Assessment and management of cancer-related fatigue in adults

Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life

PURPOSE

This study examines the impact of yoga, including physical poses, breathing, and meditation exercises, on quality of life (QOL), fatigue, distressed mood, and spiritual well-being among a multiethnic sample of breast cancer patients.

PATIENTS AND METHODS

One hundred twenty-eight patients (42% African American, 31% Hispanic) recruited from an urban cancer center were randomly assigned (2:1 ratio) to a 12-week yoga intervention (n = 84) or a 12-week waitlist control group (n = 44). Changes in QOL (eg, Functional Assessment of Cancer Therapy) from before random assignment (T1) to the 3-month follow-up (T3) were examined; predictors of adherence were also assessed. Nearly half of all patients were receiving medical treatment.

RESULTS

Regression analyses indicated that the control group had a greater decrease in social well-being compared with the intervention group after controlling for baseline social well-being and covariates (P < .0001). Secondary analyses of 71 patients not receiving chemotherapy during the intervention period indicated favorable outcomes for the intervention group compared with the control group in overall QOL (P < .008), emotional well-being (P < .015), social well-being (P < .004), spiritual well-being (P < .009), and distressed mood (P < .031). Sixty-nine percent of intervention participants attended classes (mean number of classes attended by active class participants = 7.00 +/- 3.80), with lower adherence associated with increased fatigue (P < .001), radiotherapy (P < .0001), younger age (P < .008), and no antiestrogen therapy (P < .02).

CONCLUSION

Despite limited adherence, this intent-to-treat analysis suggests that yoga is associated with beneficial effects on social functioning among a medically diverse sample of breast cancer survivors. Among patients not receiving chemotherapy, yoga appears to enhance emotional well-being and mood and may serve to buffer deterioration in both overall and specific domains of QOL.

Fatigue and Physical Activity in Older Adults With Cancer

Cancer is a disease predominantly affecting older adults. Cancer fatigue is the most common and often most distressing symptom associated with cancer and its treatment, often persisting months to years after treatment. Untreated cancer fatigue may lead to significant reductions in physical activity, physical functioning, and quality of life and may interfere with patients' adherence to cancer treatment. Physical activity has the strongest supporting evidence as an intervention to reduce cancer fatigue, maintain physical function, and optimize quality of life. This article reviews the literature related to fatigue and physical activity in older adults with cancer. Nine experimental and 10 observational studies that enrolled subjects 65 years or older were synthesized in the review and provided evidence that physical activity may be an effective intervention for cancer fatigue in older adults. The generalizability of the findings to older adults was limited by the poor representation of this age group in the studies. Few studies provided an analysis of age-related effects of physical activity on fatigue, physical function, and quality of life.

Risks and benefits of erythropoiesis-stimulating agents in cancer management

Anemia is frequently diagnosed in patients with cancer and its treatment is an important clinical problem. The deficiency in red blood cells (RBCs) can be a debilitating problem, and anemia correlates with poor performance status, deteriorates quality of life, and may negatively influence the prognosis of cancer patients. The development of recombinant human erythropoietins (rhEPO) provides a therapeutic option in patients with mild to moderate anemia. However, clinical experience demonstrates that more than half of anemic cancer patients are not treated. There is clear evidence that rhEPO reliably increases haemoglobin (Hb) levels in patients suffering from cancer-related or treatment-associated anemia. The dosing and management of these patients should strictly follow evidence-based guidelines of the clinical societies, as well as the manufacturer's recommendations. Furthermore, treatment of patients beyond the correction of anemia must be regarded as potentially harmful and should only be conducted in an experimental clinical setting. In this review, recently published recommendations and standards for the use of rhEPO will be discussed.

Mechanisms of cancer-related fatigue

Cancer-related fatigue (CRF) is one of the most prevalent symptoms patients with cancer experience, both during and after treatment. CRF is pervasive and affects patients' quality of life considerably. It is important, therefore, to understand the underlying pathophysiology of CRF in order to develop useful strategies for prevention and treatment. At present, the etiology of CRF is poorly understood and the relative contributions of the neoplastic disease, various forms of cancer therapy, and comorbid conditions (e.g., anemia, cachexia, sleep disorders, depression) remain unclear. In any individual, the etiology of CRF probably involves the dysregulation of several physiological and biochemical systems. Mechanisms proposed as underlying CRF include 5-HT neurotransmitter dysregulation, vagal afferent activation, alterations in muscle and ATP metabolism, hypothalamic-pituitary-adrenal axis dysfunction, circadian rhythm disruption, and cytokine dysregulation. Currently, these hypotheses are largely based on evidence from other conditions in which fatigue is a characteristic, in particular chronic fatigue syndrome and exercise-induced fatigue. The mechanisms that lead to fatigue in these conditions provide a theoretical basis for future research into the complex etiology of this distressing and debilitating symptom. An understanding of relevant mechanisms may offer potential routes for its prevention and treatment in patients with cancer.Disclosure of potential conflicts of interest is found at the end of this article.

Pharmacologic treatment of cancer-related fatigue

Fatigue is the most commonly reported symptom in patients with cancer, with a prevalence of over 60% reported in the majority of studies. This paper systematically reviews pharmacologic agents in the treatment of cancer-related fatigue (CRF). We conducted a literature review of clinical trials that assessed pharmacologic agents for the treatment of CRF. These agents include hematopoietics (for anemia), corticosteroids, and psychostimulants. Other therapeutic agents that are less well studied for CRF but are currently the focus of clinical trials include l-carnitine, modafinil, bupropion, and selective serotonin reuptake inhibitors such as paroxetine. Disclosure of potential conflicts of interest is found at the end of this article.

Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue

Cancer-related fatigue (CRF) is a debilitating, multi-faceted biopsychosocial symptom experienced by the majority of cancer survivors during and after treatment. CRF begins after diagnosis and frequently persists long after treatments end, even when the cancer is in remission. The etiological pathopsychophysiology underlying CRF is multifactorial and not well delineated. Mechanisms may include abnormal accumulation of muscle metabolites, dysregulation of the homeostatic status of cytokines, irregularities in neuromuscular function, abnormal gene expression, inadequate ATP synthesis, serotonin dysregulation, abnormal vagal afferent nerve activation, as well as an array of psychosocial mechanisms, including self-efficacy, causal attributions, expectancy, coping, and social support. An important first step in the management of CRF is the identification and treatment of associated comorbidities, such as anemia, hypothyroidism, pain, emotional distress, insomnia, malnutrition, and other comorbid conditions. However, even effective clinical management of these conditions will not necessarily alleviate CRF for a significant proportion of cancer survivors. For these individuals, intervention with additional therapeutic modalities may be required. The National Comprehensive Cancer Network guidelines recommend that integrative nonpharmacologic behavioral interventions be implemented for the effective management of CRF. These types of interventions may include exercise, psychosocial support, stress management, energy conservation, nutritional therapy, sleep therapy, and restorative therapy. A growing body of scientific evidence supports the use of exercise and psychosocial interventions for the management of CRF. Research on these interventions has yielded positive outcomes in cancer survivors with different diagnoses undergoing a variety of cancer treatments. The data from trials investigating the efficacy of other types of integrative nonpharmacologic behavioral therapies for the management of CRF, though limited, are also encouraging. This article provides an overview of current research on the relative merits of integrative nonpharmacologic behavioral interventions for the effective clinical management of CRF and makes recommendations for future research. Disclosure of potential conflicts of interest is found at the end of this article.

