Cancer‐Related Fatigue and Sleep Disorders

Factors associated with sleep quality in the elderly receiving chemotherapy

OBJECTIVE

to evaluate the characteristics of sleep and the factors associated with the quality of sleep in elderly patients receiving outpatient chemotherapy treatment.

METHOD

cross-sectional study with 140 elderly patients (51.2% female, average age 69.8 years) with stage III or stage IV cancer (67.9%), undertaken in a university hospital in the state of São Paulo in 2010. The following instruments were used: sociodemographic and clinical characterization questionnaire, validated by specialists; Pittsburgh Sleep Quality Index; Piper Fatigue Scale-reviewed; and a scale for the subjective measurement of pain.

RESULTS

the majority of the elderly (62.9%) had a score compatible with poor sleep quality. On average, the duration of sleep was 388.0 minutes, latency was 44.6 minutes and efficiency of 83.8%. Through multiple logistic regression analysis, an increase of 21% in the probability of having poor sleep quality was observed for each single-point increase in the intensity of the pain.

CONCLUSION

nursing interventions aiming to promote better sleep quality for elderly patients with cancer must include measures for pain control.

Sleep disturbance, cytokines, and fatigue in women with ovarian cancer

Pro-inflammatory cytokines, such as interleukin-6 (IL-6), have been implicated in the underlying processes contributing to sleep regulation and fatigue. Despite evidence for sleep difficulties, fatigue, and elevations in IL-6 among women with ovarian cancer, the association between these symptoms and IL-6 has not been investigated. To address this knowledge gap, we examined relationships between sleep disturbance, fatigue, and plasma IL-6 in 136 women with ovarian cancer prior to surgery. These relationships were also examined in 63 of these women who were disease-free and not receiving chemotherapy one year post-diagnosis. At both time-points, higher levels of IL-6 were significantly associated with sleep disturbances (p<0.05), controlling for potentially confounding biological and psychosocial covariates. Higher IL-6 was significantly associated with fatigue prior to surgery (p<0.05); however, when sleep disturbance was included in the model, the relationship was no longer significant. IL-6 was not significantly associated with fatigue at one year. Changes in sleep over time were significantly associated with percent change in IL-6 from pre-surgery to one year, adjusting for covariates (p<0.05). These findings support a direct association of IL-6 with sleep disturbances in this population, whereas the relationship between IL-6 and fatigue prior to surgery may be mediated by poor sleep. As this study is the first to examine cytokine contributions to sleep and fatigue in ovarian cancer, further research is warranted to clarify the role of biological correlates of sleep and fatigue in this population.

Promoting sleep for hospitalized patients with advanced cancer with relaxation therapy: experience of a randomized study

AIMS AND OBJECTIVES

Sleep disorders are frequent in patients with advanced cancer receiving palliative care. The objective of this study was to demonstrate whether relaxation therapy can improve their satisfaction with sleep.

BACKGROUND

Few studies have investigated the effectiveness of relaxation in patients hospitalized with an advanced chronic disease.

DESIGN

Prospective randomized study with an immediate intervention group (IIG; relaxation days 3-6) and a delayed intervention group (DIG; relaxation days 6-9).

METHODS

The main measure was the overall satisfaction of sleep measured on a Numerical Rating Scale of Satisfaction of Sleep (NRSSS) between 0 and 10.

RESULTS

Totally 18 (IIG: 9; DIG: 9) patients were included in this study (mean age 66 ± 10.7). The NRSSS improved in both the groups (almost statistically significant) between the day of inclusion and day 2. Because of the dropout of the patients during the last days of the study, we analyzed the improvement in sleep satisfaction only between day 2 and 5. The NRSSS D5 for the immediate and delayed groups were 4.0 ± 23 and 3.8 ± 2.3, respectively. There was no significant improvement in both the groups.

CONCLUSION

The results demonstrated the difficulty to include patients with advanced cancer in a randomized study with a DIG. We were not able to demonstrate the effectiveness of relaxation therapy on sleep satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Techniques that can be easily used to improve sleep in patients with an advanced cancer should be developed and used already early in the disease.

Fatigue and sleep quality are associated with changes in inflammatory markers in breast cancer patients undergoing chemotherapy

Fatigue and sleep disturbances are two of the most common and distressing symptoms reported by cancer patients. Fatigue and sleep are also correlated with each other. While fatigue has been reported to be associated with some inflammatory markers, data about the relationship between cancer-related sleep disturbances and inflammatory markers are limited. This study examined the relationship between fatigue and sleep, measured both subjectively and objectively, and inflammatory markers in a sample of breast cancer patients before and during chemotherapy. Fifty-three women with newly diagnosed stage I-III breast cancer scheduled to receive at least four 3-week cycles of chemotherapy participated in this longitudinal study. Fatigue was assessed with the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) and objective sleep was measured with actigraphy. Three inflammatory markers were examined: Interleukin-6 (IL-6), Interleukin-1 receptor antagonist (IL-1RA) and C-reactive protein (CRP). Data were collected before (baseline) and during cycle 1 and cycle 4 of chemotherapy. Compared to baseline, more fatigue was reported, levels of IL-6 increased and IL-1RA decreased during chemotherapy. Reports of sleep quality remained poor. Mixed model analyses examining changes from baseline to each treatment time point revealed overall positive relationships between changes in total MFSI-SF scores and IL-6, between changes in total PSQI scores and IL-6 and IL-1RA, and between total wake time at night and CRP (all p's<0.05). These relationships suggest that cancer-related fatigue and sleep disturbances may share common underlying biochemical mechanisms.

caREMOTE: the design of a cancer reporting and monitoring telemedicine system for domestic care

After receiving cancer treatment, patients often experience a decline of HRQoL (health-related quality of life). Physicians typically evaluate HRQoL during periodic clinical visits. However, out-patient reporting of vital signals between two visits could be used to interpret the decline of HRQoL. Considering that the vast majority of patients recovering from cancer are not in hospitals, it is often impractical for the care providers to collect these data. In this paper, we design and prototype caREMOTE, a cancer reporting and monitoring telemedicine system, which can be used in domestic cancer care. By extending a standard clinical trial informatics model, we build a prototype on cloud computing services that can be accessed by a mobile application. We aim to maximize the potential of caREMOTE to help medical practitioners efficiently monitor discharged patients' HRQoL and vital signals, and facilitate data reusability and system interoperability in future collaborative cancer research.

