Fatigue in patients with cancer: results with National Cancer Institute of Canada Clinical Trials Group studies employing the EORTC QLQ-C30

Efficacy of Moxibustion for Cancer-Related Fatigue in Patients with Breast Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Breast cancer is the most commonly diagnosed cancer worldwide, and most patients experience fatigue. However, there are no effective treatments for cancer-related fatigue (CRF). Several randomized controlled trials (RCTs) have suggested that moxibustion improves CRF. We conducted a systematic review and meta-analysis to compare the differences in fatigue scale scores, quality of life, and clinical efficacy in patients with breast cancer who developed CRF and did versus did not receive moxibustion.

METHODS

RCTs were searched in 7 databases using a standardized search method from database inception to March 2023, and RCTs that met the inclusion criteria were selected.

RESULTS

Among 1337 initially identified RCTs, 10 RCTs involving 744 participants were selected for this study. The meta-analysis involved assessment of the revised Piper Fatigue Scale scores, Cancer Fatigue Scale scores, Karnofsky Performance Scale scores, Athens Insomnia Scale scores, clinical efficacy, and Qi deficiency syndrome scale scores. Compared with the control, moxibustion was associated with significantly better Piper Fatigue Scale scores (P < 0.0001), quality of life [Karnofsky Performance Scale scores (P < 0.0001)], clinical efficacy (P = 0.0007), and Qi deficiency syndrome scale scores (P = 0.02).

CONCLUSIONS

Moxibustion improves CRF in patients with breast cancer. The efficacy of moxibustion should be further examined by high-quality studies in various countries with patients subdivided by their breast cancer treatment status.

REGISTRATION

PROSPERO ID: CRD42023451292.

Sex differences in the behavioral and immune responses of mice to tumor growth and cancer therapy

There is significant variability in the expression of cancer-related fatigue. Understanding the factors that account for this variation provide insight into the underlying mechanisms. One important, but often overlooked, variable is biological sex. While a few clinical studies have indicated that female patients report higher levels of fatigue, these studies are subject to potential socio-culture reporting biases. Only a limited number of preclinical studies have considered sex differences in animal model of fatigue and few have simultaneously considered both disease- and treatment-related factors. The present series of studies was initiated to address the current knowledge gap on the importance of sex differences in cancer-related fatigue. We selected a murine model of human papilloma virus-positive head and neck cancer based on heterotypic injection of the mEERL95 cell line that grows in both male and female mice and responds to a regimen of cisplatin plus irradiation. We also tested the impact of immunotherapy treatment targeting PD1. Voluntary wheel running was used to evaluate fatigue-like behavior. Male mice grew larger tumors than did female mice and showed more severe fatigue-like behavior. We confirmed that the tumor increased the expression of inflammatory cytokines in the liver, but no sex differences were observed. As a trend toward elevated Cd3 mRNA was observed in female mice, we tested the importance of T cells using female Rag2-/- mice. The Rag2-/- female mice had accelerated tumor growth and more severe fatigue-like behavior. In response to cisplatin alone non-tumor-bearing female mice showed a slower recovery of wheel running activity compared to males. However, in response to chemoradiation and anti-PD1 neutralizing antibody, tumor-bearing female mice showed a better tumor response to therapy than male mice, but no significant sex differences were observed for wheel running. These findings point to different mechanisms underlying tumor- and treatment-induced behavioral fatigue and indicate that the sex factor can intervene to modulate the expression of fatigue-like behavior in particular circumstances.

Cancer-related Fatigue in Breast Cancer Survivors: A Review

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

Patterns and predictors of cancer-related fatigue in ovarian and endometrial cancers: 1-year longitudinal study

BACKGROUND

Fatigue is a common and distressing symptom for patients with gynecologic cancers. Few studies have empirically examined whether it spontaneously resolves. This study was aimed at identifying longitudinal patterns of fatigue and predictors of clinically significant fatigue 1 year after treatment completion.

METHODS

This was a prospective cohort study of women with newly diagnosed ovarian (n = 81) or endometrial cancer (n = 181) that did not progress or recur within 1 year of treatment completion. Symptoms of fatigue, depression, and anxiety were assessed after surgery and 6 and 12 months after treatment completion with the Fatigue Assessment Scale and the Hospital Anxiety and Depression Scale. Patients' fatigue scores over time were classified (scores of 22-50, clinically significant; scores of 10-21, not clinically significant). Logistic regression models were fit to examine associations between fatigue and patient characteristics.

