Testing a biobehavioral model of fatigue before adjuvant therapy in women with breast cancer

Type I interferons, inflammation, and fatigue in a longitudinal RNA study of women with breast cancer

BACKGROUND

Fatigue is a common side effect of cancer and its treatment and is thought to be driven in part by activation of the proinflammatory cytokine network. However, the cellular and molecular underpinnings of cancer-related fatigue (CRF) have not been determined, nor have immune pathways beyond inflammation been carefully investigated. The goal of this study was to examine the association between CRF and activation of canonical proinflammatory gene regulation pathways and Type I interferon (IFN) signaling pathways in breast cancer patients during and after treatment.

METHODS

Women diagnosed with early-stage breast cancer (n = 181) completed assessments before and after treatment with radiation and/or chemotherapy and at 6, 12, and 18-month post-treatment follow-ups. Assessments included self-reported fatigue (Multidimensional Fatigue Symptom Inventory - Short Form) and expression of pre-specified sets of Type I IFN and pro-inflammatory immune response genes determined from mRNA sequencing of PBMCs. Mixed effect linear models examined changes in fatigue and immune gene expression over time and tested the hypothesis that fatigue would be associated with increased expression of Type I IFN and inflammatory response genes.

RESULTS

There were significant changes in fatigue and immune gene expression across the assessment period; all measures increased from pre- to post-treatment but showed diverging patterns over the follow-up, with declines in fatigue and persistent elevations in Type I IFN and proinflammatory gene expression. In mixed effect linear models, expression of Type I IFN response genes was elevated in association with fatigue across the assessment period, from pre-treatment to 18-month follow-up. In contrast, pro-inflammatory gene expression was associated with fatigue only at 6, 12, and 18-month follow-ups. Analyses controlling for changes in leukocyte subsets continued to show a significant association between fatigue and Type I IFN gene expression but reduced the time-dependent association with pro-inflammatory gene expression to non-significant.

CONCLUSIONS

Results revealed unexpected complexity in the immune underpinnings of CRF and identify a novel role for IFN signaling as a robust contributor to this symptom before, during, and after treatment. Pro-inflammatory gene expression emerged as a predictor of fatigue later in the cancer trajectory, and that effect was primarily accounted for by a concurrent increase in monocyte prevalence.

Cancer-Related Fatigue and Its Influencing Factors Among Colorectal Cancer Patients: A Generalized Linear Modeling Approach

Purpose

This study aimed to improve cancer-related fatigue (CRF) and health outcomes of colorectal cancer patients by understanding the status quo of CRF, exploring the relations of coping, anxiety symptoms, depressive symptoms, body image perception and CRF, and also identifying the factors affecting CRF based on a generalized linear modeling approach.

Patients and Methods

An exploratory cross-sectional study was conducted on 370 colorectal cancer patients at two hospitals in Anhui Province, China, from July 2020 to February 2021. The data were collected by using general information questionnaire, cancer fatigue scale, simplified coping style questionnaire, generalized anxiety disorder-7 scale, patient health questionnaire-9, and body image scale. Descriptive statistics, t-tests, one-way analysis of variance, Pearson correlation analyses, and generalized linear model analyses were applied to analyze the data.

Results

The average CRF score of the patients was 21.612 (SD=6.160), with a prevalence rate of 69.4% for clinically relevant fatigue. The generalized linear model revealed that: In step 1, gender (female) (B=1.799, Waldχ2=7.506, p=0.006), per capita monthly income (1001-3000 RMB) (B=-1.673, Waldχ2=5.536, p=0.019) and treatment modalities (chemotherapy+others) (B=2.425, Waldχ2=8.211, p=0.004) were related to CRF. In step 2, depressive symptoms (B=1.223, Waldχ2=129.019, p<0.001) and negative coping strategies (B=0.215, Waldχ2=11.347, p=0.001) exhibited significant positive correlations with CRF, positive coping strategies (B=-0.319, Waldχ2=59.175, p<0.001) showed significant negative correlations with CRF; While anxiety symptoms (B=0.162, Waldχ2=1.840, p=0.175) and body image perception (B=0.013, Waldχ2=0.048, p=0.826) had no correlations with CRF.

Conclusion

The prevalence of CRF was relatively high among colorectal cancer patients. Coping and depressive symptoms were the modifiable influencing factors of CRF. Tailored interventions dedicated to promoting positive coping behavior, diminishing negative coping behavior and reducing depressive symptoms may improve the CRF of patients with colorectal cancer. Healthcare providers working with these patients should receive corresponding education and training in these complementary treatments. Additionally, when developing non-pharmacological interventions, appropriate consideration of the patients' gender, income condition and the type of anticancer treatment is also necessary.

Revealing symptom profiles: A pre-post analysis of docetaxel therapy in individuals with breast cancer

PURPOSE

This study aimed to explore the symptom profiles and predominant symptoms in newly diagnosed breast cancer women before and after receiving docetaxel chemotherapy.

METHODS

A pre-post study recruited adult women with stage I-III breast cancer undergoing docetaxel chemotherapy using convenience sampling. The 13-item symptom severity subscale of the M. D. Anderson Symptom Inventory-Taiwan Form was used to measure symptoms. The study employed latent profile analysis to identify subgroups based on symptom severity before and after docetaxel chemotherapy. Descriptive statistics, including mean and frequency, were used to compare and contrast the most prevalent and severe symptoms within each subgroup to confirm the predominant symptoms.

RESULTS

The study identified four and two symptom profiles before and after docetaxel treatment, respectively. Disturbed sleep was identified as a prevalent symptom for all participants, regardless of their chemotherapy status. The predominant symptoms before treatment were disturbed sleep, dry mouth, difficulty remembering, and fatigue, while disturbed sleep and numbness were the predominant symptoms after treatment.