Non-apnea sleep disorders will increase subsequent liver cancer risk--a nationwide population-based cohort study

INTRODUCTION

It is well known that patients with sleep disorders (SD) have an increased risk of cardiovascular disease, diabetes mellitus, obesity, and total mortality. However, little information exists regarding the relationship between non-apnea SD and the risk of cancer. The goal of this study was to determine if any association between SD and malignancy exists in Taiwan.

METHODS

We used data from the National Health Insurance system of Taiwan to assess this issue. The SD cohort contained 42,351 patients, and each patient was randomly frequency-matched by age and sex with two people from the general population without SD. The Cox's proportional hazard regression analysis was conducted to estimate the effects of SD on cancer risk.

RESULTS

In patients with SD, the overall risk of developing cancer was significantly higher than in normal healthy subjects (adjusted Hazard ratio [HR]=1.12, 95% confidence interval=1.06-1.18). This held true even when we analyzed males and females separately. In regards to individual types of cancer, the risk for developing liver cancer among patients with SD was significantly higher than in subjects without SD. For breast cancer the risk showed a marginally significant increase.

CONCLUSION

The nationwide population-based cohort study found Taiwanese patients with SD have a higher risk of developing cancer, particularly liver cancer and, possibly, breast cancer.

Fatigue, inflammation, and ω-3 and ω-6 fatty acid intake among breast cancer survivors

PURPOSE

Evidence suggests that inflammation may drive fatigue in cancer survivors. Research in healthy populations has shown reduced inflammation with higher dietary intake of ω-3 polyunsaturated fatty acids (PUFAs), which could potentially reduce fatigue. This study investigated fatigue, inflammation, and intake of ω-3 and ω-6 PUFAs among breast cancer survivors.

METHODS

Six hundred thirty-three survivors (mean age, 56 years; stage I to IIIA) participating in the Health, Eating, Activity, and Lifestyle Study completed a food frequency/dietary supplement questionnaire and provided a blood sample assayed for C-reactive protein (CRP) and serum amyloid A (30 months after diagnosis) and completed the Piper Fatigue Scale and Short Form-36 (SF-36) vitality scale (39 months after diagnosis). Analysis of covariance and logistic regression models tested relationships between inflammation and fatigue, inflammation and ω-3 and ω-6 PUFA intake, and PUFA intake and fatigue, controlling for three incremental levels of confounders. Fatigue was analyzed continuously (Piper scales) and dichotomously (SF-36 vitality ≤ 50).

RESULTS

Behavioral (P = .003) and sensory (P = .001) fatigue scale scores were higher by increasing CRP tertile; relationships were attenuated after adjustment for medication use and comorbidity. Survivors with high CRP had 1.8 times greater odds of fatigue after full adjustment (P < .05). Higher intake of ω-6 relative to ω-3 PUFAs was associated with greater CRP (P = .01 after full adjustment) and greater odds of fatigue (odds ratio, 2.6 for the highest v lowest intake; P < .05).

CONCLUSION

Results link higher intake of ω-3 PUFAs, decreased inflammation, and decreased physical aspects of fatigue. Future studies should test whether ω-3 supplementation may reduce fatigue among significantly fatigued breast cancer survivors.

Sleep disorders in children with cancer

Approximately three-fourths of all pediatric cancer patients will be long-term survivors; however, there can be a steep cost for cancer survivorship. Cancer treatment involves exposure to chemotherapy, surgical intervention, and radiation, which can cause lasting long-term toxicities. Children with brain tumors have the highest prevalence of long-term morbidities. These effects can be attributed to direct neurologic damage to the developing brain caused by tumor, hydrocephalus, surgical removal of the tumor, and the effects of irradiation. The late effects experienced by childhood cancer survivors involve multiple domains, one of which is sleep disorders. Sleep dysfunction has an increased prevalence in the pediatric cancer survivor population. These issues are disruptive to patients and cause a decrease in quality of life. This review focuses on sleep disorders that occur in pediatric cancer survivors and discusses the possible causes, the assessments used to determine specific sleep disorders, and treatment modalities used to ameliorate this dysfunction with the hope of improving patient's quality of life.

The longitudinal relationship between fatigue and sleep in breast cancer patients undergoing chemotherapy

STUDY OBJECTIVE

Fatigue and sleep disturbances are two of the most common and distressing symptoms of cancer patients. A relationship between the two symptoms was reported in symptom cluster studies; however, only subjective measurements of sleep were examined and most studies were cross-sectional. In this study of women with breast cancer undergoing chemotherapy, we explored the longitudinal relationship between fatigue and sleep measured both subjectively and objectively.

DESIGN

Prospective study. Data were collected at 7 time points: before (baseline) and during the 3 weeks of cycle 1 and cycle 4 chemotherapy.

PARTICIPANTS

Ninety-seven women with newly diagnosed stage I-III breast cancer who were scheduled to receive at least four 3-week cycles of chemotherapy.

MEASUREMENT AND RESULTS

Objective sleep parameters were measured with an Actillume actigraph (Ambulatory Monitoring Inc.). Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Fatigue was assessed with the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). Fatigue became worse during both cycles of chemotherapy (P-values < 0.01). Subjective sleep quality was poor at baseline and remained unchanged throughout treatment. Objective nighttime and daytime total sleep time increased compared to baseline during the treatment administration week of both cycles; daytime total wake time decreased during the treatment week of both cycles and during the last 2 week of cycle 4. Mixed model results revealed that fatigue was positively associated with total PSQI scores and with objective measures of total nap time, and negatively associated with total wake time during the day (all P-values < 0.01).

CONCLUSION

Fatigue was significantly associated with subjective reports of poor sleep and objective measures of daytime sleepiness, but not with nocturnal sleep as measured with actigraphy. This relationship between fatigue and sleep warrants further studies to explore their possible common underlying etiology.

Unstable EEG-vigilance in patients with cancer-related fatigue (CRF) in comparison to healthy controls

OBJECTIVES

Cancer-related fatigue (CRF) is associated with tiredness and sleepiness. It remains unclear, whether such complaints are associated with neurophysiological signs of sleep proneness or a state of neurophysiological hyperarousal in which the patient finds it difficult to relax and to initiate sleep. Therefore the goal of this study is to compare the electroencephalographic (EEG)-vigilance regulation of patients with CRF and healthy controls.