Fatigue, depression, and insomnia: evidence for a symptom cluster in cancer

OBJECTIVES

To review the evidence for considering fatigue, depression, and insomnia as a symptom cluster in cancer.

DATA SOURCES

Empirical studies, clinical articles, and review articles.

CONCLUSION

The single- and multi-symptom measurement approaches are of limited usefulness in distinguishing fatigue, depression, and insomnia. Studies in which these symptoms have been measured concurrently in patients with cancer yield consistent evidence of high positive correlations. Results do not appear to be solely a function of overlap in measurement approaches.

IMPLICATIONS FOR NURSING PRACTICE

Successful management of fatigue, depression, and insomnia in cancer patients are likely to combine pharmacologic and nonpharmacologic therapies.

The relationship between cancer-related fatigue and patient satisfaction with quality of life in cancer

Fatigue affects a majority of patients undergoing cancer-related therapies. We conducted a study of 954 adult cancer patients presenting for treatment at our hospital between April 2001 and November 2004 to quantify the relationship between fatigue and patient satisfaction with quality of life (QoL). Fatigue was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire fatigue subscale. Patient satisfaction with QoL was measured using the Ferrans and Powers Quality of Life Index (QLI). The relationship between fatigue and QLI was evaluated using univariate and multivariate linear regression after controlling for the effects of clinical and demographic factors. Of the 954 patients, 579 were females and 375 males, with a median age at presentation of 56 years (range 20-90 years). Sixty-six percent had failed prior treatment. The most common cancers were breast (26%), colorectal (19%), and lung (16%) cancers. After controlling for the effects of age and prior treatment history, every 10-unit increase in fatigue was statistically significantly associated with 1.5-, 0.22-, 0.77-, 0.27-, and 0.85-unit declines in QLI health and physical, social and economic, psychological and spiritual, family, and global function scores, respectively. Consequently, a 30-point increase in fatigue score correlates with a 4.5-point decline in QLI health functioning-a clinically significant decline. In our study, we found that fatigue is strongly associated with patient satisfaction with QoL independent of the effects of age and prior treatment history.

The Experience of Fatigue in Turkish Patients Receiving Chemotherapy

PURPOSE/OBJECTIVES

To determine the experience of fatigue in Turkish patients receiving chemotherapy.

DESIGN

Descriptive.

SETTING

Outpatient unit in a large university hospital in Ankara, Turkey.

SAMPLE

100 patients randomly chosen from those who were undergoing chemotherapy at the outpatient unit.

METHODS

Data were collected using a personal information form developed by the investigator and a visual analog scale for fatigue.

MAIN RESEARCH VARIABLES

Measures taken by patients to cope with fatigue, fatigue experienced by individuals affecting their daily activities, age and gender, disease and treatment factors, and symptoms related to the chemotherapy.

FINDINGS

The majority of patients (86%) experienced fatigue, and 73% stated that they coped with fatigue by decreasing their activities and resting more. Age was not a statistically significant factor affecting the level of fatigue, but gender was found to have an effect. Length of illness, number of chemotherapy courses, and the patients' symptoms affected level of fatigue.

CONCLUSIONS

The majority of patients experienced fatigue, and most of the measures used to cope with fatigue were not effective. Fatigue affected patients' daily activities.

IMPLICATIONS FOR NURSING

A need exists for more and better interventions to help patients cope with chemotherapy-related fatigue.

Putting evidence into practice: evidence-based interventions for fatigue during and following cancer and its treatment

Cancer-related fatigue has a significant impact on patients' physical and psychosocial functioning, symptom distress, and quality of life, yet it remains under-recognized and undertreated. The Oncology Nursing Society's Putting Evidence Into Practice initiative sought to improve patient outcomes relative to this important problem by critically examining and summarizing the evidence base for interventions to prevent and manage fatigue during and following treatment. This article critically reviews and summarizes the available empirical evidence regarding interventions for cancer-related fatigue. In addition to offering patients and clinicians a tool to facilitate effective management of the distressing symptom, this evidence-based review identifies gaps in knowledge and research opportunities.

Using a conceptual model in nursing research--mitigating fatigue in cancer patients

AIM

This paper is a discussion of the use of the Levine Conservation Model to guide the investigation of an exercise intervention to mitigate cancer-related fatigue.

BACKGROUND

Researchers use conceptual models or theoretical frameworks to provide an organizing structure for their studies, to guide the development and testing of hypotheses, and to place research finding within the context of science. Selection of an appropriate and useful framework is an essential step in the development of a research project.

METHOD

A descriptive approach is used to present the components of the conceptual model and details of the articulation of the study intervention and outcomes with the model.

FINDINGS

The Levine Conservation Model provided a useful framework for this investigation, conducted in 2002-2006, of the effects of exercise on fatigue and physical functioning in cancer patients. The four conservation principles of the model guided the development of the exercise intervention, the identification of salient outcomes for patients, and the selection of appropriate instruments to measure study variables. The model is also proving useful in the analysis and interpretation of data in relation to the conservation principles.

CONCLUSION

Use of an appropriate conceptual model facilitates the design and testing of theory-based interventions and the development of science to support nursing practice.

A critical review of complementary therapies for cancer-related fatigue

PURPOSE

To review the available literature on the use of complementary and alternative medicine (CAM) treatments for cancer-related fatigue with an aim to develop directions for future research.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, and SPORTDiscus were searched for relevant studies. Original clinical trials reporting on the use of CAM treatments for cancer-related fatigue were abstracted and critically reviewed.

RESULTS

CAM interventions tested for cancer-related fatigue include acupuncture, aromatherapy, adenosine triphosphate infusions, energy conservation and activity management, healing touch, hypnosis, lectin-standardized mistletoe extract, levocarnitine, massage, mindfulness-based stress reduction, polarity therapy, relaxation, sleep promotion, support group, and Tibetan yoga. Several of these interventions seem promising in initial studies.

CONCLUSION

Currently, insufficient data exist to recommend any specific CAM modality for cancer-related fatigue. Therefore, potentially effective CAM interventions ready for further study in large, randomized clinical trials (eg, acupuncture, massage, levocarnitine, and the use of mistletoe) should be pursued. Other interventions should be tested in well-designed feasibility and phase II trials.

