Assessment and management of cancer-related fatigue in adults

Patient-rated emotional and physical functioning among hematologic cancer patients during hospitalization for stem-cell transplantation

In this 3-year prospective inpatient study, 220 patients received stem-cell transplantation (SCT) for hematologic cancer at a single institution. The objective of the study is to provide data on patient-rated emotional (depression and anxiety) and physical (overall physical status, energy level, and systemic symptomatology) functioning during hospitalization for SCT and to compare whether these differ between autologous and allogeneic SCT. Patients were assessed at hospital admission (T1), day of SCT (T2), and 7 days (T3) and 14 days (T4) after SCT, yielding a total of 852 evaluations. For the overall sample, anxiety was highest at T1 and decreased afterwards; a marked worsening in physical health status variables corresponded with a sharp increase in depression from T1 to T3, and was followed by an improvement in physical health and a reduction of depression. Compared to allogeneic SCT, a better physical outcome for autologous SCT was demonstrated by the significant group effect for systemic symptomatology and by the significant group x time interaction for overall physical status and energy level; there were no significant differences in depression or anxiety between SCT groups. These findings have implications for treatment decision making, coping with the transplantation process, and improving prevention and treatment strategies.

Heavy to carry: a survey of parents' and healthcare professionals' perceptions of cancer-related fatigue in children and young people

Cancer-related fatigue is a prevalent, but often under-recognized, symptom with the potential to impact the lives of both the child and the family. There is little known about the biological and the behavioral dimensions of fatigue, and not about the patterns of this symptom. The aim of this study was to investigate cancer-related fatigue from the perspective of parents of children and young people with cancer and from the perspective of healthcare professionals (HCPs) and to examine its impact on quality of life. A cross-sectional, questionnaire-based survey was undertaken with parents of patients attending 4 of the 22 United Kingdom Childhood Cancer Study Group centers; HCPs from 20 of these centers were also surveyed. Response rates were 42% for parents and caregivers (95/224) and 35% for HCPs (235/679). Results showed that fatigue was prevalent. Fifty-six percent of HCPs thought "most" or "all" patients experienced moderate fatigue; 57% of parents said that the patient experienced fatigue at least once a week. Data demonstrate that fatigue was perceived to be a significant problem by parents and HCPs. Healthcare professionals indicated that the mean percentage of patients who experience fatigue, to whom they recommended a treatment, was 29%. Rest and relaxation were recommended by the majority (59%; 138). The overall impression is that both HCPs and parents acknowledge that children and young people are likely to experience fatigue. Recognition of the significance of this symptom is a crucial first step in improving future management and offering strategies that can help both child and family.

Evidence for Classically Conditioned Fatigue Responses in Patients Receiving Chemotherapy Treatment for Breast Cancer

Fatigue is the most common side effect of chemotherapy for cancer. Not yet explored is the possibility that patients may develop conditioned fatigue responses to clinic cues as a result of the repeated pairing of the clinic environment (conditioned stimulus) with infusions of chemotherapy (unconditioned stimulus) that cause fatigue (unconditioned response). As a first critical test of this possibility, breast cancer patients (N = 82) were studied across their first four cycles of chemotherapy. Consistent with conditioning: (1) fatigue levels in the clinic environment significantly increased with repeated pairings of the clinic environment and chemotherapy administration; (2) fatigue responses in the clinic environment prior to the fourth infusion (CR) were predicted by patients' previous experiences of post-infusion fatigue (UR) above and beyond effects of concurrent emotional distress. These results provide the first evidence in the literature that fatigue can be conditioned. Additional research is warranted to determine the clinical importance of this source of fatigue in chemotherapy patients.

Fatigue, psychological distress, coping resources, and functional status during radiotherapy for uterine cancer

PURPOSE/OBJECTIVES

To evaluate how patients diagnosed with uterine cancer experience fatigue, psychological distress, coping resources, and functional status before, during, and after treatment with radiation therapy and to study whether significant correlations exist among these variables.

DESIGN

Longitudinal, descriptive, and correlational.

SETTING

The Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.

SAMPLE

60 women diagnosed with uterine cancer who were receiving curative external radiation therapy. Typical participants were 64 years old, married, and on sick leave or retired from work.

METHODS

Data were collected through self-report instruments. Demographic and clinical data were extracted from the patients' records.

MAIN RESEARCH VARIABLES

Cancer-related fatigue, psychological distress, coping resources, and functional status.