CONCLUSION

The findings of this study are significant, as they contribute to the current understanding of the symptom experience of breast cancer individuals undergoing docetaxel chemotherapy. Healthcare professionals should prioritize assessing and managing these symptoms, including identifying contributing factors to poor sleep. Addressing symptom profiles related to sleep can improve the quality of life of breast cancer individuals undergoing docetaxel chemotherapy.

Higher Levels of Multiple Types of Stress Are Associated With Worse State Anxiety and Morning Fatigue Profiles in Patients Receiving Chemotherapy

BACKGROUND

Anxiety and fatigue are common problems in patients receiving chemotherapy. Unrelieved stress is a potential cause for the co-occurrence of these symptoms.

OBJECTIVES

The aims of this study were to identify subgroups of patients with distinct state anxiety and morning fatigue profiles and evaluate for differences among these subgroups in demographic and clinical characteristics, as well as measures of global, cancer-specific, and cumulative life stress and resilience and coping.

METHODS

Patients (n = 1335) completed measures of state anxiety and morning fatigue 6 times over 2 cycles of chemotherapy. All of the other measures were completed prior to the second or third cycle of chemotherapy. Latent profile analysis was used to identify the state anxiety and morning fatigue profiles.

RESULTS

Three distinct joint profiles were identified: Low Anxiety and Low Morning Fatigue (59%), Moderate Anxiety and Moderate Morning Fatigue (33.4%), and High Anxiety and High Morning Fatigue (7.6%). Patients in the 2 highest classes were younger, were less likely to be married/partnered, and had a higher comorbidity burden. All of the stress scores demonstrated a dose-response effect (ie, as anxiety and morning fatigue profiles worsened, stress increased). Patients in the 2 highest classes reported higher rates of emotional abuse, physical neglect, physical abuse, and sexual harassment.

CONCLUSIONS

More than 40% of these patients experienced moderate to high levels of both anxiety and morning fatigue. Higher levels of all 3 types of stress were associated with the 2 highest profiles.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive evaluations of patients' levels of stress and recommend referrals to psychosocial services.

Radiotherapy-induced fatigue in Palestinian breast cancer survivors

Background

No study has investigated the cancer-related fatigue (CRF) among Palestinian breast cancer survivors. Our purpose is to assess, compare, and correlate CRF in breast cancer survivors undergoing radiotherapy (RT) with study variables.

Methods

CRF in breast cancer survivors was assessed using Functional Assessment of Chronic Illness Therapy - Fatigue Scale (FACIT-F) (version 4). The sample consisted of 148 breast cancer survivors undergoing RT. Data was collected between 1 May 2021 and 1 September 2021. The means and standard deviations of the questionnaire using one-way ANOVA, and Pearson correlation coefficient were reported.

Results

Respondents ages ranged from 20 to >65 years old and was divided into four groups: (20-35, 36-50, 51-65, and >65 years, respectively). The total fatigue mean was 2.88 and the SD was 0.84, indicating an intermediate fatigue level among breast cancer survivors. Study survivors with higher education were more likely to be fatigued (F =7.68, P-value =0.001). Divorced survivors were more prone to fatigue compared to married survivors (F =5.83, P-value= 0.001). Finally, survivors who do not have children were more vulnerable to exhaustion compared to those with children (F =7.35, P-value =0.001). Also, younger survivors were more prone to fatigue, compared to older survivors (F =5.29, P-value = 0.002). Results also showed a positive relationship between each of the variables; the number of children (R =0.221, P-value =0.007), age (R =0.311, P-value =0.000), and duration of treatment (R =0.290, P-value =0.000), which means that the greater the number of children, the younger the age, or the longer the duration of treatment, the more fatigue is reported in breast cancer survivors.

Conclusions

Fatigue is frequently observed in breast cancer survivors undergoing RT. It can limit RT treatment continuity. Therefore, early detection of fatigue can help survivors adhere to RT treatment and achieve better clinical results.

Adverse childhood events and mental health problems in cancer survivors: a systematic review

PURPOSE

The purpose of this study was to systematically review the literature on the association between adverse childhood events (ACEs) and mental health problems in cancer survivors.

METHODS

This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases (PubMed, PsychINFO, Web of Science, and Cochrane) were searched on 27-08-2023.

RESULTS

Of the 1413 references yielded by the literature search, 25 papers met inclusion criteria and were reviewed. Most studies were performed in the USA, most included breast cancer survivors, and the number of included participants ranged between 20 and 1343. ACEs were relatively prevalent, with self-report rates ranging between 40 and 95%. Having been exposed to ACEs was a risk factor for heightened levels of emotional distress, anxiety, depressive symptoms, and fatigue during cancer treatment. Results varied depending on the variables included, and per subscale, but were consistent across different cultures and heterogenous patient groups.

CONCLUSION

The association between ACE and mental health outcomes was significant in most studies. In order to improve treatment for this vulnerable population, it may be necessary to screen for ACEs before cancer treatment and adjust treatment, for example, by means of trauma-informed care (TIC), which recognizes and responds to the impact of trauma on individuals seeking healthcare.

Genetic variability of oxidative stress and DNA repair genes associated with pre-treatment cancer-related fatigue in women with breast cancer

PURPOSE

Investigate potential relationships between pre-treatment cancer-related fatigue (CRF) in women with early-stage breast cancer and variation in genes involved with oxidative stress and DNA repair.