[Secondary prevention after urological cancers. What are the pertinent facts about aftercare?]

Secondary prevention and aftercare of urological cancers are an essential part of outpatient care provided by the urologist in private practice. More than one-half of the patients who are confronted with the diagnosis of cancer turn to so-called unconventional treatment procedures. The difficulties for those affected and caregivers lie in equal measure in distinguishing between sensible and less advisable or even counterproductive treatment options. Fixed plans of action for aftercare do not do justice to the exigencies of individualized care of cancer patients in private practice, especially with respect to longer survival. Early detection of local recurrence and metastases and the management of complications are determined by the individual disease course and have to be measured against the improvement in quality of life. Secondary preventive measures in the sense of complementary medicine can be helpful. Current evidence is quite promising only for prostate cancer and is of some importance in urological practice.

Meeting information needs on cancer-related fatigue: an exploration of views held by Italian patients and nurses

BACKGROUND

Interest in cancer-related fatigue has been growing over the last two decades and efforts have been dedicated to investigate this topic. However, research addressing the adequacy of educational resources for patients with this distressing and common symptom is lacking. Only one study has been undertaken and this explored Swiss and British patients' views.

MATERIALS AND METHODS

The current study replicated and extended the study previously undertaken in the United Kingdom (UK) and Switzerland. It sought views on the adequacy of materials on cancer-related fatigue available to patients with cancer living in Italy, and to determine the educational preferences and needs of Italian patients with cancer-related fatigue. These were attained through conduct of two focus groups. One was undertaken with Italian patients and the other with a group of Italian nurses.

MAIN RESULTS

Findings from this study supported patients' desire for timely, accurate and individualised information. Barriers to effective fatigue education included the limited dialogue regarding fatigue initiated in clinical settings. It appeared that nurses and patients held different priorities in symptom management. Further, it was acknowledged that there was often insufficient time to inform patients adequately about fatigue. Participants considered written materials as helpful complements to oral information, thus supporting the provision of information in both forms. However, it was clear that fewer written resources concerning cancer-related fatigue were available in Italy compared to either in Switzerland or in the UK.

CONCLUSION

The study supported the view within the current literature that whilst cancer-related fatigue is recognised as a frequent and disruptive symptom, patient education about this symptom and its management still needs to be enhanced. The resources available to educate patients about cancer-related fatigue should be improved and made more accessible to patients who experience it.

Assessment of fatigue in chronic disease: a bibliographic study of fatigue measurement scales

A large number of fatigue scales exist and there is no consensus on which fatigue measuring scales that are most appropriate for use in assessment of fatigue in different diseases. We aimed to describe the use of fatigue scales in studies of disease-related fatigue during the last three decades. We searched databases from 1975 to 2004 for original studies reporting on disease-related fatigue and extracted information on method used to assess fatigue, diseases under study and year of publication. A total of 2285 papers reported measures of fatigue in chronic non-acute diseases of which 80% were published during the last decade. We identified 252 different ways to measure fatigue, of which 150 were use only once. Multi-symptom scales (n = 156) were used in 670 studies, while 71 scales specifically designed to measure fatigue were applied in 416 studies. The majority of these studies used scales with a multidimensional approach to fatigue, and most studies used scales that were disease-specific or only applied to few different diseases. Research in disease-related fatigue has increased exponentially during the last three decades, even if we adjust for the general increase in publishing activity. The number of scales has also increased and the majority of scales were developed for specific diseases. There is need for measure instruments with different sizes and dimensionality, and due to ceiling and floor effects, the same scale may not be useful for patients with different severity of fatigue. However, since fatigue is an unspecific symptom there should not be need for adopting disease specific fatigue scales for each individual disease. There may be differences in characteristics of fatigue between diseases and generic measurement instruments may facilitate documentation of such differences, which may be of clinical importance.

Evidence-Based Practice for Fatigue Management in Adults With Cancer: Exercise as an Intervention

PURPOSE/OBJECTIVES

To review and summarize the current state of the evidence for exercise as an intervention for cancer-related fatigue and to facilitate application to clinical practice.

DATA SOURCES

Articles, abstracts, and practice guidelines published through October 2003.

DATA SYNTHESIS

The strength of the evidence of effectiveness of exercise in managing cancer-related fatigue is growing.

CONCLUSIONS

All patients with cancer should be encouraged to maintain an optimum level of physical activity during and following cancer treatment. Patients with breast cancer and other selected patients should receive recommendations for moderate exercise programs. Referrals to physical therapy and/or rehabilitation may benefit certain patients, including those with comorbidities or deconditioning. Published multidisciplinary evidence-based guidelines for exercise programs involving patients with cancer are needed.

IMPLICATIONS FOR NURSING

Nurses may participate in implementing exercise interventions with patients with cancer in various roles depending on skill and knowledge--from encouraging physical activity to referring patients to physical therapy and/or rehabilitation programs to prescribing and monitoring exercise in certain patient populations.

Personality and fatigue in patients with benign or malignant breast disease

GOALS OF WORK

The aim of the study was to examine the role of five general personality traits in fatigue in a group of patients with breast cancer (BC) and a group with benign breast problems (BBP).

MATERIALS AND METHODS

Of the 304 participating women, 127 patients had BC and 177 BBP. A fatigue scale was completed before diagnosis and 1, 3, and 6 months after diagnosis (benign patients) or surgical treatment (BC patients). A personality questionnaire (NEO-FFI) and a depression scale (CES-D) were completed before diagnosis.

MAIN RESULTS

The BC group was less tired before diagnosis, more tired 1 month after diagnosis, and equally tired 3 and 6 months after diagnosis. In the total group, women were more tired over time when they were more neurotic, less agreeable, or more introverted. After controlling for depressive symptoms, demographics, and medical factors, baseline depressive symptoms (beta = 0.29, p < 0.05), neuroticism (beta = 0.29, p < 0.05), and extraversion (beta = -0.25, p < 0.05) predicted fatigue 6 months later. After also including baseline fatigue, only neuroticism (beta = 0.22, p < 0.05) and baseline fatigue (beta = 0.79, p < 0.001) predicted fatigue.

CONCLUSIONS

Personality is more strongly related to fatigue than demographics, the diagnosis cancer, receiving cancer treatment, and baseline depressive symptoms and fatigue. When replicated, screening and treating women who are at risk to experience high levels of fatigue is recommended.