RESULTS

Among 262 participants, 48% reported clinically significant fatigue after surgery. One year later, 39% reported fatigue. There were 6 patterns over time: always low (37%), always high (25%), high then resolves (18%), new onset (10%), fluctuating (6%), and incidental (5%). Patients with fatigue after surgery were more likely to report fatigue at 12 months in comparison with others (odds ratio [OR], 6.08; 95% confidence interval [CI], 2.82-13.11; P < .001). Patients with depressive symptoms also had higher odds of fatigue (OR, 3.36; 95% CI, 1.08-10.65; P = .039), although only one-third of fatigued patients reported depressive symptoms.

CONCLUSION

Nearly half of women with gynecologic cancers had clinically significant fatigue after surgery, whereas 44% and 39% had fatigue 6 months and 1 year later; this suggests that spontaneous regression of symptoms is relatively rare. Women who reported fatigue, depressive symptoms, or 2 or more medical comorbidities had higher odds of reporting fatigue 1 year later. Future studies should test scalable interventions to improve fatigue in women with gynecologic cancers.

Perioperative fatigue in patients with diffuse glioma

Purpose

Few studies have assessed fatigue in relation to glioma surgery. The purpose of this study was to explore the prevalence of pre- and postoperative high fatigue, perioperative changes, and factors associated with pre- and postoperative high fatigue in patients undergoing primary surgery for diffuse glioma.

Methods

A total of 112 adult patients were prospectively included. Patient-reported fatigue was assessed before and one month after surgery using the cancer-specific European Organization for Research and Treatment of Cancer questionnaire fatigue subscale. The scores were dichotomized as high fatigue (≥ 39) or low fatigue (< 39). A change in score of ≥ 10 was considered as a clinically significant change. Factors associated with pre- and postoperative high fatigue were explored in multivariable regression analyses.

Results

High fatigue was reported by 45% of the patients preoperatively and by 42% of the patients postoperatively. Female gender and low Karnofsky Performance Status (KPS) were associated with preoperative high fatigue, while postoperative complications, low KPS and low-grade histopathology were associated with postoperative high fatigue. In total 35/92 (38%) patients reported a clinically significant improvement of fatigue scores after surgery, 36/92 (39%) patients reported a clinically significant worsening of fatigue scores after surgery, and 21/92 (23%) patients reported no clinically significant change in fatigue scores after surgery. Patients with low-grade gliomas more often reported low fatigue before surgery and high fatigue after surgery, while patients with high-grade gliomas more often reported high fatigue before surgery and low fatigue after surgery.

Conclusions

Our findings indicate that fatigue is a common symptom in patients with diffuse glioma, both pre- and postoperatively. Perioperative changes were frequently seen. This is important knowledge when informing patients before and after surgery.

Electronic supplementary material

The online version of this article (10.1007/s11060-020-03403-0) contains supplementary material, which is available to authorized users.

The identification of multiple symptom clusters and their effects on functional performance in cancer patients

AIMS AND OBJECTIVES

To identify cancer-related symptom clusters, to explore their inter-relationships and to examine the effects of single symptoms and the synergistic effects of symptom clusters on functional performance using path analysis by structural equation modelling in patients with various types of cancer.

BACKGROUND

Recent studies suggest that cancer patients frequently experience three or more concurrent related symptoms and that this clustering of symptoms is likely to have negative synergistic impacts on outcomes, because of the complicated dynamics of clusters.

DESIGN

A cross-sectional design.

METHODS

One hundred and ten patients with various types of cancer were recruited as in- and out-patients at a University Hospital in Incheon, South Korea. Data collection was performed using a questionnaire and by direct interview. Pain, insomnia, fatigue, depression and functional performance were measured.

RESULTS

The developed model was composed of antecedents, symptom clusters and outcomes. Of the symptoms often encountered as clusters in cancer patients, insomnia, depression and fatigue were found to have significant single (direct) effects on functional performance. Seven symptom clusters were identified between pain and functional performance, three between insomnia and functional performance and one between depression and functional performance. These single symptoms and symptom clusters were found to have significant synergistic effects on functional performance and to explain 24% of functional performance variance.

CONCLUSIONS

Multiple cancer-related symptom clusters may occur and the dynamics within symptom clusters is complicated. Our findings provide sound evidence regarding the importance of assessing and managing clusters of symptoms simultaneously rather than focusing on single symptoms.

RELEVANCE TO CLINICAL PRACTICE

A comprehensive understanding of symptom clusters in cancer patients would help establish valid diagnostic symptom cluster entities and aid the development of subjective/objective phenotypic criteria for symptom cluster based diagnoses and of nursing care protocols for managing symptom clusters.

Fatigue assessment and rehabilitation outcomes in patients with brain tumors

OBJECTIVES

This study seeks to investigate the fatigue severity and the relationship among fatigue and other associated factors in patients with brain tumors, and to evaluate the rehabilitation outcome on fatigue.