METHODS

Investigated 39 functional and tagging single nucleotide polymorphisms (SNPs) in genes involved in oxidative stress (CAT, GPX1, SEPP1, SOD1, and SOD2) and DNA repair (ERCC2, ERCC3, ERCC5, and PARP1) in a sample (N = 219) that included n = 138 postmenopausal women diagnosed with early-stage breast cancer before initiation of therapy and n = 81 age- and education-matched healthy controls. Using the Profile of Mood States Fatigue/Inertia Subscale, fatigue occurrence and severity were evaluated in both groups. Regression analysis was used to independently identify significant SNPs for three outcomes: 1) any fatigue versus no fatigue, 2) clinically meaningful versus non-clinically meaningful fatigue, and 3) fatigue severity. Using a weighted multi-SNP method, genetic risk scores (GRS) were calculated for each participant, and GRS models were constructed for each outcome. Models were adjusted for age, pain, and symptoms of depression and anxiety.

RESULTS

SEPP1rs3877899, ERCC2rs238406, ERCC2rs238416, ERCC2rs3916874, and ERCC3rs2134794 were associated with fatigue occurrence and had a significant GRS model (OR = 1.317, 95%CI [1.067, 1.675], P ≤ 0.05). One SNP, SOD2rs5746136, was significant for clinically meaningful fatigue; therefore, a GRS model could not be constructed. ERCC3rs4150407, ERCC3rs4150477, and ERCC3rs2134794 were associated with fatigue severity with a significant GRS model (b = 1.010, 95%CI [1.647, 4.577], R² = 6.9%, P ≤ 0.01).

CONCLUSIONS

These results may contribute to identifying patients who are at risk of developing CRF. Oxidative stress and DNA repair biological pathways may be involved with CRF.

Oncolytic Newcastle Disease Virus Co-Delivered with Modified PLGA Nanoparticles Encapsulating Temozolomide against Glioblastoma Cells: Developing an Effective Treatment Strategy

Glioblastoma multiforme (GBM) is considered to be one of the most serious version of primary malignant tumors. Temozolomide (TMZ), an anti-cancer drug, is the most common chemotherapeutic agent used for patients suffering from GBM. However, due to its inherent instability, short biological half-life, and dose-limiting characteristics, alternatives to TMZ have been sought. In this study, the TMZ-loaded PLGA nanoparticles were prepared by employing the emulsion solvent evaporation technique. The prepared TMZ-PLGA-NPs were characterized using FT-IR, zeta potential analyses, XRD pattern, particle size estimation, TEM, and FE-SEM observations. The virotherapy, being safe, selective, and effective in combating cancer, was employed, and TMZ-PLGA-NPs and oncolytic Newcastle Disease Virus (NDV) were co-administered for the purpose. An AMHA1-attenuated strain of NDV was propagated in chicken embryos, and the virus was titrated in Vero-slammed cells to determine the infective dose. The in vitro cytotoxic effects of the TMZ, NDV, and the TMZ-PLGA-NPs against the human glioblastoma cancer cell line, AMGM5, and the normal cell line of rat embryo fibroblasts (REFs) were evaluated. The synergistic effects of the nano-formulation and viral strain combined therapy was observed on the cell lines in MTT viability assays, together with the Chou–Talalay tests. The outcomes of the in vitro investigation revealed that the drug combinations of NDV and TMZ, as well as NDV and TMZ-PLGA-NPs exerted the synergistic enhancements of the antitumor activity on the AMGM5 cell lines. The effectiveness of both the mono, and combined treatments on the capability of AMGM5 cells to form colonies were also examined with crystal violet dyeing tests. The morphological features, and apoptotic reactions of the treated cells were investigated by utilizing the phase-contrast inverted microscopic examinations, and acridine orange/propidium iodide double-staining tests. Based on the current findings, the potential for the use of TMZ and NDV as part of a combination treatment of GBM is significant, and may work for patients suffering from GBM.

Acute health-related quality of life outcomes and systemic inflammatory markers following contemporary breast cancer surgery

Contemporary breast cancer surgical procedures vary greatly by the amount of tissue removed, anesthesia time, and reconstruction. Despite historical literature comparing the health-related quality of life (HRQOL) after lumpectomy and mastectomy, HRQOL data are limited regarding contemporary surgical procedures. Further, biological processes (e.g., inflammation) associated with HRQOL outcomes have not been described. We conducted two studies to examine differences in post-operative physical and mental functioning, pain, fatigue, and systemic inflammatory markers including interleukin (IL)-6, tumor necrosis factor (TNF)-α, and C-reactive protein (CRP) in women with early-stage breast cancer. Study 1 assessed women before and after surgery (n = 27) and Study 2 used a large cross-sectional sample (n = 240) to confirm findings from Study 1 and included a no-surgery comparison group. In Study 1, women who received mastectomy had lower physical functioning than lumpectomy (ps < 0.05), and those who received bilateral mastectomy had worse pain (p < 0.01) and fatigue (p = 0.029) than lumpectomy. Results were replicated in Study 2: mastectomy groups exhibited poorer physical functioning (ps < 0.01) and greater pain (ps < 0.001) than lumpectomy, and bilateral mastectomy was associated with worse fatigue (p < 0.05). Women who received bilateral mastectomy had higher levels of CRP than lumpectomy (p < 0.01) and higher TNF-α than the no-surgery group (p < 0.05). All surgery groups exhibited higher IL-6 than no-surgery (ps < 0.05). More extensive surgery is associated with poorer postoperative HRQOL. As compared to lumpectomy and no-surgery, mastectomy is associated with higher concentrations of systemic inflammatory markers.

Younger women are more susceptible to inflammation: A longitudinal examination of the role of aging in inflammation and depressive symptoms

BACKGROUND

The degree to which effects of inflammation on mood and behavior vary across the lifespan remains relatively unexplored despite well-established, age-related alterations in both the immune and central nervous systems. Further, the implications of this developmental process within different symptom domains warrants careful consideration.