Differential effects of dexamethasone, ondansetron and a tachykinin NK1 receptor antagonist (GR205171) on cisplatin-induced changes in behaviour, food intake, pica and gastric function in rats

This study aimed to dissect the mechanisms involved in malaise induced by the anti-cancer drug cisplatin by attempting to uncouple its effects on locomotor activity, arguably at least partly indicative of fatigue, from those effects indicative of emesis (pica, gastric stasis, reduced food intake) using pharmacological agents in the rat. Over 2 days cisplatin (6 mg/kg i.p.) reduced food intake, stimulated kaolin consumption, increased the wet weight of gastric contents and reduced locomotor activity. In animals treated with cisplatin: the 5-HT3 receptor antagonist ondansetron (1 mg/kg s.c. bd.) had no effect on either activity or weight of gastric contents but did increase food intake on day 1 (P<0.05) and the total over both days (27.6+/-1.8 vs. 19.9+/-2.3g, P<0.05), reducing kaolin consumption on day 2 (P<0.01) but not the total over both days; the NK1 receptor antagonist GR205171 (1 mg/kg s.c. bd.) was without effect on activity, but reduced the wet weight of gastric contents (P<0.05), increased food intake on day 2 (P<0.01) and total consumption over both days (28.1+/-1.7 g vs. 19.9+/-2.3 g; P<0.05) and reduced kaolin consumption on day 2 (P<0.05) but not over both days; dexamethasone (2 mg/kg s.c. bd.) blocked the cisplatin-induced reduction in activity on days 1 and 2 (P<0.01), reduced the wet weight of gastric contents by 43% (P<0.01), reduced kaolin consumption on both days (P<0.01) and arguably decreased the reduction in food intake caused by cisplatin. This study has revealed novel insights into the different spectra of activities of 5-HT3 and NK1 receptor antagonists and dexamethasone, which have implications for therapeutic strategies to alleviate the emetic, anorectic, dyspeptic and activity-reducing effects of anti-cancer chemotherapy.

The burden of fatigue and quality of life in myeloproliferative disorders (MPDs)

BACKGROUND

Few objective data exist on the burden of fatigue and other constitutional symptoms in patients with myeloproliferative disorders (MPD).

METHODS

The authors used validated instruments of fatigue and physical activity assessment during an Internet-based symptom survey of 1179 MPD patients (median age, 56 years; 41.4% men).

RESULTS

The frequency of self-reporting was 80.7% for fatigue, which was substantially higher than that of pruritus (52.2%), night sweats (49.2%), bone pain (43.9%), fever (13.7%), and weight loss (13.1%). In the majority of patients, these symptoms restricted participation in both social functions and physical activity. In addition, 34.5% of patients needed assistance with activities of daily living, and 11.2% reported MPD-associated medical disability. As expected, the presence of myelofibrosis, anemia, splenomegaly, or other features associated with advanced disease favored a higher degree of fatigue. However, fatigue remained the major complaint also in polycythemia vera (84.9%) and essential thrombocythemia (72.4%); these figures were significantly higher than those of published controls (P < .0001).

CONCLUSIONS

The current study identifies fatigue as the major contributor to poor quality of life in MPD, provides baseline information on constitutional symptoms, and underscores the need for the incorporation of quality of life assessment in clinical trials.

Cancer-related fatigue: predictors and effects of rehabilitation

BACKGROUND

The aims of the study were to examine the effects of a multidimensional rehabilitation program on cancer-related fatigue, to examine concurrent predictors of fatigue, and to investigate whether change in fatigue over time was associated with change in predictors.

METHODS

SAMPLE

72 cancer survivors with different diagnoses.

SETTING

rehabilitation center.

INTERVENTION

15-week rehabilitation program.

MEASURES

Fatigue (Multidimensional Fatigue Inventory), demographic and disease/treatment-related variables, body composition (bioelectrical impedance), exercise capacity (symptom-limited bicycle ergometry), muscle force (handheld dynamometry), physical and psychological symptom distress (Rotterdam Symptom Check List), experienced physical and psychological functioning (RAND-36), and self-efficacy (General-Self-Efficacy Scale, Dutch version). Measurements were performed before (T0) and after rehabilitation (T1).

RESULTS

At T1 (n = 56), significant improvements in fatigue were found, with effect sizes varying from -0.35 to -0.78. At T0, the different dimensions of fatigue were predicted by different physical and psychological variables. Explained variance of change in fatigue varied from 42%-58% and was associated with pre-existing fatigue and with change in physical functioning, role functioning due to physical problems, psychological functioning, and physical symptoms distress.

CONCLUSIONS

Within this selected group of patients we found that (a) rehabilitation is effective in reducing fatigue, (b) both physical and psychological parameters predicted different dimensions of fatigue at baseline, and (c) change in fatigue was mainly associated with change in physical parameters.

Cardiopulmonary exercise testing in the evaluation of functional capacity after treatment of lymphomas in adults

The present study assessed several parameters of cardiopulmonary function in patients, after treatment for aggressive non-Hodgkin's lymphoma and Hodgkin's disease, to determine the influence of these parameters on patient's performance status. One hundred and six patients (66 male and 40 female) aged 40 +/- 15 years were examined 1-2 years (median 14 months) after anticancer treatment. The patients were examined by means of rest and dynamic stress echocardiography and cardiopulmonary exercise. The rest and post-exercise ejection fraction (EF), Doppler parameters of left ventricular diastolic function and peak oxygen consumption (pVO2) were used as parameters of cardiopulmonary performance. The cumulative dose (CD) of doxorubicin (DOX) given was 240 +/- 70 (240 mg/m2). Thirty-seven percent of patients received mediastinal irradiation in accordance with the used treatment protocol. Sixty-four patients (60%) experienced fatigue after the treatment. Three patients (3%) demonstrated an decreased EF <50%, 34 (32%) demonstrated impaired diastolic function, 14 (13%) demonstrated decreased pVO2<20 ml/kg/min and 15 (14%) demonstrated a value of pVO2 below the reference value, respectively. None of the patients exhibited clinical signs of heart failure. Apart from three patients with a rest EF<50%, all the other patients responded to stress echocardiography with an increment of EF > 5%. The parameter pVO2 significantly correlated with stress EF (0.58, P < 0.0002). A significant relationship was found with all parameters of diastolic function: to index E/A of diastolic filling (r = 0.67, P < 0.0001), isovolumic relaxation time (r = -0.56, P < 0.0009) and to deceleration time (r = -0.54, P < 0.009), respectively. A negative relationship was found with age (r = -0.74, P < 0.0001), CD of DOX (r = -0.53, P < 0.003) and radiotherapy-involving mediastinum (r = - 0.44, P < 0.04), respectively. Using multivariate analysis, a significant relationship was found between pVO2 and parameters of diastolic filling, age, female sex and CD of DOX, respectively (r = 0.58, P < 0.0001). Diastolic dysfunction was correlated with age, CD of DOX and radiotherapy-involving mediastinum, respectively (r = 0.51, P < 0.01). The results show that diastolic dysfunction was the most affected parameter of cardiopulmonary function in cancer survivors. This parameter negatively influenced cardiopulmonary performance and was significantly correlated with the cumulative dose of doxorubicin given and radiotherapy on mediastinum. Despite a high number of patients experiencing fatigue, the study demonstrates that only a relatively small number of patients show a depressed pVO2 on a cardiopulmonary stress test and other cardiac abnormalities. The results of the tests support the introduction of regular aerobic exercise for cancer survivors to increase their cardiopulmonary performance and well-being. Hypothetically, aerobic training may also positively influence diastolic function. However, this assumption warrants a prospective follow-up.