DESIGN

We assessed 25 patients in whom brain tumors had been resected and transferred to the rehabilitation department of our hospital. Patients were evaluated for fatigue severity using the Piper Fatigue Scale (PFS) and the Brief Fatigue Inventory (BFI), for mood using the Beck Depression Inventory, for motor function using the Motricity Index (MI), for functional status using the Karnofsky Performance Status (KPS) scale and the Modified Barthel Index (MBI), and for quality-of-life using the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30). We also measured the levels of serum hemoglobin, C-reactive protein, albumin, and creatine kinase; and anthropometric variables before and 4 weeks after rehabilitation.

RESULTS

Of the 25 patients, 21 (84.0%) reported fatigue during the previous week. The average PFS score was 4.6 ± 1.8 and the average BFI score 5.2 ± 2.2, indicating the moderate level of fatigue. Patients with recurrent tumors had significantly higher PFS scores than did those with initial tumors. Fatigue correlated significantly with the KPS, MBI, and EORTC QLQ-C30 physical functioning and insomnia scales. In addition, insomnia was a significant predictor of fatigue before rehabilitation, and the baseline fatigue scales, MBI, MI, and EORTC QLQ-C30 physical functioning scale were the important independent predictors of fatigue after rehabilitation. During rehabilitation, the KPS, MBI, and MI scores improved significantly, whereas total PFS and BFI scores did not change.

CONCLUSIONS

These findings suggest that patients with brain tumors commonly complain of moderate level of fatigue, which may reduce daily functioning and quality of life, with sleep disturbance being a significant predictor of fatigue. During rehabilitation, functional outcomes and motor power showed improvements in those patients, not aggravating fatigue.

Review Article: A Systematic Review of Cancer-Related Fatigue Measurement Questionnaires

Purpose: Cancer-related fatigue (CRF) is a common symptom experienced by patients in all stages and in cancer survivors. The main objectives of this review were to identify validated CRF instruments, and populations in whom these tools have been validated. Methods: We used a systematic review methodology. Three separate searches were performed using different MeSH terms in Pub Med and Ovid databases. Articles were analyzed for validation and reliability. Results: A total of 1453 papers from 3 different searches identified 40 instruments (3 unidimensional and 37 multidimensional). Instruments varied by psychometric properties, items, scale, dimension, cancer site, and population. Five were optimally tested for validity and reliability. Completion rates, sensitivity to change, and test—retest reliability were reported for a few. Discussion: Most tools had been validated in mixed populations and are relatively insensitive to differences in fatigue to cancer stage. Most instruments are burdensome for those with advanced cancer. The Brief Fatigue Inventory and 3 fatigue items of the European Organization for Research and Treatment Quality of Life Questionnaire Fatigue Scale (EORTC QLQ-C30) are optimal instruments in advanced cancer. Conclusions: In all, 40 CRF instruments were identified. Validity and reliability varied by questionnaire. The ideal item numbers, scale, and domains are not established and may be population dependent.

Quality criteria and user-friendliness in self-reported questionnaires on cancer-related fatigue: a review

OBJECTIVE

Cancer-related fatigue (CRF) is a distressing, persistent, subjective sense of tiredness or exhaustion that occurs in 70-100% of cancer patients. The purpose of this review was to provide an overview of the quality of research performed on existing CRF self-report questionnaires and compare their reported psychometric properties and user-friendliness.

METHODS

Database searches of CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus, PEDro, and PsycINFO were undertaken to find published scales. Standardized criteria were used to assess quality and user-friendliness.

RESULTS

Thirty-five articles were included that described 18 questionnaires-seven one-dimensional questionnaires and 11 multidimensional questionnaires. The mean item count was 20.8 (range: 3-83). The mean overall score of the one-dimensional questionnaires was 10.4 of a maximum of 18 points (range: 7.6-14.3). The mean overall score of the multidimensional questionnaires was 9.4 of a maximum of 18 points (range: 4.3-14.4).

CONCLUSION

Recommendations were made for the selection of a scale. We argue in favor of repeatedly reassessing psychometric properties of even established questionnaires to ensure they comply with evermore increasing stringent quality criteria.

Differences in symptom clusters identified using occurrence rates versus symptom severity ratings in patients at the end of radiation therapy

The purposes of this study were to identify the number and types of symptom clusters using yes/no responses from the Memorial Symptom Assessment Scale, identify the number and types of symptom clusters using severity scores from the Memorial Symptom Assessment Scale, compare the identified symptom clusters derived using severity scores to those derived using occurrence ratings, and evaluate for differences in symptom cluster severity scores between patients with breast and prostate cancer at the end of radiation therapy. Separate exploratory factor analyses were performed to determine the number of symptom clusters based on symptom occurrence rates and symptom severity ratings. Although specific symptoms within each symptom cluster were not identical, 3 very similar symptom clusters (ie, "mood-cognitive" symptom cluster, "sickness-behavior" symptom cluster, "treatment-related" symptom cluster) were identified regardless of whether occurrence rates or severity ratings were used to create the symptom clusters at the end of radiation therapy. However, the factor solution derived using the severity ratings fit the data better. Significant differences in severity scores for all 3 symptom clusters were found between patients with breast and prostate cancer. For all 3 symptom clusters, the patients with breast cancer had higher symptom cluster severity scores than the patients with prostate cancer.