METHODS

Women diagnosed with breast cancer (n = 188; ages 27-89) provided blood samples and reported depressive symptoms prior to adjuvant treatment, at the end of adjuvant treatment, and 6-, 12-, and 18-months after completing adjuvant treatment via the CES-D. Blood was assayed for C-reactive Protein (CRP) and interleukin (IL)-6. We used mixed linear effect models to estimate within- and between-person effects of CRP or IL-6 on 4 domains of depressive symptoms: depressed affect, low positive affect, somatic complaints, and interpersonal problems.

RESULTS

High average inflammation was associated with elevated somatic complaints (CRP p = .009, IL-6: p = .05), interpersonal problems (CRP p = .002, IL-6 p < .001), and positive affect (IL-6 p = .03), but only among the youngest women in the sample (age 50 or younger). Younger women also reported more depressed affect at assessments when inflammation was higher (CRP p = .045, IL-6 p = .09).

CONCLUSIONS

The association between inflammation and specific depressive symptoms is dynamic and varies across the lifespan, which may help clarify apparent inconsistencies in the extant literature as well as inform more precise interventions targeting this pathway.

Acute and chronic effects of adjuvant therapy on inflammatory markers in breast cancer patients

Background

Inflammation contributes to poor behavioral, functional, and clinical outcomes in cancer survivors. We examined whether standard cancer treatments—radiation and chemotherapy—led to acute and persistent changes in circulating markers of inflammation in breast cancer patients.

Methods

A total of 192 women diagnosed with early stage breast cancer provided blood samples before and after completion of radiation and/or chemotherapy and at 6-, 12-, and 18-month posttreatment follow-ups. Samples were assayed for circulating inflammatory markers, including tumor necrosis factor-α (TNF-α) and interleukin (IL)–6, downstream markers of their activity (soluble TNF receptor type II [sTNF-RII], C reactive protein), and other inflammatory mediators (IL-8, interferon-γ [IFN-γ]). Analyses evaluated within-group changes in inflammatory markers in 4 treatment groups: no radiation or chemotherapy (n = 39), radiation only (n = 77), chemotherapy only (n = 18), and chemotherapy with radiation (n = 58).

Results

Patients treated with chemotherapy showed statistically significant increases in circulating concentrations of TNF-α, sTNF-RII, IL-6, and IFN-γ from pre- to posttreatment, with parameter estimates in standard deviation units ranging from 0.55 to 1.20. Those who received chemotherapy with radiation also showed statistically significant increases in IL-8 over this period. Statistically significant increases in TNF-α, sTNF-RII, IL-6, IFN-γ, and IL-8 persisted at 6, 12, and 18 months posttreatment among patients treated with chemotherapy and radiation (all P < .05). Patients treated with radiation only showed a statistically significant increase in IL-8 at 18 months posttreatment; no increases in any markers were observed in patients treated with surgery only.

Conclusions

Chemotherapy is associated with acute increases in systemic inflammation that persist for months after treatment completion in patients who also receive radiation therapy. These increases may contribute to common behavioral symptoms and other comorbidities in cancer survivors.

Long-Term Longitudinal Patterns of Patient-Reported Fatigue After Breast Cancer: A Group-Based Trajectory Analysis

PURPOSE

Fatigue is recognized as one of the most burdensome and long-lasting adverse effects of cancer and cancer treatment. We aimed to characterize long-term fatigue trajectories among breast cancer survivors.

METHODS

We performed a detailed longitudinal analysis of fatigue using a large ongoing national prospective clinical study (CANcer TOxicity, ClinicalTrials.gov identifier: NCT01993498) of patients with stage I-III breast cancer treated from 2012 to 2015. Fatigue was assessed at diagnosis and year 1, 2, and 4 postdiagnosis. Baseline clinical, sociodemographic, behavioral, tumor-related, and treatment-related characteristics were available. Trajectories of fatigue and risk factors of trajectory-group membership were identified by iterative estimates of group-based trajectory models.

RESULTS

Three trajectory groups were identified for severe global fatigue (n = 4,173). Twenty-one percent of patients were in the high-risk group, having risk estimates of severe global fatigue of 94.8% (95% CI, 86.6 to 100.0) at diagnosis and 64.6% (95% CI, 59.2 to 70.1) at year 4; 19% of patients clustered in the deteriorating group with risk estimates of severe global fatigue of 13.8% (95% CI, 6.7 to 20.9) at diagnosis and 64.5% (95% CI, 57.3 to 71.8) at year 4; 60% were in the low-risk group with risk estimates of 3.6% (95% CI, 2.5 to 4.7) at diagnosis and 9.6% (95% CI, 7.5 to 11.7) at year 4. The distinct dimensions of fatigue clustered in different trajectory groups than those identified by severe global fatigue, being differentially affected by sociodemographic, clinical, and treatment-related factors.

CONCLUSION

Our findings highlight the multidimensional nature of cancer-related fatigue and the complexity of its risk factors. This study helps to identify patients with increased risk of severe fatigue and to inform personalized interventions to ameliorate this problem.

Cancer-related accelerated ageing and biobehavioural modifiers: a framework for research and clinical care

A growing body of evidence indicates that patients with cancer who receive cytotoxic treatments (such as chemotherapy or radiotherapy) have an increased risk of accelerated physical and cognitive ageing. Furthermore, accelerated biological ageing is a suspected driving force behind many of these observed effects. In this Review, we describe the mechanisms of biological ageing and how they apply to patients with cancer. We highlight the important role of specific behavioural factors, namely stress, sleep and lifestyle-related factors such as physical activity, weight management, diet and substance use, in the accelerated ageing of patients with cancer and cancer survivors. We also present a framework of how modifiable behaviours could operate to either increase the risk of accelerated ageing, provide protection, or promote resilience at both the biological level and in terms of patient-reported outcomes.

Development and Validation of a Predictive Model of Severe Fatigue After Breast Cancer Diagnosis: Toward a Personalized Framework in Survivorship Care

PURPOSE

Fatigue is common and troublesome among breast cancer survivors; however, limited tools exist to predict its risk.