Management of fatigue in cancer patients

Cancer-related fatigue (CRF) is either a symptom or a syndrome depending on criteria for diagnosis. CRF is present in 20% to 30% of long-term cancer survivors and 80% to 90% during treatment and at the end of life. Assessment requires determining the presence, severity, and interference with daily activities. Different descriptors for fatigue (eg, tiredness, lack of vigor) measure different patient experiences. Associated factors such as depression, pain, insomnia, dyspnea, anemia, and deconditioning worsen CRF and should be treated if present. Associated factors that contribute to the severity of fatigue differ depending on the stage of cancer. Pharmacologic interventions include recombinant erythropoietin, psychostimulants, corticosteroid, anti-inflammatory drugs other than steroids, and L-carnitine. Advances in the management of CRF will require an understanding of the underlying mechanism before target-specific therapies can be developed.

Cancer-Related Fatigue

PURPOSE

Cancer-related fatigue contributes to negative outcomes relative to psychosocial and symptom distress, functional status, and quality of life, and yet it is often underdiagnosed and management is frequently suboptimal.

DESIGN

Systematic database searches were conducted, and primary research reports and meta-analyses of quantitative studies of interventions for fatigue published in English were identified and critically examined.

RESULTS

This paper reviews the etiology and evaluation of cancer-related fatigue and analyzes current empirical evidence supporting pharmacologic and nonpharmacologic techniques for its management.

DISCUSSION

A variety of pharmacologic and nonpharmacologic techniques to manage cancer-related fatigue have been studied, although most of the evidence is from single-arm pilot studies with small sample sizes, rather than from adequately powered, multicenter, randomized controlled trials. Continued research in ethnically and racially diverse samples is needed to identify the interventions that are most effective in specific cancer subpopulations and to develop and test interventions for fatigue at each phase in the illness trajectory.

An open-label study of the effects of bupropion SR on fatigue, depression and quality of life of mixed-site cancer patients and their partners

This preliminary study investigated whether bupropion sustained release (SR) improved symptomatic fatigue, depression and quality of life in cancer patients and caregiver quality of life. The sample consisted of a prospective open case series of 21 cancer patients, with fatigue and with or without depression at moderate to severe levels, referred for psychiatric assessment from a tertiary care cancer centre. Both patient symptom ratings and caregiver ratings were measured before and after 4 weeks of treatment with the maximally tolerated dose of bupropion in the range of 100-300 mg per day. At trial completion, significant improvement was found for symptoms of fatigue and depression. Subjects were divided into two groups: depressed and non-depressed (based on a cut-off score of 17 on the Hamilton Depression Rating Scale). Both groups reported improvement for fatigue and depressive symptoms. Depressed subjects and their caregivers did not experience any change in quality of life, while the non-depressed subjects and their caregivers reported improvements. Results from this small group of patients suggest that bupropion may have potential as an effective pharmaceutical agent for treating cancer-related fatigue. A randomized, placebo-controlled trial with this medication is indicated.

Redefining Cancer-Related Asthenia-Fatigue Syndrome

BACKGROUND

Asthenia fatigue syndrome (AFS) is a common symptom perceived by patients with cancer and consists of reported pathologic fatigue, poor endurance, and impaired motor and cognitive function.

OBJECTIVE

The purpose of this study was to examine the relationship between a traditional measure of AFS, visual analogue scale (VAS) fatigue ratings, and a set of more objective functional and physiologic measures (Dietz oncology classification, C-reactive protein, serum albumin, hemoglobin, body mass index [BMI]), Motor Functional Independence Measure (FIM) Score, Cognitive FIM Score. We hypothesized a relationship could suggest the utility of alternative means of assessing and addressing AFS.

METHODS

We retrospectively examined the records of 131 patients admitted to our facility for inpatient rehabilitation because of disability-causing cancer or its treatment.

RESULTS

Of our sample, 94.7% (124 cases) indicated at least mild fatigue and 97.7% (128 cases) showed abnormal serum albumin, C-reactive protein, hemoglobin, or BMI. We used multiple regression analysis to examine the relationship between VAS fatigue ratings and the aforementioned set of functional and physiologic variables. The regression explained a significant proportion of the variability in VAS fatigue ratings (F = 2.25, df = 7,123, p = 0.03, R = 0.34, R(2) = 0.11). However, only Motor FIM Score accounted for a significant independent contribution to the variability in VAS fatigue ratings.

CONCLUSION

The data indicate physiologic and functional variables may provide an alternative, objective, and reliable operational definition of AFS. Specifically, using Motor FIM Score, as a surrogate for VAS fatigue ratings may be used to measure the efficacy of AFS treatment.

Cancer-related anemia and recombinant human erythropoietin--an updated overview

For cancer patients, anemia can be a debilitating problem that negatively influences their overall quality of life and worsens their prognosis. The condition is caused either by the cancer itself or by cytotoxic treatment. Anemia is the primary indication for transfusion of red blood cells, but the development of recombinant human erythropoietins (epoetins) provides an alternative to red blood cell transfusions. Treatment with epoetins has been shown to reduce transfusion rates and increase hemoglobin response. There is some evidence that epoetins improve quality of life. It remains unclear, however, whether erythropoietin affects tumor growth and survival, and this area requires further investigation. Data from clinical trials suggest that erythropoietin increases the risk of thromboembolic complications. In the management of anemic patients, physicians should follow closely the dosing recommendations in products' package inserts or the ASCO/American Society of Hematology guidelines. Treatment of patients beyond the correction of anemia, however, has to be regarded as experimental and is potentially harmful, so should only be conducted in clinical trials.

Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer

Breast cancer treatment can have a profound influence on a woman's physical, psychological, social, and spiritual well-being. Anxiety, depression, anger, fatigue, and fear of recurrence are common responses to a diagnosis of breast cancer and undergoing breast cancer treatment. Women develop their own coping strategies for the pain and other effects of treatment. However, it is unclear whether there is a relationship between adaptation to pain and psychological distress during breast cancer treatment. Findings from the present study reveal that breast cancer patients who have better pain coping strategies also have lower levels of anxiety, fatigue and depression. These results suggest that pain coping interventions may reduce fatigue and psychological distress among women with breast cancer.