FINDINGS

Patients' fatigue scores increased significantly during and after completion of radiotherapy. The participants reported normal levels of anxiety and depression, and their coping resources changed over time. After completing therapy, all dimensions of function had decreased; for social function, the decrease was significant. The correlation over time was significant among fatigue and physical function, role function, and cognitive function. The variation of the change in fatigue after therapy was completed was explained only by the level of fatigue experienced at baseline.

CONCLUSIONS

Fatigue is a symptom that increases in connection with radiotherapy. Functional status is influenced by the variation in fatigue levels. Fatigue level before treatment may be an important variable when trying to find a risk factor for the development of fatigue over the course of treatment.

IMPLICATIONS FOR NURSING

Nurses must inform patients receiving radiotherapy about the expected changes in fatigue and functional status. Pretreatment screening for fatigue is needed to identify patients at risk for developing fatigue.

Fatigue in gynaecological cancer patients: a pilot study

RATIONALE

Fatigue is a frequent complaint of women with cancer. However, the incidence of fatigue has not been well studied, in particular gynaecological cancer, which despite its prevalence has received minimal investigation.

GOALS OF WORK

The study aims were (1) to explore the symptoms experienced in a gynaecological cancer population, primarily fatigue and (2) to determine the acceptability of a fatigue questionnaire for use in a longitudinal survey.

PATIENTS AND METHODS

Over the course of 1 month, women with gynaecological cancer attending a Regional Cancer Centre completed a demographic and symptom questionnaire and the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF).

MAIN RESULTS

Of the 32 individuals approached, 30 agreed to participate (mean age, 61 years; the most common treatment received was surgery followed by chemotherapy n=11; mean time from commencement of treatment, including surgery = 3 months). All participants completed the MFSI-SF. Tiredness was the most commonly reported symptom, experienced by 90% of subjects and the most frequently stated worst symptom, reported by 23.3%. Furthermore, 23 of 27 subjects reported that tiredness interfered completely with their daily living. The MFSI-SF mean total fatigue score was 14.4 (SD 15.9), ranging from -15 to 50. The possible total fatigue score ranges from -24 to 96.

CONCLUSION

Despite the heterogeneous nature of the group, all participants completed the MFSI-SF. The study suggests that fatigue could be a problem for this population group. Thus, a longitudinal survey using the MFSI-SF to investigate the phenomenon further would appear feasible and justified.

A phenomenologic study of fatigue in adolescents receiving treatment for cancer

PURPOSE/OBJECTIVES

To generate a detailed description of how adolescents with cancer manage their daily lives and the way in which fatigue affects this.

DESIGN

Phenomenologic.

SETTING

A pediatric oncology unit at a regional cancer center in the United Kingdom.

SAMPLE

A convenience sample of adolescents (N = 8), aged 16-19 years and with hematologic or solid tumors, who currently were undergoing primary treatment.

METHODS

Semistructured interviews were conducted using 11 open-ended questions.

MAIN RESEARCH VARIABLES

Adolescents' perceptions of fatigue, well-being, and ability to maintain normal activities.

FINDINGS

Adolescents reported fatigue as overwhelming and embedded in a syndrome of symptoms and emotions associated with the illness itself and with treatment. Fatigue had a significant effect on physical, psychological, and social well-being, placing an extra burden on adolescents who were striving for normality.

CONCLUSIONS

Equipped with a rich description of fatigue, clinicians will be better prepared to initiate strategies congruent with their own work settings and particular patients.

IMPLICATIONS FOR NURSING

The findings should enable healthcare professionals to construct a more accurate and perceptive picture of the needs of particular individuals, highlighting those that may be amenable to intervention.

The experience of fatigue, other symptoms and global quality of life during radiotherapy for uterine cancer

This paper reports on how patients with uterine cancer, receiving radiotherapy, experience fatigue, other symptoms and global quality of life. The results showed that fatigue increased significantly during the therapy. Also the other symptoms; loss of appetite, nausea/vomiting and diarrhoea increased significantly and were significantly correlated to general fatigue. Global quality of life decreased significantly during treatment compared to baseline. The variation of the level in general fatigue after completed therapy was only explained by the level of general fatigue experienced at baseline. The result can lead to a better understanding of the severity of symptoms experienced by patients with uterine cancer treated with radiotherapy.

