic data, prior medical history and related medical therapy, and site and stage of breast cancer information were collected from electronic health record. Fasting blood was used to detect soluble ST-2 and brain natriuretic peptide (BNP) levels before and after 6 months doxorubicin or trastuzumab therapy. Echocardiography was performed before and after 6 months of doxorubicin or trastuzumab therapy.Participants were divided into 3 groups based on tertiary soluble ST-2 level. Compared with 1st tertiary group, patients in the 3rd tertiary group had higher proportion receiving combined therapy (14.3% vs 4.7%, P < .05). Baseline soluble ST-2 level was similar across groups. After 6 months' therapy, soluble ST-2 level was significantly higher in the 3rd tertiary group. Pearson correlation analysis showed that soluble ST-2 level was positively correlated with left ventricular volume and E/e' ratio while negatively correlated with LVEF. Doxorubicin, trastuzumab, combined therapy, soluble ST-2 level, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment were all independently associated with LVEF change.In breast cancer patients receiving doxorubicin or trastuzumab therapy, soluble ST-2 level can be used to predict cardiac function and structure changes.