METHODS

A 15-min resting EEG with eyes closed was recorded in 22 patients with CRF and 22 matched healthy controls. Consecutive 1-s segments were classified into seven different vigilance stages ranging from high alertness to relaxed wakefulness (stage 0, A1, A2, A3) and further on to drowsiness (B1, B2/3) and sleep onset (stage C).

RESULTS

Results showed that patients with CRF revealed a higher number of vigilance stages A3 (mean 15.26 vs. 6.67%, P = 0.004) dropped significantly earlier to vigilance levels A3 (drop after 130.8 vs. 533.3 s, P = 0.000) and B2/3&C (407.8 vs. 604.1 s, P = 0.035) and showed significantly more transitions between vigilance stages (46.0 vs. 31.1%, P = 0.003) in comparison to healthy controls.

CONCLUSIONS

These findings suggest an unstable vigilance regulation in patients with CRF and provide a neurophysiological framework for the reported efficacy of psychostimulants in CRF.

A critical review of women's sleep-wake patterns in the context of neo-/adjuvant chemotherapy for early-stage breast cancer

Complaints of poor nocturnal sleep and daytime dysfunction may be frequent among women receiving chemotherapy for breast cancer. A critical review of the literature was conducted, which aimed at summarising and critically analysing findings regarding sleep in women with early-stage breast cancer across neo-/adjuvant chemotherapy treatment. A systematic search of three electronic databases (Medline, CINAHL, EMBASE) was conducted from January 1980 to July 2011. Twenty-one articles reporting on 12 studies were included for analysis based on pre-specified selection criteria. Varying deficits in sleep parameters may be evident in a significant part of this population. Yet, research data are not equally distributed among the different sleep components, or across all major time points throughout chemotherapy. More systematic investigation of the experience of disrupted sleep in this population with longitudinal mixed-methods studies is warranted to ensure that person-tailored and clinically meaningful care is delivered.

The effect of sleep disturbance on quality of life in women with ovarian cancer

OBJECTIVE

To estimate the prevalence of sleep disturbances, and to determine if there is an association between sleep disturbances with quality of life (QOL), depression or clinical demographic variables.

METHODS

Patients diagnosed with ovarian, fallopian tube or primary peritoneal cancer during the last 5years completed questionnaires regarding sleep patterns and disturbances [Pittsburgh Sleep Quality Index (PSQI)], depression [Beck Depression inventory (BDI)], and QOL [The Functional Assessment of Cancer Therapy-Ovarian (FACT-O), fatigue module (-F)]. Data were analyzed by Student's t-test or Pearson correlation coefficient to determine if there were differences between PSQI score with QOL, depression or clinical demographic variables.

RESULTS

86/275 (31% response) of patients returned the surveys. Mean age was 58.1 (SD=14.6) years and 70% had advanced disease at diagnosis. Thirty-six percent had current disease of which 81% were receiving chemotherapy. Sixty-seven percent of patients had a PSQI score≥5 corresponding to overall poor sleep quality and 46% of patients reported using sleep medication at least once during the prior month. PSQI score was significantly inversely correlated with all QOL domains (physical: r=-.599, p<.001, functional: r=-.692, p<.001, social: r=-.212, p<.001, emotional: r=-.379, p<.001, fatigue; r=-.655 p<.001) and with depression (r=.539, p<.001). PSQI was not correlated with age, time since diagnosis, number of previous chemotherapy regimens. PSQI score did not differ by current disease or chemotherapy status.

CONCLUSIONS

Sleep disturbances reduce QOL, a prognostic indicator for survival, in ovarian cancer patients. These patients should undergo routine screening and would benefit from interventions that aim to promote restful sleep.

Few changes observed in polysomnographic-assessed sleep before and after completion of chemotherapy

OBJECTIVE

Sleep disturbance is prevalent among patients undergoing chemotherapy and is strongly associated with cancer-related fatigue (CRF). However, little objective evidence has been gathered on the patterns of sleep before and following chemotherapy.

METHODS

Twenty-six patients scheduled to receive chemotherapy were recruited. Sleep parameters were assessed by in-lab polysomnography (PSG) for two consecutive nights prior to first chemotherapy, approximately 3weeks following the patients' last chemotherapy, and 3months following the last treatment. Fatigue was measured on the first night of each of the two-night PSG assessments. We focus on Slow-Wave Sleep (SWS) as we hypothesized that a decrease of this restorative phase of sleep might be implicated in CRF.

RESULTS

Repeated-measures analyses examining changes from baseline to the later time points in the proportion of time asleep spent in each of the four sleep architecture stages (Stage 1, Stage 2, SWS, and REM sleep) were non-significant, all Ps>0.41. Canonical correlation analysis showed that the proportion of time spent in SWS was not significantly correlated with any of the three CRF measures at any of the three assessment points, P=0.28.

CONCLUSIONS

Sleep architecture is not affected by cancer treatment. No evidence of an association between CRF and SWS, or alterations in SWS, was found.

Prevalence and predictors of sleep difficulty in a national cohort of women with primary breast cancer three to four months postsurgery

CONTEXT

Mounting evidence suggests that many cancer patients suffer from sleep difficulty, but there is conflicting evidence regarding the prevalence and predictors of this adverse symptom.

OBJECTIVES

The present study investigated the prevalence and predictors of clinically significant sleep difficulty in women with primary breast cancer.

METHODS

Danish women (n=3343) with primary breast cancer completed the Pittsburgh Sleep Quality Index (PSQI) along with measures of depression, anxiety, physical activity/functioning, and health behaviors three to four months postsurgery. Data on disease status, treatment, and comorbidity were obtained from the Danish Cancer Cooperative Group and surgical departments, and information on sociodemographic factors and psychiatric history was obtained from Danish national longitudinal registries.

RESULTS

More than half (57.9%) of the women reported clinically significant sleep difficulty (PSQI >5). Multiple logistic regression identified seven significant predictors of sleep difficulty in the full sample. In order of strength, these were the following: more depressive symptoms, poorer physical functioning, older age, higher levels of trait anxiety, consuming more cigarettes, having undergone lumpectomy, and lower levels of physical activity. Subgroup analysis found that more depressive symptoms and poorer physical functioning were the only two predictors that were significant in both pre- and postmenopausal women.

CONCLUSION

These findings indicate that a high proportion of women with breast cancer experience sleep difficulty. Depression and poorer physical functioning appear to be robust predictors of sleep difficulty, whereas other predictors may depend on sample characteristics, including menopausal status.