PATIENTS AND METHODS

Participants with stage I-III breast cancer were prospectively included from CANTO (ClinicalTrials.gov identifier: NCT01993498), collecting longitudinal data at diagnosis (before the initiation of any cancer treatment) and 1 (T1), 2 (T2), and 4 (T3) years after diagnosis. The main outcome was severe global fatigue at T2 (score ≥ 40/100, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-C30). Analyses at T3 were exploratory. Secondary outcomes included physical, emotional, and cognitive fatigue (EORTC Quality of Life Questionnaire-FA12). Multivariable logistic regression models retained associations with severe fatigue by bootstrapped Augmented Backward Elimination. Validation methods included 10-fold internal cross-validation, overoptimism-corrected area under the receiver operating characteristic curves, and external validation.

RESULTS

Among 5,640, 5,000, and 3,400 patients at T1, T2, and T3, respectively, the prevalence of post-treatment severe global fatigue was 35.6%, 34.0%, and 31.5% in the development cohort. Retained risk factors for severe global fatigue at T2 were severe pretreatment fatigue (adjusted odds ratio v no 3.191 [95% CI, 2.704 to 3.767]); younger age (for 1-year decrement 1.015 [1.009 to 1.022]), higher body mass index (for unit increment 1.025 [1.012 to 1.038]), current smoking behavior (v never 1.552 [1.291 to 1.866]), worse anxiety (v noncase 1.265 [1.073 to 1.492]), insomnia (for unit increment 1.005 [1.003 to 1.007]), and pain at diagnosis (for unit increment 1.014 [1.010 to 1.017]), with an area under the receiver operating characteristic curve of 0.73 (95% CI, 0.72 to 0.75). Receipt of hormonal therapy was a risk factor for severe fatigue at T3 (v no 1.448 [1.165 to 1.799]). Dimension-specific risk factors included body mass index for physical fatigue and emotional distress for emotional and cognitive fatigue.

CONCLUSION

We propose a predictive model to assess fatigue among breast cancer survivors, within a personalized survivorship care framework. This may help clinicians to provide early management interventions or to correct modifiable risk factors and offer more tailored monitoring and education to patients at risk of severe post-treatment fatigue.

Fatigue in breast cancer patients on chemotherapy: a cross-sectional study exploring clinical, biological, and genetic factors

Background

Cancer-related fatigue (CRF) is one of the most common and distressing complaints reported by cancer patients during chemotherapy considerably impacting all aspects of a patient’s life (physical, psychosocial, professional, and socioeconomic). The aim of this study was to assess the severity of cancer-related fatigue in a group of breast cancer patients undergoing chemotherapy and explore the association between fatigue scores and sociodemographic, clinical, biological, psychiatric, and genetic factors.

Methods

A cross-sectional pilot study carried out at the oncology outpatient unit of Hôtel-Dieu de France University Hospital recruited 67 breast cancer patients undergoing chemotherapy between November 2017 and June 2019 to evaluate fatigue using the EORTC QLQ-C30 scale (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire). Genotyping for seven gene polymorphisms (COMT, DRD2, OPRM1, CLOCK, PER2, CRY2, ABCB1) was performed using the Lightcycler^® (Roche).

Results

The prevalence of fatigue was 46.3%. Multivariable analysis taking the fatigue score as the dependent variable showed that a higher number of cycles and a lower hemoglobin level were significantly associated with higher odds of exhibiting fatigue. Moreover, having at least one C allele for DRD2 SNP (vs. TT) was significantly associated with a 4.09 higher odds of expressing fatigue compared to TT patients. Finally, patients with at least one C allele for CLOCK SNP tended to display higher fatigue levels than TT patients.

Conclusions

Our study showed that anemic breast cancer patients with a high number of chemotherapy cycles and those carrying at least one C allele for DRD2 and CLOCK SNPs are at greater risk of exhibiting fatigue. Since no previous research has reported such genetic results, future studies are necessary to confirm our findings.

Socioeconomic Status and Inflammation in Women with Early-stage Breast Cancer: Mediation by Body Mass Index

BACKGROUND

Breast cancer is the most common cancer among women in the US, and women of low socioeconomic status (SES) show markedly poorer outcomes than those of high SES. SES may influence health through inflammation, although links between SES and inflammatory biomarkers have not been investigated in women with breast cancer. This study tested the hypothesis that breast cancer patients of lower SES would show higher levels of inflammation than those of higher SES. BMI was examined as a mediator of this association.

METHODS

Women recently diagnosed with early-stage breast cancer (N = 194) were recruited before neoadjuvant or adjuvant therapy. Participants completed questionnaires and provided blood samples for immune assessment. SES was indexed by participants' self-reported education and annual household income, BMI was determined by height and weight measurements, and blood was assayed for inflammatory biomarkers linked with cancer outcomes: IL-6, CRP, TNF-α, and sTNF-RII. General linear models tested associations between SES and inflammation, and mediation models examined indirect effects through BMI.

RESULTS

Consistent with hypotheses, education status was associated with CRP, (F(2,185) = 4.72, p = 0.001), and sTNF-RII, (F(2,185) = 4.19, p = 0.02), such that lower education was associated with higher levels of both biomarkers. Further, BMI mediated the associations between education and CRP, (95% CIs [-0.62, -0.11; -0.76, -0.21]), sTNF-RII, (95% CIs [-0.09, -0.01; -0.10, -0.02]), and IL-6, (95% CIs [-0.32, -0.05; -0.38, -0.09]). Annual household income was not significantly associated with inflammation (ps > 0.25), and indirect effects on inflammation through BMI were not significant.