Review and critique of the quality of exercise recommendations for cancer patients and survivors

The benefit of exercise for cancer patients is starting to become recognized. The purposes of this paper were to review the literature to examine whether research findings are being converted into guidelines for patients and survivors and to examine the quality of evidence on which they were based. A computer search of major health databases was conducted for peer-reviewed literature and books on exercise and cancer, and an Internet search was conducted for cancer websites reporting any exercise guidelines/recommendations for cancer patients. Seven peer-reviewed articles, eight books and eight cancer websites were identified that suggested exercise guidelines for cancer patients and survivors. None of the published guidelines identified appeared to have been developed via a process that would allow them to be cited as evidence-based guidelines. Based on the studies to date, no direct cancer-specific evidence about the best type, frequency, duration or intensity of exercise is currently available in the peer-reviewed literature. It is currently not known what would be most beneficial for which cancers, at which stage of disease or treatment. Given the current interest in cancer and exercise, there is an urgent need for an evidence-based set of exercise guidelines to be developed.

Exercise manages fatigue during breast cancer treatment: A randomized controlled trial

Fatigue is the most prevalent and debilitating symptom experienced by breast cancer patients receiving adjuvant chemotherapy or radiation therapy and few evidence-based treatments are available to manage this distressing side-effect. The purpose of this multi-institutional randomized controlled trial was to determine the effects of exercise on fatigue levels during treatment for breast cancer. Sedentary women (N=119) with Stage 0-III breast cancer receiving outpatient adjuvant chemotherapy or radiation therapy were randomized to a home-based moderate-intensity walking exercise program or to usual care for the duration of their cancer treatment. Of participants randomized to exercise, 72% adhered to the exercise prescription; 61% of the usual care group adhered. The intention-to-treat analysis revealed no group differences in part because of a dilution of treatment effect as 39% of the usual care group exercised and 28% of the exercise group did not. When exercise participation was considered using the data analysis method of instrumental variables with principal stratification, a clinically important and statistically significant (p=0.03) effect of exercise on pretest-to-posttest change in fatigue levels was demonstrated. Adherence to a home-based moderate-intensity walking exercise program may effectively mitigate the high levels of fatigue prevalent during cancer treatment.

Impact of dysphagia on quality-of-life in nasopharyngeal carcinoma

BACKGROUND

Little is known about dysphagia or quality of life (QOL) in patients treated for nasopharyngeal carcinoma (NPC). The aim of this study was to determine the impact of dysphagia on QOL in patients treated for NPC as measured by two standard tools, the University of Washington Quality-of-Life Questionnaire(1) (UW-QOL) and the Swallow Quality-of-Life Questionnaire(3) (SWAL-QOL).

METHODS

This is a cross-sectional survey of 59 consecutive disease-free survivors of NPC attending the head and neck cancer clinic at the National University Hospital, Singapore. The UW-QOL and SWAL-QOL underwent minor modification and were translated into Mandarin. A linear regression analysis was performed to identify significant predictors of health-related QOL.

RESULTS

Fifty-one patients (86%) responded; of these, 43 had self-reported swallowing difficulties. On the UW-QOL, respondents indicated the three most important issues to be swallowing (59%), hearing (45%), and saliva/dry mouth (41%). Respondents with swallowing difficulty reported a lower UW-QOL composite score (p = .002) and a lower health-related QOL score (HR-QOL) than those without swallowing difficulty (p = .004). Self-reported swallowing difficulty predicted a lower HR-QOL score (p = .004). A longer time since treatment predicted a better score in HR-QOL (p = .024). A lower score in fatigue predicted a lower HR-QOL score (p = .001).

CONCLUSIONS

Swallowing difficulties negatively impact QOL. It is recommended that future QOL studies aimed specifically at swallowing function in NPC use a swallowing specific questionnaire (eg, SWAL-QOL) in addition to a head and neck-specific measure. Further research is needed to look at the adaptation and usefulness of swallowing-specific QOL surveys for use with people treated for NPC.

Comparison of proposed diagnostic criteria with FACT-F and VAS for cancer-related fatigue: proposal for use as a screening tool

The objective was to validate the use of the proposed International Statistical Classification of Diseases and Related Health Problems (10th revision) (ICD-10) criteria for fatigue (P-ICD10) through comparison with the Functional Assessment of Cancer Therapy Fatigue (FACT-F) subscale and three visual analogue scale (VAS) qualities in cancer patients thought to be fatigued. Fatigue was assessed in 834 cancer patients at three clinical centres in Belgium, using P-ICD10, FACT-F, and VAS to assess: level of energy (VAS1), quality of life (VAS2), and ability to perform daily activities (VAS3). Of the 834 interviewed cancer patients, 54% were classified as fatigued by the P-ICD10 criteria. Internal consistency of P-ICD10 was very good (alpha coefficient 0.82). The principal component analysis corroborated good internal consistency with all variables included in the first component; a second component was used to identify psychological fatigue (concentration and short-term memory disabilities). An abridged set of screening tools based on the first three general symptoms of the P-ICD10 is proposed with 100% specificity and 86% specificity, respectively. There was a marked decrease in FACT-F and VAS1 scores in patients diagnosed as fatigued by the P-ICD10 (mean+/-SD, FACT-F 20+/-9 vs 39+/-8, VAS1 34+/-21 vs 61+/-21). A logistic regression model between P-ICD10 criteria diagnosis and FACT-F (VAS1) identified a score of 34 (61) on the FACT-F scale as a proposed cut-off point for the diagnosis of fatigue. The ICD-10 criteria can be recommended as a diagnostic tool, whereas the FACT-F scale and the level of energy 100-mm VAS assess the intensity of fatigue, and are more suitable for follow-up of cancer-related fatigue.