Does self-regulation and autonomic regulation have an influence on survival in breast and colon carcinoma patients? results of a prospective outcome study

Background

Cancer Related Fatigue (CRF) and circadian rhythm have a great impact on the quality of life (HRQL) of patients with breast (BC) and colon cancer (CRC). Other patient related outcomes in oncology are measured by new instruments focusing on adaptive characteristics such as sense of coherence or self-regulation, which could be more appropriate as a prognostic tool than classical HRQL. The aim of this study was to assess the association of autonomic regulation (aR) and self-regulation (SR) with survival.

Methods

146 cancer patients and 120 healthy controls took part in an initial evaluation in 2000/2001. At a median follow up of 5.9 years later, 62 of 95 BC, 17 of 51 CRC patients, and 85 of 117 healthy controls took part in the follow-up study. 41 participants had died. For the follow-up evaluation, participants were requested to complete the standardized aR and SR questionnaires.

Results

On average, cancer patients had survived for 10.1 years with the disease. Using a Cox proportional hazard regression with stepwise variables such as age, diagnosis group, Charlson co-morbidity index, body mass index (BMI)) aR and SR. SR were identified as independent parameters with potential prognostic relevance on survival While aR did not significantly influence survival, SR showed a positive and independent impact on survival (OR = 0.589; 95%-CI: 0.354 - 0.979). This positive effect persisted significantly in the sensitivity analysis of the subgroup of tumour patients and in the subscale 'Achieve satisfaction and well-being' and by tendency in the UICC stages nested for the different diagnoses groups.

Conclusions

Self-regulation might be an independent prognostic factor for the survival of breast and colon carcinoma patients and merits further prospective studies.

Validity and reliability of the Taiwanese version of the Pittsburgh Sleep Quality Index in cancer patients

BACKGROUND

Sleep disturbance remains a common symptom among cancer patients. Assessment of sleep disturbance in cancer patients is hindered by infrequent use of standardized tools for sleep management.

OBJECTIVES

The purposes of this study were to validate the Taiwanese version of the Pittsburgh Sleep Quality Index (PSQI-T) and to determine detection cut-off points in cancer patients.

DESIGN

A cross-sectional and descriptive correlational design.

PARTICIPANTS

A sample of 205 Taiwanese patients with various cancer diagnoses.

METHODS

The survey included the Pittsburgh Sleep Quality Index-Taiwanese version, the MD Anderson Symptom Inventory-Taiwanese version, the Brief Fatigue Inventory-Taiwanese version, the seven-day sleep log, and Manual of Mental Disorders, Fourth Edition.

RESULTS

The internal consistency Cronbach's alpha for the PSQI was 0.79. Test-retest reliability was 0.91 for the global score over a 20- to 28-day interval in a sample of 16 patients. Construct validity was established by a significant relationship of the PSQI-T global score to the total symptom severity score and the fatigue severity score. Convergent validity was examined by correlating the PSQI-T scores and scores of the DSM-IV and scores on the seven-day sleep log. Known-group validity was established by comparing PSQI-T scores for patients having low fatigue levels and those having high fatigue levels. Receiver-operating characteristic (ROC) curves were used to determine the detection cut-off points.

CONCLUSIONS

We found that a PSQI-T global score of 8 generates the best sensitivity and specificity for measuring sleep disturbance in cancer patients. The PSQI-T is a reliable, valid, and sensitive instrument for measuring sleep quality among Taiwanese cancer patients.

Quality of life issues in elderly acute myeloid leukemia patients

The median age of acute myeloid leukemia (AML) is 70 years. Treatment approaches include standard chemotherapy, palliative chemotherapy and investigational agents, depending upon disease biology and patient factors. In this article, we highlight the issues involved in the treatment of AML in older patients, focusing on the quality of life changes associated with each treatment modality at different stages of their disease course. We further discuss recent insights into the biological basis of quality of life changes, and examine potential ways to improve these through pharmacological and nonpharmacological means. Finally, we explore avenues for future research into the quality of life of the older AML patient.

Quality of life outcomes in patients with anal cancer after combined radiochemotherapy

PURPOSE

To assess self-reported quality of life (QoL) experienced by anal cancer patients after radiochemotherapy, and to identify patient- and disease-related factors associated with QoL.

PATIENTS AND METHODS

A total of 88 patients treated for anal cancer at our institution between 1990 and 2006 were identified from our database. Of these, 15 patients had died, and 4 were lost to follow-up. QoL was assessed using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the colorectal cancer module QLQ-CR38 (site-specific QoL); 52 responses were received. The median follow-up was 36 months (range, 5-137 months).

RESULTS

As for cancer-specific QoL, global health QoL score (mean 60.4) was similar to the general German population, whereas most of the function and symptom scale scores were considerably lower/higher in anal cancer patients. The most prominent mean score differences were observed in role functioning (-21.8 points), emotional functioning (-20.7 points), social functioning (-28.9 points), diarrhea (+34.6 points), and financial difficulties (+26.9 points; p < 0.001). As for site-specific QoL, the mean function scale scores ranged from 22.1 (sexual function) to 63.2 (body image), and the mean symptom scale scores from 14.7 (weight loss) to 69.0 (stoma-related problems, 4 patients) and 67.9 (male sexual dysfunction), respectively. Most of the QoL scores were not affected by late toxicity, patient- or disease-related factors. Fatigue (+18.2 points) emerged as the strongest predictor of impaired QoL.

CONCLUSION

The global health QoL of anal cancer patients is comparable with that of the general German population, but there are specific limitations, e.g., sexual dysfunction, urological/gastrointestinal complaints, financial difficulties, fatigue, and a reduction in emotional and social well-being.

Sleep-wake functioning along the cancer continuum: focus group results from the Patient-Reported Outcomes Measurement Information System (PROMIS(®))

OBJECTIVE

Cancer and its treatments disturb sleep-wake functioning; however, there is little information available on the characteristics and consequences of sleep problems associated with cancer. As part of an effort to improve measurement of sleep-wake functioning, we explored the scope of difficulties with sleep in a diverse group of patients diagnosed with cancer.

METHODS

We conducted 10 focus groups with patients recruited from the Duke University tumor registry and oncology/hematology clinics. Separate groups were held with patients scheduled to begin or currently undergoing treatment for breast, prostate, lung, colorectal, hematological, and other cancer types and with patients who were in posttreatment follow-up. The content of the focus group discussions was transcribed and analyzed for major themes by independent coders.