Nursing education as an intervention to decrease fatigue perception in oncology patients

People with cancer have identified fatigue as a major obstacle to normal functioning and a good quality of life. It is a nearly universal symptom for patients undergoing primary antineoplasic therapy or treatment with biologic response modifiers (BRM) and is extremely common in patients with persistent or advanced disease. The aim of the study was to determine whether nursing education decreased the perception of fatigue in patients with colon or gastric cancer. We compared the fatigue level between two groups of patients who received the same treatment and had the same type of cancer (experimental group and control group). We provided an individualised and structured nursing intervention with education to the experimental group. We followed up the fatigue level in both groups with three different measures on the Functional Assessment of Cancer Therapy Fatigue (FACT-F) Scale. After the nursing intervention there was a decrease in the level of fatigue in the experimental group, whereas the group of patients that did not receive this intervention showed an increase in fatigue level along the treatment. The nursing intervention with the individualised education and counselling has provided patients with cancer with an effective tool to manage fatigue.

The effects of group exercise on fatigue and quality of life during cancer treatment

PURPOSE/OBJECTIVES

To determine the feasibility of participating in a structured group exercise program (SGEP) for adult patients receiving cancer treatment and to test the impact of an SGEP on reducing cancer-related fatigue (CRF) and improving quality of life (QOL).

DESIGN

One-group, prospective, pre- and post-test design.

SETTING

Two community outpatient infusion centers.

SAMPLE

Convenience sample of 12 adults with varying cancer diagnoses receiving cancer treatment.

METHODS

Nine of 12 subjects participated in SGEP twice weekly for six weeks. Exercises focused on strengthening proximal muscle groups and improving functional ability. All subjects completed the Fatigue Symptom Inventory and the Short Form-36 version 2 (SF-36v2) Health Survey at baseline and six weeks.

MAIN RESEARCH VARIABLES

Feasibility of the intervention, CRF, and QOL.

FINDINGS

No difference in reported fatigue was found. The SF-36v2 subscale score for bodily pain showed a significant decrease in this symptom. Subscale scores for physical role, vitality, and social function increased but did not yield statistical significance. Social interactions resulted in strong group cohesiveness. A postprogram questionnaire identified themes of support, learning from shared information, and the usefulness of having an exercise program that also serves as an informal support group.

CONCLUSIONS

SGEP is feasible, safe, and well tolerated by adult patients with cancer and may have positive effects on CRF and QOL.

IMPLICATIONS FOR NURSING

The benefits of exercise for patients with cancer receiving treatment are well documented. Using a multidisciplinary approach, oncology nurses, working with an exercise physiologist, can safely create an SGEP, combining the power of group interactions with the appeal of a wellness-promoting behavior, and provide an additional tool to assist in the management of physiologic and psychosocial effects of cancer treatment.

Translation and cultural adaptation of the Piper Fatigue Scale for use in Sweden

The aim of this study was to translate and culturally adapt the revised Piper Fatigue Scale to Swedish. For translation, guidelines for cross-cultural adaptation were used. Two teams independently translated the instrument and two other teams produced back-translations, after which a multidisciplinary committee decided on a Swedish version. In pre-test interviews, ten cancer patients were encouraged to think out loud while completing the Swedish version. Their verbal responses were analysed and used for a second revision. The initial translations varied in words, expressions and grammar, shown in a lack of equivalence to the original instrument after back-translation. In order to establish semantic equivalence, the committee changed some grammatical constructions, and some words were replaced for experiential and conceptual equivalence. When analysing the pre-test, obscurities due to the phrasing of some items were revealed and dealt with in the second revision. This study does not fulfil the process of validation for a translated instrument but offers a sound basis for further accumulation of evidence for validity, and facilitates the choice of an appropriate instrument for studying cancer-related fatigue in Sweden.

Patient-controlled methylphenidate for cancer fatigue: a double-blind, randomized, placebo-controlled trial

PURPOSE

To evaluate the effectiveness of patient-controlled methylphenidate as compared with placebo in cancer patients with fatigue, as measured by the Functional Assessment for Chronic Illness Therapy-Fatigue (FACIT-F).

PATIENTS AND METHODS

Patients with a fatigue score of at least 4 on a scale of 0 to 10 (0 = no fatigue, 10 = worst possible fatigue) and hemoglobin level of at least 10 g/dL were included. Patients were randomly assigned to receive 5 mg methylphenidate or placebo every 2 hours as needed (maximum of four capsules a day), for 7 days. Patients completed a daily diary including study drug record and fatigue intensity. A research nurse telephoned patients daily to assess toxicity and fatigue level. All patients were offered open-label methylphenidate for 4 weeks. FACIT-F and the Edmonton Symptom Assessment System (ESAS) were assessed at baseline, and days 8, 15, and 36. The FACIT-F fatigue subscore on day 8 was considered the primary end point.

RESULTS

Of 112 patients randomly assigned, 52 patients in the methylphenidate and 53 in the placebo group were assessable for analysis. Fatigue intensity improved significantly on day 8 in both the methylphenidate and placebo groups. However, there was no significant difference in fatigue improvement by FACIT-F (P = .31) or ESAS (P = .14) between groups. In open-label phase, fatigue intensity maintained low as compared with baseline. No significant toxicities were observed.

CONCLUSION

Both methylphenidate and placebo resulted in significant symptom improvement. Methylphenidate was not significantly superior to placebo after 1 week of treatment. Longer study duration is justified. The role of daily telephone calls from a research nurse should be explored as a palliative care intervention.

Assessment of quality of life outcomes in the treatment of advanced colorectal malignancies

QOL assessment in oncology has made great strides in recent years. There was a difficult time initially, during which QOL tools were "thrown in" to many clinical trials as an afterthought, without a pre-specified scientific question. As expected from such a scattershot approach, the results were underwhelming and disappointing. The disappointing results from this period led many practitioners to question the value added by QOL assessment in oncology clinical trials. This healthy skepticism has led to a renaissance period, in which situation-specific and disease-specific QOL assessments have been developed and have contributed substantial information to the cause of the disease, the effects of treatments, and the experiences of cancer patients. Today, there is a dawning recognition that asking the patient directly about their QOL using the same scientific rigor required of other clinical outcomes can provide valuable data for prognosis, treatment, symptom management, and supportive care. With time and further successful experiences like those cited in this article, QOL assessment may eventually become as routinely collected and integrated into oncology clinical practice as pain and blood pressure assessments are today.

Complementary and Alternative Medicine

Thirty years ago, the integration of complementary medicine into cancer care almost was dismissed as quackery. Today, a whole range of complementary and alternative medicine (CAM) techniques have been integrated into the management of cancer, which are often of benefit to patients, when conventional treatment is deemed to have failed or caused intolerable side effects. Health care workers need to inquire about the use of CAM in their patients routinely in a sensitive and nonjudgmental way, and may need to advise patients to stop certain therapies. Yet in advanced cancer, a sensible balance needs to be struck between fear about adverse effects and interactions and the importance of making the remaining weeks/days/months as comfortable and enjoyable as possible.

Will improvement in quality of life (QOL) impact fatigue in patients receiving radiation therapy for advanced cancer?