CONCLUSIONS

Lower education was associated with higher levels of inflammation in this sample, which may presage poor breast cancer-related and clinical outcomes. SES should inform the development of interventions targeting BMI and inflammation in breast cancer.

Building a biopsychosocial model of cancer-related fatigue: the BIOCARE FActory cohort study protocol

Background

Cancer-related fatigue (CRF) is the most common side effect of cancer and cancer treatment. CRF prevalence is up to 50% in breast cancer patients and can continue several years after cancer remission. This persistent subjective sense of exhaustion is multifactorial. Numerous parameters have been evidenced to be related to CRF across biological, physical, psychological, social and/or behavioral dimensions. Although CRF has been studied for many years, the majority of previous studies focused on only one dimension, i.e., physical function. Moreover, few studies investigated CRF longitudinally with repeated measures. These are the two main obstacles that limit the understanding of CRF mechanisms. The purpose of this study is to create a biopsychosocial model of CRF with simultaneous and longitudinal anthropometric, clinical, biological, physical, psychological and sociological parameters.

Methods

BIOCARE FActory is a multicentric prospective study that will consist of an 18-month follow-up of 200 women diagnosed with breast cancer. Four visits will be scheduled at diagnosis, after treatments, and 12 and 18 months after diagnosis. The same procedure will be followed for each visit. Each session will be composed of anthropometric data collection, a semi-structured interview, cognitive tests, postural control tests, neuromuscular fatigability tests and a cardiorespiratory fitness test. Clinical and biological data will be collected during medical follow-ups. Participants will also complete questionnaires to assess psychological aspects and quality of life and wear an actigraphy device. Using a structural equation modeling analysis (SEM), collected data will build a biopsychosocial model of CRF, including the physiological, biological, psychological, behavioral and social dimensions of CRF.

Discussion

This study aims to highlight the dynamics of CRF and its correlates from diagnosis to post treatment. SEM analysis could examine some relations between potential mechanisms and CRF. Thus, the biopsychosocial model will contribute to a better understanding of CRF and its underlying mechanisms from diagnosis to the aftermaths of cancer and its treatments.

Trial registration

This study is registered at ClinicalTrials.gov (NCT04391543), May 2020.

Targeted self-management limits fatigue for women undergoing radiotherapy for early breast cancer: results from the ACTIVE randomised feasibility trial

PURPOSE

The ACTIVE intervention uses a novel fatigue propensity tool to target a behavioural fatigue self-management programme for women undergoing radiotherapy for early breast cancer. We assess feasibility and outcomes for ACTIVE.

METHODS

Mixed methods comprised a randomised feasibility trial with qualitative process evaluation and a nested fatigue risk substudy. Participants at a higher risk of fatigue were allocated 2:1 to behavioural intervention or information alone. Participants at a lower risk of fatigue entered the fatigue risk substudy. Feasibility was assessed by rates of eligibility, recruitment, retention and adherence. Qualitative interviews explored acceptability of the intervention and trial processes. Measures of fatigue, anxiety, depression, quality of life and self-efficacy were self-reported before, during and 10 days, 3 weeks and 6 months after radiotherapy. Pre-treatment fatigue risk score and post-treatment fatigue were correlated.

RESULTS

Fifty percent (n = 75) of eligible patients were recruited with 33 higher risk participants randomised to the trial and 42 entering the fatigue risk score substudy. Trial design and methods were feasible and acceptable with 91% of participants completing all measures according to protocol. Fatigue was clinically-significantly lower in the intervention group during, and in the weeks after, treatment compared to the control: all secondary measures favoured the intervention group. Positive group differences were not maintained at 6 months.

CONCLUSION

Our targeted approach to fatigue self-management is feasible and acceptable within the early breast cancer pathway. Multiple benefits were reported by patients who received the intervention, which is worthy of further investigation.

TRIAL REGISTRATION

ISRCTN 10303368. Registered August 2017. Health and Care Research Wales Clinical Trial Portfolio Registration 31419.

Do all patients with cancer experience fatigue? A longitudinal study of fatigue trajectories in women with breast cancer

BACKGROUND

Fatigue is a common and expected side effect of cancer treatment. However, the majority of studies to date have focused on average levels of fatigue, which may obscure important individual differences in the severity and course of fatigue over time. The current study was designed to identify distinct trajectories of fatigue from diagnosis into survivorship in a longitudinal study of women with early-stage breast cancer.

METHODS

Women with stage 0 to stage IIIA breast cancer (270 women) were recruited before (neo)adjuvant therapy with radiotherapy, chemotherapy, and/or endocrine therapy and completed assessments at baseline; posttreatment; and at 6 months, 12 months, and 18 months of follow-up. Growth mixture modeling was used to identify trajectories of fatigue, and differences among the trajectory groups with regard to demographic, medical, and psychosocial variables were examined.

RESULTS

Five distinct trajectories of fatigue were identified: Stable Low (66%), with low levels of fatigue across assessments; Stable High (13%), with high fatigue across assessments; Decreasing (4%), with high fatigue at baseline that resolved over time; Increasing (9%), with low fatigue at baseline that increased over time; and Reactive (8%), with increased fatigue after treatment that resolved over time. Both psychological and treatment-related factors were found to be associated with fatigue trajectories, with psychological factors most strongly linked to high fatigue at the beginning of and over the course of treatment.

CONCLUSIONS

There is considerable variability in the experience of fatigue among women with early-stage breast cancer. Although the majority of women report relatively low fatigue, those with a history of depression and elevated psychological distress may be at risk of more severe and persistent fatigue.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vulnerability to inflammation-related depressive symptoms: Moderation by stress in women with breast cancer

BACKGROUND

Stress precipitates depression and may do so in part by increasing susceptibility to inflammation-induced depressive symptoms. However, this has not been examined among individuals facing a major life stressor. Accordingly, the present study tested the moderating role of stress on the longitudinal association between inflammation and depressive symptoms among women with breast cancer.