RESULTS

Participants not only reported causes of sleep disturbance common in other populations, such as pain and restless legs, but they also reported causes that may be unique to cancer populations, including abnormal dreams, anxiety about cancer diagnosis and recurrence, night sweats, and problems with sleep positioning. Many participants felt that sleep problems reduced their productivity, concentration, social interactions, and overall quality of life. Many also shared beliefs about the increased importance of sleep when fighting cancer.

CONCLUSIONS

The findings underscore the need for interventions that minimize the negative impact of cancer and its treatments on sleep. This study will inform efforts now underway to develop a patient-reported measure of sleep-wake functioning that reflects the breadth of concepts considered important by patients with cancer.

A comparison of disrupted sleep patterns in women with cancer-related fatigue and postmenopausal women without cancer

PURPOSE

Fatigue and disrupted sleep often coexist and both are prominent clinical problems in cancer affecting quality of life. Disrupted sleep patterns are likely related to cancer-related fatigue. The relationship needs further investigation. This study aimed to characterize and compare disrupted sleep patterns in fatigued breast cancer patients receiving chemotherapy with postmenopausal women without a history of cancer. Anxiety levels were also examined.

METHODS

Data for this secondary analysis came from two studies. Global sleep quality and state anxiety were self-reported by 30 fatigued female breast cancer chemotherapy outpatients and 32 non-cancer postmenopausal women using Pittsburgh Sleep Quality Index (PSQI) and State-Trait Anxiety Inventory, respectively.

RESULTS

Fatigued breast cancer patients showed significant sleep difficulties, characterized by prolonged sleep onset latency (M=54.3, SD=49.2 min) and frequent nighttime awakenings, despite 40% of the patients using sleep medications three or more times a week. Compared to the non-cancer comparison group, fatigued patients reported significantly longer sleep latency (p=0.041), more use of sleep medications (p=0.006), and higher total PSQI scores (p=0.005). State anxiety levels did not differ between the two groups (p=0.88).

CONCLUSIONS

Sleep is disrupted in fatigued breast cancer women undergoing chemotherapy. Nearly all fatigued patients (97%) had trouble sleeping (global PSQI scores>5), indicating significant difficulties in overall sleep quality among those patients. Knowledge of the nature of sleep disruption among cancer patients may contribute to CRF symptom management leading to tailored interventions designed to improve sleep quality in cancer patients thereby managing fatigue and improving quality of life.

Patterns of fatigue in adolescents receiving chemotherapy

PURPOSE/OBJECTIVES

To describe patterns of fatigue in adolescents and the impact of fatigue during one month of chemotherapy, to explore variables that affect fatigue, and to explore the feasibility of collecting daily self-report data in this population.

DESIGN

Longitudinal, descriptive.

SETTING

Two pediatric oncology centers in central Virginia.

SAMPLE

20 adolescents with a variety of cancer diagnoses receiving chemotherapy.

METHODS

Adolescents described daily fatigue for one month using rating scales and qualitative diaries.

MAIN RESEARCH VARIABLES

Fatigue severity.

FINDINGS

Adolescents commonly reported a peak in fatigue in the days immediately following chemotherapy administration. The most common pattern for adolescents who received chemotherapy on a schedule every three to four weeks was a "declining rollercoaster" pattern, with fatigue severity alternating on a daily basis but gradually declining until chemotherapy was scheduled again. Adolescents who received chemotherapy weekly showed more frequent peaks and troughs (the "yo-yo" pattern) that did not diminish in severity over the weeks of the study. Adolescents associated fatigue with other symptoms, particularly sleep-wake disturbances, pain, and nausea, and frequently reported that fatigue interfered with daily activities.

CONCLUSIONS

Fatigue commonly bothers adolescents receiving chemotherapy, particularly in the days following chemotherapy administration and when other symptoms are present. Although fatigue interfered with the adolescents' abilities to maintain their usual lifestyles, many still participated in the typical activities of adolescence.

IMPLICATIONS FOR NURSING

Fatigue is a complex and dynamic symptom. Oncology clinicians and researchers should frequently assess fatigue in adolescents receiving chemotherapy and apply timely and tailored interventions to match the factors that contribute to fatigue and influence fatigue severity. Management of fatigue during treatment will help adolescents stay involved in age-related activities and meet developmental milestones.

Factors predicting clinically significant fatigue in women following treatment for primary breast cancer

Cancer-related fatigue is common, complex, and distressing. It affects 70–100% of patients receiving chemotherapy and a significant number who have completed their treatments. We assessed a number of variables in women newly diagnosed with primary breast cancer (BrCa) to determine whether biological and/or functional measures are likely to be associated with the development of clinically significant fatigue (CSF). Two hundred twenty-three women participated in a study designed to document the impact of the diagnosis and treatment of primary breast cancer on function. Forty-four had complete data on all variables of interest at the time of confirmed diagnosis but prior to treatment (baseline) and ≥9 months post-diagnosis. Objective measures and descriptive variables included history, physical examination, limb volume, hemoglobin, white blood cell count, and glucose. Patient-reported outcomes included a verbal numerical rating of fatigue (0–10, a score of ≥4 was CSF), five subscales of the SF-36, Physical Activity Survey, and Sleep Questionnaire. At baseline, the entire cohort (n = 223) and the subset (n = 44) were not significantly different for demographic, biological, and self-reported data, except for younger age (p = 0.03) and ER+ (p = 0.01). Forty-five percent had body mass index (BMI) ≥ 25, 52% were post-menopause, and 52% received modified radical mastectomy, 39% lumpectomy, 52% chemotherapy, 68% radiation, and 86% hormonal therapy. Number of patients with CSF increased from 1 at baseline to 11 at ≥9 months of follow-up. CSF at ≥9 months significantly correlated with BMI ≥ 25, abnormal white blood cell count, and increase in limb volume and inversely correlated with vigorous activity and physical function (p < 0.05). Fatigue increases significantly following the treatment of BrCa. Predictors of CSF include high BMI and WBC count, increase in limb volume, and low level of physical activity. These are remediable.

Fatigue and its correlates in cancer patients who had returned to work--a cohort study

OBJECTIVES

Fatigue and other symptoms in cancer patients often interfere with social and occupational activities. Only a few studies, however, have examined relationship between fatigue and work-related outcomes. The aim of this study was to investigate which disease-related factors (treatment, diagnosis, cognitive dysfunction, depression, pain, and sleep disturbance) and work-related factors (work-load, work pressure, relationship to supervisor and colleagues, size of the company, and workplace accommodations) were related to fatigue in employed cancer survivors.