BACKGROUND

Fatigue has a significant impact on the quality of life (QOL) of cancer patients. Recent research has suggested that physical activity can reduce fatigue in patients receiving active cancer treatment. In this project, we examined the impact that participation in a randomized controlled trial of a multidisciplinary intervention designed to impact overall QOL had on fatigue for advanced cancer patients actively receiving treatment.

METHODS

Patients with newly diagnosed cancer were randomly assigned to an 8-session structured multidisciplinary intervention or a standard-care arm at the beginning of their course of radiotherapy (RT) designed to impact QOL. Ninety-minute sessions were led by either a psychiatrist or psychologist, collaborating with a nurse, physical therapist, chaplain, or social worker, depending on the session's theme. The fatigue assessments used in this trial included the Linear Analogue Self Assessment (LASA), the Profile of Mood States (POMS), Spielberger's State-Trait Anxiety Inventory (STAI), and the Symptom Distress Scale (SDS).

RESULTS

There were 115 participants enrolled and the 2 randomization arms were well balanced in terms of baseline characteristics and treatment received except for increased commuting distance for the patients in the intervention arm (P = 0.042). Most of scores indicated less fatigue (higher score) in the standard treatment group, but there were no statistically significant differences found at baseline and weeks 4, 8, and 27 except for SDS at week 8 (P = 0.018) with less patients reporting significant fatigue in the standard treatment arm. For the entire participant population, fatigue levels initially worsened with radiotherapy, stabilized at week 8, and returned to baseline by week 27. Disease site, chemotherapy use, and radiotherapy dose did not have a significant impact on fatigue levels.

CONCLUSIONS

Radiotherapy initially caused a worsening of fatigue but with time fatigue levels returned to baseline. Clinically, this structured multidisciplinary intervention had no impact on fatigue, and there was the suggestion the multiple sessions may have contributed to worse fatigue during active cancer treatment.

Cancer-related fatigue: A critical appraisal

This aim of this systematic review was to determine the prevalence and pattern of cancer-related fatigue (CRF), and identify factors associated with its development. Relevant literature was identified through an electronic database search using specified keywords. Included studies investigated CRF in adult cancer patients using a multidimensional fatigue measure. The methodological quality was assessed using six published standards. CRF is apparent both during and after anti-cancer therapy, however, the prevalence of CRF varied between studies. The variables associated with the development and persistence of CRF remain to be identified. Inconsistencies were evident in the pattern of CRF and its associated factors. This is likely to have arisen from the inherent difficulties in the measurement of a subjective sensation, further complicated by the myriad of outcome measures used. More methodologically sound research; assessing CRF from the commencement of therapy, considering all pertinent variables is needed.

Behavioural and hypothalamic molecular effects of the anti-cancer agent cisplatin in the rat: A model of chemotherapy-related malaise?

Many cancer patients receiving chemotherapy experience fatigue, disturbed circadian rhythms, anorexia and a variety of dyspeptic symptoms including nausea. There is no animal model for this 'chemotherapy-related malaise' so we investigated the behavioural and molecular effects of a potent chemotherapeutic agent, cisplatin (CP, 6 mg/kg, i.p.) in rats. Dark-phase horizontal locomotor activity declined post-CP reaching a nadir on day 3 (P < 0.001), before recovering after 7 days. CP's effect was most marked in the late part (05.00-07.00) of the dark-phase. Food intake reached a nadir (P > 0.001) at 2 days, coincident with an increase in gastric contents (cisplatin 9.04+/-0.8 vs. saline 2.32+/-0.3 g; P < 0.001). No changes occurred in hypothalamic mRNA expression for AGRP, NPY, HCRT, CRH, IL-1, IL-6, TNFalpha, ABCG1, SLC6A4, PPIA and HPRT mRNA but tryptophan hydroxylase (TPH) mRNA was decreased (47%, P < 0.05) at day 21 post-CP. This shows that despite marked behavioural effects of cisplatin, only a discrete change (TPH) was found in hypothalamic mRNA expression and that occurred when the animals' behaviour had recovered. Findings are discussed in relation to the neuropharmacology of chemotherapy-induced malaise.

Mass-dependent decline of skeletal muscle function in cancer cachexia

CD2F1 mice were inoculated with C26 adenocarcinoma cells, followed by assessment of ex vivo muscular function. Muscles from tumor-bearing mice had a significantly lower force output during a single maximal contraction and during repeated contractions than control muscles. The relative force output, however, did not differ when corrected for muscle mass. Thus, cachexia significantly reduces absolute skeletal muscle function, but muscle "quality" appears unaltered.

Random control clinical trial on the effects of aerobic exercise training on erythrocyte levels during radiation treatment for breast cancer

BACKGROUND

Erythrocyte changes from aerobic exercise training were examined during radiation treatment of breast cancer.

METHODS

Twenty sedentary females with breast carcinoma who were ages 35 to 65 years were randomized to aerobic exercise (AE) of walking for 20 to 45 minutes, 3 to 5 times per week, at 50% to 70% of measured maximum heart rates or to placebo stretching (PS) activities 3 to 5 days per week during 7 weeks of radiation treatment. Measures were obtained 1 week before and after the radiation regimen. Serum blood analyses, through complete blood counts, measured red blood cell counts (RBC), hematocrit (HCT), and hemoglobin (HB). Peak aerobic capacity (peak VO(2)) was measured by exercise testing with oxygen uptake analysis to assess training. A Wilcoxon Mann-Whitney U test examined changes between groups (P < or = .05 for significance).

RESULTS

AE peak VO(2) increased by 6.3% (P = .001) and PS decreased by 4.6% (P = .083). RBC increased in AE from 4.10 to 4.21 million cells/microL and declined in PS from 4.30 to 4.19 million cells/microL; the between-group differences were significant (P = .014). HCT increased in AE from 38.0% to 38.8% and declined in PS from 37.40% to 36.50%; the between-group differences were significant (P = .046). HB increased in AE from 12.3 to 12.4 g/dL and declined in PS from 12.25 to 11.77 g/dL; the between-group differences were significant (P = .009).

CONCLUSIONS

The results of the current study suggest that moderate intensity aerobic exercise appears to maintain erythrocyte levels during radiation treatment of breast cancer compared with the declines observed in nontraining individuals. These findings suggest a safe, economical method to improve fitness and maintain erythrocytes in women during radiation treatment of breast cancer.

Comprehensive Symptom Management in Patients with Advanced-Stage Non–Small-Cell Lung Cancer

Although we have made steady improvements in the survival rates of patients with advanced-stage lung cancer, the majority of patients still experience distress and suffering. Although the symptom burden is greatest in patients in the end stages of life, many patients living with lung cancer suffer from troubling symptoms and side effects of therapy. Even long-term survivors with early-stage non-small-cell lung cancer (NSCLC) often experience respiratory symptoms, such as dyspnea and cough. Because of the high prevalence of NSCLC and the frequency with which it presents in an incurable stage, symptom management is a large component of the care of these patients. Dyspnea, cough, fatigue, anorexia/cachexia, and pain are the most common symptoms in patients with advanced-stage NSCLC. Cancer-directed therapy can improve some of these symptoms but often incompletely and temporarily. Therefore, comprehensive care of patients with advanced-stage NSCLC must include therapies targeted at these difficult and distressing symptoms.