METHODS

Women recently diagnosed with early-stage breast cancer (N = 187) were enrolled before starting adjuvant/neoadjuvant treatment. Blood draws and self-reported depressive symptoms were collected pre-treatment, post-treatment, and at 6, 12, and 18-month post-treatment follow ups. C-reactive protein (CRP) was used to index inflammation. Measures of psychological stress, including cancer-related stress, general stress perceptions, and childhood stress, were administered pre-treatment.

RESULTS

Stress moderated the association between CRP and depressive symptoms, such that higher levels of CRP were associated with elevated depressive symptoms only among women who reported high cancer-related stress (β = 0.080, p = .002) and perceived stress (β = 0.053, p = .044); childhood stress effects were non-significant. Moreover, elevated CRP was associated with increased odds of exhibiting clinically significant depressive symptoms (OR = 1.64, p < .001) among women who reported high cancer-related stress. Results were independent of age, BMI, race and cancer-related covariates.

CONCLUSIONS

Stress was found to heighten sensitivity to inflammation-associated depressive symptoms over a 2-year period, with notably stronger effects for subjective stress responses to a concurrent life event. Individuals who are most distressed following a major life event may exhibit the greatest risk for inflammation-induced depression.

Neuromuscular, Psychological, and Sleep Predictors of Cancer-Related Fatigue in Cancer Patients

BACKGROUND

Cancer-related fatigue (CRF) is the most reported side effect of cancer and its treatments. This distressing sense of exhaustion critically impairs quality of life and can persist for years after treatment completion. Mechanisms of CRF are multidimensional (eg, physical, psychological, or behavioral), suggesting the need for a complex assessment. Nevertheless, CRF remains assessed mainly with 1-dimensional questionnaires. The purpose of this study was to test whether neuromuscular parameters enhance a model including well-known predictors of CRF.

PATIENTS AND METHODS

Forty-five participants with cancer history completed self-assessment questionnaires about quality of life, CRF, sleep disturbances, and emotional symptoms. They also completed a 5-minute handgrip fatiguing test composed of 60 maximal voluntary contractions to assess neuromuscular fatigability. Hierarchical linear regression analyses were performed to determine whether the neuromuscular fatigability threshold improved the FA12 score prediction beyond that provided by anxiety/depression and sleep disturbances.

RESULTS

The hierarchical linear regression analysis evidenced that a model including anxiety/depression, sleep disturbances, and neuromuscular fatigability explained 56% of CRF variance. In addition, the results suggest that the mechanisms leading to CRF may be different from one person to another.

CONCLUSION

Results revealed that sleep disturbances, emotional symptoms, and neuromuscular fatigability were the most important CRF predictors in cancer patients. This information could be useful for healthcare professionals offering tailored, individual support to patients with CRF.

Fatigue, anxiety, and quality of life in breast cancer patients compared to non-cancer controls: a nationwide longitudinal analysis

PURPOSE

Fatigue and anxiety are common and significant symptoms reported by cancer patients. Few studies have examined the trajectory of multidimensional fatigue and anxiety, the relationships between them and with quality of life.

METHODS

Breast cancer patients (n = 580) from community oncology clinics and age-matched controls (n = 364) completed fatigue and anxiety questionnaires prior to chemotherapy (A1), at chemotherapy completion (A2), and six months post-chemotherapy (A3). Linear mixed models (LMM) compared trajectories of fatigue /anxiety over time in patients and controls and estimated their relationship with quality of life. Models adjusted for age, education, race, BMI, marital status, menopausal status, and sleep symptoms.

RESULTS

Patients reported greater fatigue and anxiety compared to controls at all time points (p's < 0.001, 35% clinically meaningful anxiety at baseline). From A1 to A2 patients experienced a significant increase in fatigue (β = 8.3 95%CI 6.6,10.0) which returned to A1 values at A3 but remained greater than controls' (p < 0.001). General, mental, and physical fatigue subscales increased from A1 to A2 remaining significantly higher than A1 at A3 (p < 0.001). Anxiety improved over time (A1 to A3 β =  - 4.3 95%CI -2.6,-3.3) but remained higher than controls at A3 (p < 0.001). Among patients, fatigue and anxiety significantly predicted one another and quality of life. Menopausal status, higher BMI, mastectomy, and sleep problems also significantly predicted change in fatigue.

CONCLUSION

Breast cancer patients experience significant fatigue and anxiety up to six months post-chemotherapy that is associated with worse quality of life. Future interventions should simultaneously address anxiety and fatigue, focusing on mental and physical fatigue subdomains.

Childhood maltreatment and monocyte gene expression among women with breast cancer

BACKGROUND

Childhood adversity is reliably associated with immune alterations in adulthood, including increases in inflammatory processes. However, relatively few studies have investigated these associations in clinical populations such as cancer patients who are at risk for negative immune-related health outcomes. The current study tested the hypothesis that childhood maltreatment would be associated with alterations in immune-related gene expression in monocytes from women with breast cancer.

METHODS

Women (n = 86) were recruited after diagnosis with early-stage breast cancer but before onset of adjuvant therapy with radiation, chemotherapy, and/or endocrine therapy. Participants completed questionnaires to assess childhood maltreatment (Childhood Trauma Questionnaire; CTQ) and depressive symptoms (Center for Epidemiologic Studies Depression Scale; CES-D) and provided blood samples for immune assessment. CD14+ monocytes were isolated for RNA extraction and gene expression analyses.