Predictors of Symptom Severity and Response in Patients With Metastatic Cancer

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

Predictors of the intensity of symptoms in a cluster in patients with breast cancer

PURPOSE

To examine the influence of selected demographic and clinical variables on the intensity of symptoms in two previously identified symptom clusters (psychoneurological and upper gastrointestinal) across the treatment trajectory for breast cancer.

DESIGN

A secondary analysis was conducted with a sample of 282 female breast-cancer patients who were receiving chemotherapy or radiation therapy in two American cancer centers. Data were collected three times across the treatment trajectory: baseline (before chemotherapy or radiation treatment) and two follow-up times after treatment initiation.

METHOD

Multiple regression analyses were done at each time point to examine the influence of selected demographic and clinical variables on the intensity of symptoms in each cluster.

FINDINGS

Baseline physical performance status was a consistent predictor of symptom intensity in the psychoneurological cluster across time whereas age and treatment modality were consistent predictors of symptom intensity in the upper gastrointestinal cluster. Poor physical performance at baseline predicted more intense psychoneurological symptoms. Younger women and women undergoing chemotherapy experienced more intense gastrointestinal symptoms. In addition, at the second follow-up treatment modality also influenced intensity of symptoms in the psychoneurological cluster and race and baseline physical performance status also influenced the intensity of symptoms in the upper gastrointestinal cluster.

CONCLUSIONS

Clinicians can anticipate that younger patients, patients with poor baseline physical performance status, and patients who receive chemotherapy will have more intense treatment-related gastrointestinal and psychoneurological symptoms during adjuvant breast cancer therapy. Further research is needed to determine whether collective management for symptoms in a cluster may be beneficial.

CLINICAL RELEVANCE

Clinicians can use findings from the present study to identify patients who need greater attention to symptom assessment and management, including anticipatory counseling of patients and families.

Modafinil for the treatment of fatigue in lung cancer: a pilot study

Cancer-related fatigue is the most prevalent and distressing symptom experienced by patients with advanced cancer. Central nervous system stimulants have been shown to relieve fatigue in nonmalignant disease. Modafinil is a stimulant with a selective site of action in the brain that is better tolerated than traditional stimulants, such as methylphenidate. The aim of this study was to determine the feasibility of conducting a randomised controlled trial to assess the efficacy and safety of modafinil for the treatment of fatigue in patients with lung cancer. Twenty patients with non-small cell lung cancer were recruited to this open-label study. Modafinil was taken in a fixed dose-titration schedule of 100 mg daily for 7 days followed by 200 mg daily for 7 days. Fifteen patients completed the study. During the study period, there was a rapid and statistically significant reduction in the primary outcome, fatigue (P = 0.001) and the secondary outcomes of daytime sleepiness and depression/anxiety. This improvement in fatigue was also clinically significant. Ten patients chose to continue modafinil after the study and the drug was well-tolerated. It would be both feasible and worthwhile to conduct a definitive randomised controlled trial to determine the role of modafinil in the treatment of cancer-related fatigue.

The measurement of fatigue in chronic illness: a systematic review of unidimensional and multidimensional fatigue measures

Fatigue is a common symptom associated with a wide range of chronic diseases. A large number of instruments have been developed to measure fatigue. An assessment regarding the reliability, validity, and utility of fatigue measures is time-consuming for the clinician and researcher, and few reviews exist on which to draw such information. The aim of this article is to present a critical review of fatigue measures, the populations in which the scales have been used, and the extent to which the psychometric properties of each instrument have been evaluated to provide clinicians and researchers with information on which to base decisions. Seven databases were searched for all articles that measured fatigue and offered an insight into the psychometric properties of the scales used over the period 1980-2007. Criteria for judging the "ideal" measure were developed to encompass scale usability, clinical/research utility, and the robustness of psychometric properties. Twenty-two fatigue measures met the inclusion criteria and were evaluated. A further 17 measures met some of the criteria, but have not been tested beyond initial development, and are reviewed briefly at the end of the article. The review did not identify any instrument that met all the criteria of an ideal instrument. However, a small number of short instruments demonstrated good psychometric properties (Fatigue Severity Scale [FSS], Fatigue Impact Scale [FIS], and Brief Fatigue Inventory [BFI]), and three comprehensive instruments demonstrated the same (Fatigue Symptom Inventory [FSI], Multidimensional Assessment of Fatigue [MAF], and Multidimensional Fatigue Symptom Inventory [MFSI]). Only four measures (BFI, FSS, FSI, and MAF) demonstrated the ability to detect change over time. The clinician and researcher also should consider the populations in which the scale has been used previously to assess its validity with their own patient group, and assess the content of a scale to ensure that the key qualitative aspects of fatigue of the population of interest are covered.