METHODS

Data was collected by questionnaire at 6 months (baseline) and 18 months (end of the follow-up) after cancer diagnosis from 135 people with different types of cancer who had returned to work at follow-up. Fatigue was measured with a four-item sub-scale of MFI. Scores ranged from 4 to 20, with higher scores indicating more fatigue.

RESULTS

The mean rate of general fatigue was 11.9 at baseline decreasing to 10.4 at the end of the follow-up (p<0.0001). At 6 months, higher work pressure (p = 0.02), physical workload (p<0.05) and less workplace accommodations (p = 0.03) were related to higher levels of fatigue. From disease-related factors, depression was associated with fatigue (p<0.0001) at baseline. Lack of workplace accommodations was the only factor affecting higher levels of fatigue at 18 months (p<0.001) and was also related to higher levels of depression at 6 months (p = 0.02) and at 18 months (p<0.001).

CONCLUSIONS

Lack of workplace accommodations was significantly related to fatigue at the end of the follow-up, which suggests that accommodations for illness can help to reduce fatigue and depression.

Relaxation acupressure reduces persistent cancer-related fatigue

Persistent cancer-related fatigue (PCRF) is a symptom experienced by many cancer survivors. Acupressure offers a potential treatment for PCRF. We investigated if acupressure treatments with opposing actions would result in differential effects on fatigue and examined the effect of different "doses" of acupressure on fatigue. We performed a trial of acupressure in cancer survivors experiencing moderate to severe PCRF. Participants were randomized to one of three treatment groups: relaxation acupressure (RA), high-dose stimulatory acupressure (HIS), and low-dose stimulatory acupressure (LIS). Participants performed acupressure for 12-weeks. Change in fatigue as measured by the Brief Fatigue Inventory (BFI) was our primary outcome. Secondary outcomes were assessment of blinding and compliance to treatment. Fatigue was significantly reduced across all treatment groups (mean ± SD reduction in BFI: RA 4.0 ± 1.5, HIS 2.2 ± 1.6, LIS 2.7 ± 2.2), with significantly greater reductions in the RA group. In an adjusted analysis, RA resulted in significantly less fatigue after controlling for age, cancer type, cancer stage, and cancer treatments. Self-administered RA caused greater reductions in fatigue compared to either HIS or LIS. The magnitude of the reduction in fatigue was clinically relevant and could represent a viable alternative for cancer survivors with PCRF.

Predictors of poor sleep quality among head and neck cancer patients

OBJECTIVES/HYPOTHESIS

The objective of this study was to determine the predictors of sleep quality among head and neck cancer patients 1 year after diagnosis.

STUDY DESIGN

This was a prospective, multisite cohort study of head and neck cancer patients (N = 457).

METHODS

Patients were surveyed at baseline and 1 year after diagnosis. Chart audits were also conducted. The dependent variable was a self-assessed sleep score 1 year after diagnosis. The independent variables were a 1 year pain score, xerostomia, treatment received (radiation, chemotherapy, and/or surgery), presence of a feeding tube and/or tracheotomy, tumor site and stage, comorbidities, depression, smoking, problem drinking, age, and sex.

RESULTS

Both baseline (67.1) and 1-year postdiagnosis (69.3) sleep scores were slightly lower than population means (72). Multivariate analyses showed that pain, xerostomia, depression, presence of a tracheotomy tube, comorbidities, and younger age were statistically significant predictors of poor sleep 1 year after diagnosis of head and neck cancer (P < .05). Smoking, problem drinking, and female sex were marginally significant (P < .09). Type of treatment (surgery, radiation and/or chemotherapy), primary tumor site, and cancer stage were not significantly associated with 1-year sleep scores.

CONCLUSIONS

Many factors adversely affecting sleep in head and neck cancer patients are potentially modifiable and appear to contribute to decreased quality of life. Strategies to reduce pain, xerostomia, depression, smoking, and problem drinking may be warranted, not only for their own inherent value, but also for improvement of sleep and the enhancement of quality of life.

Associations among hypogonadism, C-reactive protein, symptom burden, and survival in male cancer patients with cachexia: a preliminary report

CONTEXT

Cachexia is characterized by muscle wasting, anorexia, and elevated inflammatory markers. In patients without cancer, hypogonadism is associated with lower lean body mass, increased symptom burden, and decreased survival. Hypogonadism in cancer cachexia could exacerbate symptoms, facilitate a proinflammatory state, and decrease survival.

OBJECTIVES

To explore the relationships among these factors, a retrospective study of male cancer patients was conducted.

METHODS

The charts of 98 consecutive male patients referred to a cachexia clinic at a comprehensive cancer center were reviewed. All patients reported weight loss of >5% within the preceding six months; the median age was 60 years. Fifty-seven (58%) had serum C-reactive protein (CRP), and 68 (69%) had total testosterone evaluated. Symptoms were evaluated by the Edmonton Symptom Assessment Scale.

RESULTS

Median CRP was 20mg/L, and median testosterone level was 185 ng/dL (6.42 nmol/L) (normal > or = 240 ng/dL or 8.36 nmol/L). There was an inverse correlation between testosterone and CRP levels (P<0.01). Lower testosterone was associated with increased dyspnea and insomnia (P<0.05). Poor appetite and insomnia (P<0.05) correlated with elevated CRP. Survival of patients with testosterone levels < or = 185 ng/dL (6.42 nmol/L) was decreased compared with that of those with levels >185 ng/dL (13 vs. 62 weeks, P=0.004). Patients with CRP levels >10mg/L had decreased survival compared with those with levels < or = 10mg/L (15 vs. 46 weeks, P=0.01). The combination of hypogonadism and elevated CRP was associated with poorer prognosis. Elevated CRP levels were associated with increased symptom burden and decreased survival. Low testosterone was associated with decreased survival and correlated inversely with CRP levels, dyspnea, and insomnia.

CONCLUSION

Our preliminary results suggest that testosterone and CRP may be additive or synergistic as markers for survival in male patients and could be useful in future prognostic models.

Factors correlated with fatigue in breast cancer survivors undergoing a rehabilitation course, Denmark, 2002-2005

OBJECTIVE

The aim of this prospective cohort study was to identify factors associated with fatigue in women with breast cancer who attended a 6-day rehabilitation course. Furthermore, to investigate level of fatigue 1 year after the rehabilitation course, after accounting for baseline fatigue levels.