Fatigue and psychological distress--exploring the relationship in women treated for breast cancer

Disabling fatigue and psychological symptoms of depression or anxiety are commonly reported by women with treated breast cancer. However, most instruments designed to assess fatigue do not assess concurrent psychological symptoms. This study compared the characteristics of two conceptually different, self-report instruments assessing fatigue to determine the extent to which common psychological symptoms co-exist with the symptom of fatigue in women treated for breast cancer. Women attending an oncology day-care facility for adjuvant treatment of breast cancer or ongoing surveillance post-treatment, completed two self-report questionnaires. The Somatic and Psychological Health REport-34 items (SPHERE) and the Functional Assessment of Cancer Therapy-Fatigue (FACT-F subscale-13 items). One hundred and nine women (mean age 52.8 years) completed both questionnaires and total scores on both fatigue assessment scales, FACT-F and SOMA-6, were highly correlated (r = 0.72, P < 0.001). Using the SPHERE case criteria, prolonged fatigue (37% [40/109]) and psychological distress 31% (34/109) were common in women treated for breast cancer. However, those who reported fatigue were much more likely to also report psychological symptoms (22/40 vs. 12/69, X(2) = 16.7: degrees of freedom (df)=1; P < 0.001) and the levels of fatigue on the FACT-F were not significantly different between those who reported "fatigue only" and those who reported "psychological distress only" (18.8 vs. 17.8, P = 0.79). Thus the recent emphasis on recording fatigue during and following treatments for cancer needs to be accompanied by concurrent measurement of psychological symptoms.

Levels of fatigue compared to levels of cytokines and hemoglobin during pelvic radiotherapy: a pilot study

Cancer-related fatigue (CRF) is a prevalent and distressing symptom experienced by patients during cancer therapy. One proposed mechanism for the development of fatigue is the increased secretion of proinflammatory cytokines and/or the development of anemia. The major purpose of this pilot study was to investigate the levels of fatigue and cytokines during radiation therapy and determine whether there was a correlation between the two. A secondary purpose was to explore the relationships among hemoglobin values, cytokines, and fatigue. Participants included 15 women diagnosed with uterine cancer, who received curative external radiation therapy. Fatigue was assessed by a self-report instrument (Multidimensional Fatigue Inventory [MFI-20]) and hemoglobin and cytokines (Il-1, Il-6, and TNF-alpha) were measured before, during, and after radiotherapy. The degree of fatigue increased during radiotherapy without a significant change in IL-1, IL-6, or TNF-alpha levels. There was no significant correlation between changes in general fatigue and the changes in IL-1 and TNF-alpha. There was a significant negative correlation between the change in IL-6 and general fatigue. The hemoglobin levels did decrease significantly during radiotherapy, but there was no significant correlation between general fatigue and hemoglobin after 3 weeks of therapy or after the completion of therapy. In conclusion, pelvic radiotherapy in women with uterine cancer is associated with increased fatigue. There were no significant relationships between anemia or cytokine levels and fatigue. The pathogenesis of fatigue during radiation therapy remains to be elucidated.

Current management of fatigue and anemia in patients with cancer

OBJECTIVES

To describe the management of fatigue and anemia in patients with cancer.

DATA SOURCES

Published literature and clinical experience.

CONCLUSION

Anemia is a common cause of cancer-related fatigue. Epoetin alfa increases hemoglobin, decreases transfusion requirements, and improves energy and quality of life in patients with cancer-related anemia. Nonpharmacologic treatment options include exercise, nutrition optimization, and psychosocial interventions. Effective management of fatigue improves overall cancer treatment, quality of life, and functional status.

IMPLICATIONS FOR NURSING PRACTICE

Fatigue and anemia are commonly undertreated complications of cancer and its treatment. Oncology nurses play a key role in identifying and managing these conditions.