Patient optimism and mastery-do they play a role in cancer patients' management of pain and fatigue?

In the present study, we investigated longitudinally (baseline, 10 weeks, 16 weeks) whether patient personality traits, such as dispositional optimism and mastery, play a role in patients' ability to effectively control the severity of their pain and fatigue in the context of a symptom control intervention among patients with cancer. Two hundred fourteen patients currently undergoing chemotherapy received a baseline interview followed by a 10-week, nurse-assisted symptom control intervention. At 10 weeks, patients received a second interview to assess the effectiveness of the intervention, with a final follow-up interview at 16 weeks. Random effects regression models were used to investigate the effects of mastery and optimism on the severity of pain and fatigue, adjusting for the effects of other important covariates, such as age, gender, cancer site, stage of disease, and comorbidity. Patients who were older, more optimistic, suffered from fewer comorbid conditions, or reported higher levels of mastery tended to report less severe pain, whereas higher levels of mastery and fewer comorbid conditions predicted lower fatigue severity scores. These findings underscore the need for physicians and nurses involved in the care of cancer patients to recognize, encourage, promote, and take advantage of these traits in their patients to help them more effectively manage their cancer care, so that they ultimately can achieve a better quality of life during the sequelae of the cancer experience.

Study of the prevalence of tumour-related asthenia in Spanish cancer patients

INTRODUCTION

Asthenia is the most prevalent symptom in oncological patients but it is underestimated by the majority of healthcare professionals. The aim of the present study is to estimate the prevalence of tumour-related asthenia in the Spanish population, while defining the associated factors.

METHODS

An epidemiological, multicentre, cross-sectional study was conducted in oncology services from Spain, including 712 cancer patients (58.4+/-13.5 years).

RESULTS

42.5% patients showed asthenia. This prevalence appeared to be tumour-related (p<0.05) and increased among patients with a more advanced stage of disease or with a worsening of performance status (p<0.001). The prevalence of asthenia increased in the presence of the following factors: chemotherapy (in the past: 52.1% vs. 31.0%; at the time of the study: 46.1% vs. 38.2%), symptomatic treatment (in the past: 60.4% vs. 39.8%; at the time of the study: 61.3% vs. 38.6%), present interferon treatment (100%), anaemia (59.7% vs. 31.3%), dehydration/waterelectrolyte imbalance (58.3% vs. 41.6%), respiratory failure (61.4% vs. 39.7%), liver disease (59.5% vs. 41.3%), malnutrition (76.1% vs. 38.7%), pain (57.7% vs. 27.0%), anxiety (56.1% vs. 38.6%), depression (57.9% vs. 40.0%) and sleep disturbances (51.1% vs. 39.4%). A multivariate logistic regression showed that a model including performance status, patient circumstance, chemotherapy, anaemia, pain and anxiety correctly diagnosed asthenia in 70.9% of cases.

CONCLUSIONS

The physiopathology of tumour-related asthenia remains relatively unknown, despite its high prevalence and considerable quality of life impact. Determining factors related to asthenia in clinical practice can favour the use of concrete treatments and improve the conditions of cancer patients.

Fatigue in Advanced Cancer: A Prospective Study

Fatigue is a common advanced cancer symptom. Clinical features are not well known. The authors surveyed consecutive patients admitted to a palliative medicine program to identify clinical correlates of fatigue. Data collected included age, sex, performance status, primary site, prior chemotherapy/radiation therapy, and blood transfusions. Visual analogue scales assessed fatigue, quality of life, and ability to perform daily activities. Weight change was estimated. Laboratory results including lactate dehydrogenase and hemoglobin were recorded. Fatigue severity was associated with brain metastases, poor performance status, poor quality of life, and reduced ability to perform activities. Prior radiation therapy was associated with less severe fatigue. Age, sex, and hemoglobin level were not associated with fatigue. Fatigue was universal on referral. Brain metastases and poor quality of life independently predicted severity. Hemoglobin level did not predict fatigue. Further studies are necessary to define the clinical features and relationships of fatigue.

Evaluating health-related quality of life in cancer clinical trials: the National Cancer Institute of Canada Clinical Trials Group experience

INTRODUCTION

The National Cancer Institute of Canada (NCIC) Clinical Trials Group (CTG) Quality of Life (QOL) Committee was initiated in 1986.