METHODS

Between 2002 and 2005 we included 775 women with breast cancer and measured fatigue, emotional functioning and insomnia using the EORTC subscales and sociodemographics from a baseline questionnaire prior to participation in the rehabilitation course. Information on disease-specific and treatment factors was obtained from a nationwide clinical database. From the 12-month follow-up questionnaire we obtained level of fatigue. We estimated the influence of factors on the relative risk for a 10-points increase in fatigue score in generalised linear models. For the analysis of fatigue at 12 months follow-up we added fatigue level at baseline and relapse since baseline.

RESULTS

Higher tumour grade and insomnia predicted higher levels of fatigue, whereas better emotional functioning was associated with lower levels. After 12 months of follow-up fatigue levels were associated with level at baseline and with emotional functioning, insomnia, relapse and being on sick leave or unemployed. Emotional level, insomnia and high grade were associated with level of fatigue. After 1 year, a high level at baseline, insomnia and low emotional functioning was associated with greater fatigue.

CONCLUSIONS

These longitudinal results support that cancer-related fatigue can be a persistent phenomenon and that focus on psychological distress and sleeping problems might be beneficial in these women.

Does effective management of sleep disorders reduce cancer-related fatigue?

Cancer and cancer therapy are often associated with symptoms such as fatigue and sleep disturbances, before, during and after therapy. These symptoms of fatigue and poor sleep often occur in parallel having a significant impact on the physical functioning of patients with cancer. A strong correlation between cancer-related fatigue (CRF) and sleep has been observed in several studies, suggesting that they may be reciprocally related. The co-clustering of these symptoms suggests that they may have similar underlying aetiology and that treatments targeting either symptom may positively affect the other. Studies examining these clusters have shown that these symptoms often co-vary together. The potential mechanisms that link the relationship between insomnia and CRF are intriguing but require further investigation. Despite the high prevalence of insomnia and the often bidirectional relationship between poor sleep and fatigue, there are limited data to support the use of sleep management interventions as a means to reduce fatigue in patients with cancer. Assessment of the available evidence across trials is complicated by different study designs, patient selection criteria, stage of cancer treatment and by the nature of the interventions studied. Improvements from baseline in both sleep parameters and CRF have been documented in a limited number of studies, including two randomized-controlled trials using cognitive behavioural therapy for insomnia (CBT-I). In contrast, the efficacy of pharmacological therapies in reducing both insomnia and CRF is largely lacking. Clearly, treating clinically significant insomnia is likely to have benefits for the patient with cancer and for those who are recovering from cancer. In particular, pharmacotherapies for insomnia, singly or in combination with CBT-I, should be evaluated in multicentre randomized clinical trials to examine their efficacy in improving sleep quality and reducing associated CRF.

The role of the primary care physician during the active treatment phase

Although more research needs to be done to determine the optimal role for PCPs during the active phase of cancer treatment, patients, PCPs, and oncologists all see a significant role for primary care in the care of patients with cancer. In the United States, family physicians are actively involved in the care of cancer patients, especially in provision of support, education, and care of intercurrent illness and chronic disease. Fatigue, depression, pain, and psychosocial distress are important symptoms that should be screened for and addressed. The PCP should be aware of adverse effects of chemotherapy and radiation and cancer-related emergencies. Sexual and intimacy concerns, including contraception and fertility, are important to patients entering active cancer treatment but may not be addressed adequately in usual cancer care. Advising the patient in active cancer treatment on issues of general health including common nutritional issues can provide value through the treatment period. Use of CAM is common and several modalities have been shown to benefit patients in the course of cancer treatment.

Why treat insomnia?

OBJECTIVE

To make the case that insomnia is better conceptualized, not as a symptom, but as a primary disorder.

DATA SOURCES

PubMed was searched from 1975-2009 using the search terms insomnia, insomnia and treatment, insomnia and cost, and insomnia and treatment and safety.

STUDY SELECTION

English-language articles and other materials were selected to address the following claims: insomnia is unremitting, insomnia is disabling, insomnia is costly, insomnia is pervasive, insomnia is pernicious, and insomnia treatment is safe and effective.

DATA EXTRACTION/SYNTHESIS

Insomnia, at least when chronic, should be conceptualized as a comorbid condition, one for which effective interventions are available.

CONCLUSIONS

It is speculated that treatment for insomnia will only become the norm when it has been demonstrated that treatment not only addresses the problem of insomnia but also serves to reduce medical and psychiatric morbidity. At that time, the question will no longer be "Why treat insomnia?" but instead "When isn't insomnia treatment indicated?"

Circadian Disruption, Fatigue, and Anorexia Clustering in Advanced Cancer Patients: Implications for Innovative Therapeutic Approaches

A disruption of the circadian timing system, as identified by monitoring of marker biorhythms, is common in cancer patients. The recording of the rest—activity rhythm with a wrist actigraph has been commonly used. This noninvasive monitoring allows a robust estimation of circadian disruption. The authors have previously found that altered patterns of circadian rest—activity rhythms are significantly and independently associated with the severity of fatigue and anorexia in patients with metastatic colorectal cancer. Elevated proinflammatory cytokines could partly account for this circadian disruption and its associated constitutional symptoms. Here, the authors present and discuss the data supporting the hypothesis that circadian disruption is often associated with fatigue and anorexia, which in turn further alter and dampen circadian synchronization, thus, creating a vicious cycle. This body of evidence paves the path for innovative therapeutic approaches targeting the circadian timing system in an effort to diminish constitutional symptoms induced by cancer and some anticancer treatments.

One-year outcomes of a behavioral therapy intervention trial on sleep quality and cancer-related fatigue

PURPOSE

To determine 1-year outcomes of a four-component behavioral therapy (BT) sleep intervention (Individualized Sleep Promotion Plan [ISPP]) versus a healthy eating control (HEC) on cancer-related fatigue in women receiving breast cancer adjuvant chemotherapy treatment (CTX).

PATIENTS AND METHODS

A total of 219 participants from 12 oncology clinics were randomly assigned in a clinical trial. Before CTX, research nurses coached intervention participants to develop a BT plan including stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene. BT plans were revised before each CTX and 30, 60, and 90 days after the last CTX and reinforced 7 to 9 days later. HEC participants received nutritional information and equal attention. Pittsburgh Sleep Quality Index (PSQI), Daily Diary, Wrist Actigraph, and Piper Fatigue Scale measures and Repeated Linear Mixed Model analysis following the Intent to Treat paradigm were used.