Clinical factors associated with fatigue in haematologic cancer patients receiving stem-cell transplantation

We have evaluated risk factors associated with fatigue in 220 cancer patients during hospitalization for stem-cell transplantation (SCT). Fatigue was assessed using a validated one-item energy scale and a comprehensive set of fatigue predictors, at hospital admission (baseline), day of SCT, and 7 days and 14 days after SCT. In cross-sectional multivariate analysis, depression was the variable most consistently and strongly associated with fatigue; other factors significantly associated with fatigue at some time during the study included older age, higher education, smoking, lower Karnofsky performance status, loss of appetite, nausea/vomiting, pain, higher regimen-related toxicity, low hemoglobin level, requirement for red blood-cell transfusions, and third year of the study period. In prospective multivariate analysis, baseline depression showed significance or a trend towards significance in its ability to predict subsequent measures of fatigue during hospitalization. Our findings may help to shed light on the mechanisms underlying fatigue and may also guide future interventions.

Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis

BACKGROUND

Approximately 9.8 million cancer survivors are alive in the United States today. Enthusiasm for prescribing physical activity for cancer survivors depends on evidence regarding whether physical activity during or after completion of treatment results in improved outcomes such as cardiorespiratory fitness, fatigue, symptoms, quality of life, mental health, or change in body size.

METHODS

A systematic qualitative and quantitative review of the English language scientific literature identified controlled trials of physical activity interventions in cancer survivors during and after treatment. Data from 32 studies were abstracted, weighted mean effect sizes (WMES) were calculated from the 22 high-quality studies, and a systematic level of evidence criteria was applied to evaluate 25 outcomes.

RESULTS

There was qualitative and quantitative evidence of a small to moderate effect of physical activity interventions on cardiorespiratory fitness (WMES = 0.51 and 0.65 during and after treatment respectively, P < 0.01), physiologic outcomes and symptoms during treatment (WMES = 0.28, P < 0.01 and 0.39, P < 0.01, respectively), and vigor posttreatment (WMES = 0.83, P = 0.04). Physical activity was well tolerated in cancer survivors during and after treatment, but the available literature does not allow conclusions to be drawn regarding adverse events from participation.

CONCLUSIONS

Physical activity improves cardiorespiratory fitness during and after cancer treatment, symptoms and physiologic effects during treatment, and vigor posttreatment. Additional physical activity intervention studies are needed to more firmly establish the range and magnitude of positive effects of physical activity among cancer survivors.

Randomized controlled trial of an educational intervention for managing fatigue in women receiving adjuvant chemotherapy for early-stage breast cancer

PURPOSE

To evaluate the efficacy of a psychoeducational intervention in improving cancer-related fatigue.

PATIENTS AND METHODS

This randomized controlled trial involved 109 women commencing adjuvant chemotherapy for stage I or II breast cancer in five chemotherapy treatment centers. Intervention group patients received an individualized fatigue education and support program delivered in the clinic and by phone over three 10- to 20-minute sessions 1 week apart. Instruments included a numeric rating scale assessing confidence with managing fatigue; 11-point numeric rating scales measuring fatigue at worst, average, and best; the Functional Assessment of Cancer Therapy-Fatigue and Piper Fatigue Scales; the Cancer Self-Efficacy Scale; the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; and the Hospital Anxiety and Depression Scale. For each outcome, separate analyses of covariance of change scores between baseline (T1) and the three follow-up time points (T2, T3, and T4) were conducted, controlling for the variable's corresponding baseline value.

RESULTS

Compared with the intervention group, mean difference scores between the baseline (T1) and immediate after the test (T2) assessments increased significantly more for the control group for worst and average fatigue, Functional Assessment of Cancer Therapy-Fatigue, and Piper fatigue severity and interference measures. These differences were not observed between baseline and T3 and T4 assessments. No significant differences were identified for any pre- or post-test change scores for confidence with managing fatigue, cancer self-efficacy, anxiety, depression, or quality of life.

CONCLUSION

Preparatory education and support has the potential to assist women to cope with cancer-related fatigue in the short term. However, further research is needed to identify ways to improve the potency and sustainability of psychoeducational interventions for managing cancer-related fatigue.

Use of a case definition approach to identify cancer-related fatigue in women undergoing adjuvant therapy for breast cancer

PURPOSE

Use a proposed case-definition approach to identify the prevalence of cancer-related fatigue (CRF), demographic, clinical and psychosocial predictors of subsequent CRF, and psychosocial factors associated with concurrent CRF.

PATIENTS AND METHODS

Women (n = 288) undergoing adjuvant therapy for early-stage breast cancer were recruited from two outpatient clinics. Women completed a baseline assessment before adjuvant therapy and a post-treatment assessment at the conclusion of an initial course of adjuvant chemotherapy or radiotherapy. At both assessments, women completed a clinical interview and measures of fatigue, distress, coping, and quality of life (QOL). The clinical interview consisted of modules from the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and a diagnostic interview to identify cases of CRF.

RESULTS

CRF prevalence at the baseline and post-treatment assessments was 10% and 26%, respectively. Multivariate analyses identified factors prospectively associated with greater risk for CRF at the post-treatment assessment, including receipt of adjuvant chemotherapy and a tendency to catastrophize in response to fatigue. Patients with and without CRF differed on a host of concurrent measures of fatigue, depression, functioning, and QOL with mean effect sizes in the range of 1.0 standard deviation.

CONCLUSION

CRF is a clinical syndrome experienced before and during adjuvant therapy for breast cancer. Results suggest CRF has a multifactorial etiology and support use of the proposed case definition approach to defining CRF. Future research is necessary to determine the scientific value of these criteria for understanding the etiology and management of fatigue in the oncology setting.

Cancer-related fatigue: An update

Fatigue, one of the most common symptoms experienced by cancer patients, is multidimensional and is associated with significant impairment in functioning and overall quality of life. Although the precise pathophysiology of cancer-related fatigue is not well understood, a number of metabolic, cytokine, neurophysiologic, and endocrine changes have been described in these patients. A better understanding of these abnormalities is likely to lead to novel therapeutic interventions. Clinically, all patients presenting with significant fatigue should be evaluated for treatable conditions that might contribute to this symptom. Exercise and treatment of anemia are the two most established interventions for cancer-related fatigue. Psychostimulants seem promising based on early studies. Several complementary medicine treatments that showed efficacy in preliminary studies merit further testing.