PURPOSE

The purpose of this review is to describe the evolution of the Committee's work and to highlight key developments such as the formulation of a policy regarding health-related quality-of-life (HRQOL) assessment, the provision of guidelines to ensure completion of HRQOL data within the protocol requirements, the rationale behind the choice of HRQOL instruments, the timing of assessments and the development of data analytic methods. These developments are illustrated with examples from CTG studies.

RECOMMENDATIONS

There is a lack of concordance between conventional toxicity data and HRQOL data and comparative studies designed to elucidate these differences are to be encouraged. Also, more studies are required to compare different analytic strategies and to determine how much missing data is acceptable, particularly in oncology studies where attrition is inevitable.

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.

Women experience higher levels of fatigue than men at the end of life: a longitudinal home palliative care study

Few studies have evaluated sex differences in the prevalence, severity, and correlates of fatigue at the end of life. The Brief Fatigue Inventory, McGill Quality of Life (MQOL) Questionnaire, and Karnofsky Performance Scale were administered at two-week intervals to 102 patients in a home palliative program. Outcomes in the sample and a regional palliative database (n=3,096) were analyzed. Cancer was the diagnosis in 96% of patients enrolled. Prevalence (P=0.0091) and severity of fatigue (P<0.001) were higher in women at entry and in a repeated measures analysis over time (severity, P=0.0048). Performance status did not explain this difference. MQOL scores were inversely correlated to fatigue (Spearman coefficient=-0.48, P<0.0001), but did not differ by sex. There was no difference in fatigue interference with MQOL in women and men. Although depression was higher in women (P=0.042) and related to fatigue at entry, it did not explain the sex difference in fatigue scores. Of the sociodemographic variables examined, neither education nor living situation contributed to the fatigue difference. This study shows a sex effect in the fatigue experienced by patients with advanced illnesses, which is not explained by baseline differences in performance, depression, MQOL, education, or living situation. That fatigue interference with MQOL is the same for men and women suggests that higher fatigue scores in women reflect not only a difference in the dimension of fatigue severity, but are also relevant in relation to impact on QOL. Assessment of fatigue should include the dimension of QOL important for both women and men.

Fatigue and depression in cancer patients undergoing chemotherapy: an emotion approach

Fatigue and depressive symptoms are common in cancer patients, but the nature of the relationship between the two remains unclear. We examined the degree to which two dimensions of emotion assessed as psychological factors (i.e., arousal and valence) predicted changes in fatigue and depressive symptoms over four cycles of chemotherapy in cancer patients who participated in a randomized clinical trial. Among 549 patients enrolled in the study, 525 provided data from a minimum of two treatments and were included in the multilevel modeling analyses. Multilevel models were used to identify significant predictors of initial levels and changes of fatigue and depressive symptoms and to determine the relationship between fatigue and depressive symptoms independent of other predictors proposed in this study. Multiple factors, including age, gender, and cancer site, predicted the initial levels. More importantly, the two dimensions of psychological factors significantly predicted changes in fatigue and depressive symptoms, in similar patterns but to different degrees. Specifically, changes in fatigue depended more on the valence dimension, whereas changes in depressive symptoms depended on both the valence and arousal dimensions. Theoretical and practical implications of the current findings are discussed and suggestions for interventions to alleviate fatigue and depressive symptoms in cancer patients are proposed.

Longitudinal Study of the Relationship Between Chemoradiation Therapy for Non–Small-Cell Lung Cancer and Patient Symptoms

Purpose

Cancer patients undergoing aggressive therapy suffer from multiple nonspecific treatment-related symptoms. The goal of this prospective study was to establish a profile of the development of different symptoms over the time of therapy and to examine symptom-related functional interference in patients with non–small-cell lung cancer (NSCLC) undergoing concurrent chemoradiation therapy (CXRT).

Patients and Methods

Patients with locally advanced unresectable (stage II-IIIB) NSCLC were recruited for the study (N = 64). The M.D. Anderson Symptom Inventory (MDASI) was used to measure multiple symptoms before and weekly for 12 weeks after the start of CXRT. Mixed-effect growth curve models were used to estimate symptom development during CXRT.

Results

Approximately 63% of patients suffered from moderate to severe levels of multiple symptoms by the end of CXRT. Symptom clusters with four development patterns appeared over the time of CXRT. With some variation between patients, all symptoms had a significant impact on the level of interference (all P < .001). Fatigue, distress, and sadness were the single strongest predictors of total symptom interference (each R2 ≥ 0.49). Physical symptoms had greater impact on interference with function when they were moderate to severe, whereas affective symptoms had the largest effect on interference when they were mild to moderate.