RESULTS

Based on responses to the CTQ, 28% of participants were classified as experiencing physical and/or emotional abuse or neglect and 7% as experiencing sexual abuse. Genome-wide transcriptional profiling of isolated monocytes identified 202 gene transcripts that differed in average expression level by > 25% over the range of maltreatment exposure. Bioinformatics analyses of those gene transcripts identified a significantly greater prevalence of NF-κB-binding motifs within the promoters of up-regulated vs. down-regulated genes (p = .028) in women exposed to childhood maltreatment, indicating greater inflammatory signaling. Parallel analyses of Type I interferon signaling also indicated greater prevalence of Interferon Response Factor (IRF)-related binding sites in women with a childhood maltreatment history (p = .020). Results remained significant in analyses controlling for current depression; however, NF-κB and IRF-related gene expression was higher in women with both maltreatment exposure and current depression.

CONCLUSIONS

In women recently diagnosed with early-stage breast cancer, childhood maltreatment was associated with increases in the classical NF-kB-related pro-inflammatory signaling pathway and with increases in the Type I interferon system. These results suggest a broad pattern of chronic immunologic activation in breast cancer patients with a history of childhood maltreatment, particularly those who are currently experiencing clinically significant depressive symptoms. These findings have implications for the long-term health and well-being of maltreatment exposed breast cancer patients.

The acute effects of adjuvant radiation and chemotherapy on peripheral blood epigenetic age in early stage breast cancer patients

Survival has increased in early stage breast cancer (BC), and the late effects of treatment persist for decades. Molecular mechanisms underlying the acceleration of age-related diseases after chemotherapy and radiotherapy are poorly understood. We examined epigenetic changes in peripheral whole blood cells in early stage BC patients undergoing surgery followed by adjuvant radiotherapy, or surgery followed by adjuvant chemotherapy and radiotherapy. DNA methylation experiments were performed on whole blood samples collected before and after adjuvant therapy. Methylation profiles were used to estimate four measures of epigenetic age acceleration-intrinsic, extrinsic, phenotypic, and Grim-and cell counts. We found significant increases in extrinsic, phenotypic, and Grim epigenetic age acceleration and in estimated proportions of senescent T lymphocytes from pre- to post-treatment. When examining differential effects by treatment category, most of these increases were significant only in women undergoing radiation alone. Further studies are needed to examine whether these effects are related to the risk of cognitive and functional decline in BC survivors.

Cross-Sectional Associations of Fatigue Subtypes with Pain Interference in Younger, Middle-Aged, and Older Adults with Chronic Orofacial Pain

Objective

Mental, emotional, physical, and general fatigue, as well as vigor, have each been associated with pain interference—defined as pain-related disruption of social, recreational, and work-related activities—in patients with chronic orofacial pain (COFP). The objectives of the current study were to compare levels of these fatigue subtypes across younger, middle-aged, and older patients with COFP and test the associations between fatigue subtypes and pain interference in these age groups.

Design

A cross-sectional cohort design was used.

Setting

Participants self-reported fatigue subtypes (Multidimensional Fatigue Symptom Inventory–Short Form), pain interference (West Haven–Yale Multidimensional Pain Inventory), pain intensity (visual analog scale), pain duration (months), depression (Symptom Checklist 90–Revised), and sleep quality (Pittsburgh Sleep Quality Index) at their initial appointment at a tertiary orofacial pain clinic.

Subjects

Sixty younger (age 18–39), 134 middle-aged (age 40–59), and 51 older (age 60–79) COFP patients provided data for the study.

Methods

Analysis of variance was used to compare levels of fatigue subtypes between the age groups. Regression with dummy-coding was used to test if the relationship between fatigue subtypes and pain interference varied by age.

Results

Older COFP patients reported less general fatigue and more vigor than younger or middle-aged adults. Fatigue subtypes were each associated with greater pain interference, but associations became nonsignificant after controlling for depression, sleep, and pain intensity/duration. Age group–by–fatigue subtype interactions were not observed.

Conclusions

Managing fatigue may be important to reduce pain interference in COFP populations and may be accomplished in part by improving depression and sleep.

Cancer-Related Fatigue: Causes and Current Treatment Options

Cancer-related fatigue (CRF) is a problem for a significant proportion of cancer survivors during and after active cancer treatment. However, CRF is underdiagnosed and undertreated. Interventions are available for CRF although there is no gold standard. Based on current level of evidence, exercise seems to be most effective in preventing or ameliorating CRF during the active- and posttreatment phases.

Higher levels of stress and different coping strategies are associated with greater morning and evening fatigue severity in oncology patients receiving chemotherapy

PURPOSE

A cancer diagnosis and associated treatments are stressful experiences for most patients. Patients' perceptions of stress and their use of coping strategies may influence fatigue severity. This study extends our previous work describing distinct profiles of morning (i.e., Very Low, Low, High, and Very High) and evening (i.e., Low, Moderate, High, and Very High) fatigue in oncology patients by evaluating for differences in stress and coping strategies among these fatigue classes.

METHODS

This longitudinal study evaluated for changes in morning and evening fatigue in oncology patients (n = 1332) over two cycles of chemotherapy (CTX). Patients completed measures of cumulative exposure to stressful life events (SLEs) (i.e., the Life Stressor Checklist-Revised), general stress (i.e., Perceived Stress Scale [PSS]), cancer-specific stress (i.e., Impact of Event Scale-Revised [IES-R]), and coping strategies (i.e., Brief Cope). Differences among the latent classes were evaluated using analyses of variance, Kruskal-Wallis, or chi-square tests.

RESULTS

Patients in both the Very High morning and evening fatigue classes reported higher numbers of and a higher impact from previous SLEs and higher PSS scores than the other fatigue classes. The IES-R scores for the Very High morning fatigue class met the criterion for subsyndromal PTSD. Patients in the Very High evening fatigue class used a higher number of engagement coping strategies compared with the Very High morning fatigue class.

CONCLUSIONS

Our findings suggest that interventions to reduce stress and enhance coping warrant investigation to decrease fatigue in patients undergoing CTX.