RESULTS

Sleep quality differed over 1 years time (F [4,162] = 7.7, P < .001; by group, F [1,173] = 4.8, P = .029; and over time by group, F [4,162] = 3.3, P = .013). Pairwise comparisons revealed significant differences between groups at 90 days (P = .002) but not at 1 year (P = .052). Seven days of diary and actigraphy data did not corroborate with monthly reflections (PSQI). The night awakenings (Actigraph) pattern was significantly different by group over time (P = .046), with no differences between groups at 90 days or at 1 year. Fatigue was lower at 1 year than before CTX; no group effects were found.

CONCLUSION

The BT group, on average, experienced significant improvement on global sleep quality compared with the HEC group, but not on objective sleep or fatigue outcomes.

Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue

BACKGROUND

To determine whether sleep quality and fatigue associated with breast cancer adjuvant chemotherapy treatments can be improved with behavioral therapy (BT) [Individualized Sleep Promotion Plan (ISPP)] including modified stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene.

METHODS

Randomized-controlled trial based on Piper Integrated Fatigue Model, 219 stages I-IIIA breast cancer patients. Prior to the initial chemotherapy treatment, BT participants developed an ISPP plan that was regularly reinforced and revised. Controls received healthy eating information and attention. Pittsburgh Sleep Quality Index (PSQI), daily diary, actigraph, and Piper Fatigue Scale (PFS) data were collected 2 days prior, during the 7 days after each treatment, and 30 days after the last treatment. Repeated measures analysis of variance was used.

RESULTS

Prior to chemotherapy, participants reported mild fatigue and fairly poor sleep quality. All variables changed over time. A group by time interaction was found for sleep quality (PSQI) improving in the BT group. Diary revealed group differences on number of awakenings, minutes awake after sleep onset, and sleep efficiency. Fatigue (PFS) was similar between groups.

CONCLUSIONS

The BT group showed improved sleep quality over time and better sleep (diary). Perceptions of improved sleep quality over time are not consistently associated with diary or actigraph, or result in lower fatigue.

Prevalence and predictors of insomnia in women with invasive ovarian cancer: anxiety a major factor

The estimated prevalence of insomnia in cancer patients varies between 20% and 50%, which is substantially higher than the general population. To date, little is known about the risk factors for insomnia in patients with cancer. This study examines the prevalence and predictors of insomnia in a population-based sample of women with ovarian cancer. Participants were 772 women participating in the Australian Ovarian Cancer Study - Quality of Life Study. Insomnia was assessed using the Insomnia Severity Index (ISI). Demographic, disease and treatment variables, and psychosocial variables, including anxiety and depression, support care needs and social support and coping, were investigated as potential predictors of insomnia. Twenty-seven percent of women reported sub-clinical symptoms of insomnia (ISI score 8-14) and 17% reported clinically significant insomnia (ISI score 15-28). Three variables were significant predictors of clinically significant insomnia: young age (<50 years: Odds Ratio (OR)=2.36; Confidence Interval (CI) 1.06-5.26; 50-59 years: OR=2.73; CI 1.33-5.64) relative to 70+ years; higher unmet needs in the physical/daily living domain (OR=1.02; CI 1.01-1.03) and elevated anxiety (sub-clinical anxiety (Hospital Anxiety and Depression Scale (HADS) score 8-10): OR=1.83; CI 1.04-3.24; clinical anxiety (HADS score 11-21): OR=2.03; CI 1.08-3.85). In contrast to predictors of primary insomnia, women with cancer aged <60 years were more likely to report clinical levels of insomnia than women of 70+ years. Consistent with primary insomnia, elevated anxiety predicted insomnia in women with ovarian cancer. Given that both anxiety and insomnia are relatively common, and the relationship may potentially be bi-directional, the efficacy of interventions targeting insomnia and anxiety, rather than insomnia alone, is worthy of consideration.

The prevalence of nocturnal hypoxemia in advanced cancer

Nocturnal hypoxemia is associated with excessive daytime sleepiness in patients with chronic respiratory disease. This relationship has not been explored in patients with cancer. This study examined the prevalence of nocturnal hypoxemia in patients admitted to a specialist palliative care unit, and explored relationships with demographic and physiological parameters, opioid or other sedative drug use, and daytime sleepiness, fatigue, and quality of life. Demographic details, diagnosis, performance status, body mass index, opioid or other sedative drug use, hemoglobin, spirometry, and sniff nasal inspiratory pressures were obtained, along with Epworth Sleepiness Scale, Multidimensional Fatigue Inventory, and Short Form-36 health questionnaire scores. An oximeter recorded resting daytime oxygen saturation (SaO2); overnight SaO2 was recorded for a minimum of five hours. Nocturnal hypoxemia was defined as SaO2<90% for >or=2% of the monitored nighttime. Of 100 patients, 35 had nocturnal hypoxemia. These were more likely to have lung disease (P<0.05), a lower forced expiratory volume in one second % predicted (P=0.01), lower daytime SaO2 (P=0.01) and higher levels of mental fatigue (difficulty concentrating) (P=0.02), compared to those without nocturnal hypoxemia. Both groups exhibited abnormal levels of daytime sleepiness. Nocturnal hypoxemia is common in this group of patients and may contribute to mental fatigue (difficulty concentrating).

Diagnostic criteria of cachexia and their assessment: decreased muscle strength and fatigue

PURPOSE OF REVIEW

The classification of cachexia or wasting disease is currently being revised to improve clinical trial design and clinical care. Decreased muscle strength and fatigue are proposed as diagnostic criteria for cachexia or wasting disease including, but not limited to, cancer. This review discusses their expected value in cancer cachexia.

RECENT FINDINGS

Fatigue is frequent and multifactorial in cancer patients with limited value to predict cachexia, however, most cachectic patients have fatigue. Its assessment requires multimodal subjective instruments, for outcome monitoring many other fatigue cofactors need to be controlled. Cachexia seems a dominant cause for decreased muscle strength. Most cachectic patients lose muscle strength, usually together with reduced muscle mass. High-individual variability of muscle strength limits its use to longitudinal monitoring. Physical activity monitoring, applying also body-worn sensors, offers additional monitoring tools.

SUMMARY

To diagnose and monitor cachexia, muscle strength should be measured directly, whereas fatigue is seen as a global outcome.