Conclusion

Longitudinal analysis identified symptom clusters that have different development patterns in NSCLC patients receiving CXRT, providing a base for more accurate symptom management and suggesting the need for further study to identify potential mechanisms that might lead to better symptom control or prevention.

Association of coping style, pain, age and depression with fatigue in women with primary breast cancer

The purpose of this study was to explore the relative contributions of coping, depression, pain and age, in the experience of cancer related fatigue. A total of 353 women treated for primary breast cancer were assessed within one year of diagnosis using the Profile of Mood States, the Hospital Anxiety and Depression Scale and the mini-Mental Adjustment to Cancer Scale. Fatigue was positively associated with depression and pain, but inversely related to age. In contrast to our expectations, fighting spirit was not associated with less fatigue. A relationship between coping style and cancer-related fatigue was found exclusively for 'positive reappraisal', a combination of fighting spirit and fatalism. Detectable only in multivariate analysis together with depression, the results suggest a weak association between coping and fatigue. The relationship between cancer related fatigue, age and coping styles requires further exploration within longitudinal studies.

Subjective Reports of Fatigue During Early Recovery From Traumatic Brain Injury

OBJECTIVE

To determine whether patients with traumatic brain injury (TBI) report higher levels of fatigue than do normal controls and to identify demographic and cognitive correlates of self-reported fatigue.

DESIGN

Prospective study.

SETTING

Inpatient neurorehabilitation unit in a medical center and neurological institute.

PARTICIPANTS

Forty-seven neurorehabilitation inpatients with TBI.

MAIN OUTCOME MEASURES

Barrow Neurological Institute (BNI) Fatigue Scale and BNI Screen for Higher Cerebral Functions.

RESULTS

Patients reported significantly greater levels of fatigue compared to the levels reported by normal controls, although fatigue was found to be unrelated to injury severity, number of days from injury to assessment, cognitive impairment, and gender. Inspection of individual items revealed no significant differences between severe versus moderate versus mild TBI groups. However, being able to last the day without taking a nap (ie, item 10) was found to be the most sensitive item associated with fatigue in the TBI group.

CONCLUSIONS

Results of this study suggest the need to integrate activities and interventions to increase endurance in patients with TBI during early rehabilitation. Accommodating regular rest breaks and increasing restful sleep should be a focus of inpatient neurorehabilitation units.

Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer

GOALS

Previous investigations have shown that women undergoing chemotherapy for breast cancer experience both disturbed sleep and fatigue. However, most of the previous research examined women either during or after chemotherapy. This study examined sleep, fatigue, and circadian rhythms in women with breast cancer before the start of chemotherapy.

PATIENTS AND METHODS

Eighty five women with Stages I-IIIA breast cancer who were scheduled to begin adjuvant or neoadjuvant anthracycline-based chemotherapy participated. Each had sleep/wake activity recorded with actigraphy for 72 consecutive hours and filled out questionnaires on sleep, fatigue, depression, and functional outcome.

MAIN RESULTS

On average, the women slept for about 6 h a night and napped for over an hour during the day. Sleep was reported to be disturbed and fatigue levels were high. Circadian rhythms were robust, but women who were more phase-delayed reported more daily dysfunction (p<0.01).

CONCLUSIONS

The data from the current study suggest that the women with breast cancer likely experience both disturbed sleep and fatigue before the beginning of chemotherapy. Although their circadian rhythms are robust, breast cancer patients with more delayed rhythms experience more daily dysfunction secondary to fatigue. These data suggest that strategies to improve disturbed sleep and to phase-advance circadian rhythms prior to initiation of chemotherapy may be beneficial in improving daily function in breast cancer patients.

Management of cancer-related fatigue

Fatigue is among the most commonly reported symptoms of patients with cancer, with prevalence exceeding 60% in many studies. It is among the most distressing symptoms associated with cancer and cancer treatments because it substantially disturbs patients' quality of life and ability to function optimally on a daily basis. Although the development of this condition has been associated with a number of factors, its etiology remains poorly understood. Important elements to include in any definition of cancer-related fatigue include its pervasiveness, persistence, detrimental effect on quality of life, and its inability to be relieved by rest or sleep. Several validated questionnaires can be used to measure fatigue in patients with cancer, and research efforts are currently focused on ways to distinguish it from depression with which it shares many symptoms. All patients with cancer should be evaluated for fatigue, and treatment options should be considered for those who are experiencing excessive levels of fatigue. Treatment should be individualized according to the underlying pathology when a specific cause has been identified (e.g., anemia, sleep disorder, depression, or metabolic disorder). Nonspecific therapies may be useful in short- and long-term cancer-related fatigue management in many patients. In addition to older therapies, such as hematopoietics, antidepressants, corticosteroids, and psychostimulants, the effectiveness of the new wake-promoting agent modafinil is currently being studied. A more thorough evaluation of the various therapeutic options is required to better define their efficacy and safety profiles in this patient population.

Outcomes research in cancer clinical trial cooperative groups: the RTOG model

BACKGROUND

The Radiation Therapy Oncology Group (RTOG), a National Cancer Institute sponsored cancer clinical trials research cooperative, has recently formed an Outcomes Committee to assess a comprehensive array of clinical trial endpoints and factors impacting the net effect of therapy.

METHODS

To study outcomes in a consistent, comprehensive and coordinated manner, the RTOG Outcomes Committee developed a model to assess clinical, humanistic, and economic outcomes important in clinical trials.

RESULTS

This paper reviews how the RTOG incorporates outcomes research into cancer clinical trials, and demonstrates utilization of the RTOG Outcomes Model to test hypotheses related to non-small-cell lung cancer (NSCLC). In this example, the clinical component of the model indicates that the addition of chemotherapy to radiotherapy (RT) improves survival but increases the risk of toxicity. The humanistic component indicates that esophagitis is the symptom impacting quality of life the greatest and may outweigh the benefits in elderly (> or =70 years) patients. The economic component of the model indicates that accounting for quality-adjusted survival, concurrent chemoRT for the treatment of NSCLC is within the range of economically acceptable recommendations.

CONCLUSION

The RTOG Outcomes Model guides a comprehensive program of research that systematically measures a triad of endpoints considered important to clinical trials research.

Combined modality treatment for locally advanced non-small cell lung cancer: preoperative chemoradiation does not result in a poorer quality of life

The German Lung Cancer Cooperative Group (GLCCG) is assessing the impact of chemoradiation in addition to chemotherapy in the neoadjuvant treatment of stage III NSCLC. After three cycles of cisplatin/etoposide patients receive either hyperfractionated radiotherapy (RT) with concurrent carboplatin/vindesine and then surgery (arm A) versus surgery and then conventional RT (arm B). Quality of life (QL) was assessed throughout therapy using the EORTC QLQ-C30 and EORTC QLQ-LC 13. Of 126 eligible patients, 54 completed treatment. For patients in both treatment arms physical functioning decreased, whereas dyspnoea, fatigue and pain increased from beginning to the end of treatment. For self-assessed QL no statistically significant effect was found in or between the two treatment arms. The combined modality approach with preoperative radio/chemotherapy proves to be feasible in treating locally advanced NSCLC patients without decreasing their subjective QL.

Endoscopic laser ablation as palliative treatment of endobronchial, nonresectable, or recurrent lung cancer: assessment of its impact on quality of life

Laser ablation (LA) is currently used in our institute as palliative treatment for endobronchial nonresectable or recurrent lung cancer. The objective of this study was to assess the impact of LA on the quality of life (QOL) in a large group of patients with endobronchial obstructions due to nonresectable or re-current lung cancer. Evaluation was based on Eastern Cooperative Oncology Group performance status (ECOG PS) for the "objective" assessment of QOL and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 version 1.0 (EORTC QLQ-C30(v1)) for the "subjective" assessment of QOL. From May 1994 to June 1997, 133 LAs were performed using neodymium: yttrium-aluminum garnet (Nd:YAG) laser at low power settings (< 30W) on 89 evaluable patients (Male/Female 78/11, mean age 63.5/62.8 years, range 42-82/47-73). The QOL was evaluated by ECOG PS and QLQ-C30(v1) at baseline (3 days before LA), t1 (7 days after LA), and t2 (1 month after LA). The objective tumor response was evaluated at t2. The objective tumor response to LA intervention was "excellent," ie, complete response (CR), in 33 (24.8%) patients and "fair," ie, partial response (PR), in 97 (72.9%) patients, with an overall response rate (ORR) of 97.7%. A highly significant decrease in high score (ECOG PS 3-4) was registered from baseline to t1 and from t1 to t2. However, at the same time a significant increase of low score (ECOG PS 0-2) was observed. The comparison of patient QOL assessment by QLQ-C30(v1) at different times during the study was also made; the functioning scales, the global QOL scale, and the symptom scales/items showed a highly significant improvement at t1 compared to baseline (P < 0.001), whereas only global QOL improved at t2 compared to t1. A comparison of baseline ECOG PS scale with QLQ-C30(v1) scale revealed a strong relationship between PS and the symptom "fatigue." Our study demonstrates that dramatic clinical improvement obtained by an effective though palliative treatment such as LA improves QOL based on both physician-rated (PS) and mostly self-rated (QLQ-C30(v1)) assessment.

The validity of EORTC QLQ-C30 fatigue scale in advanced cancer patients and cancer survivors

Fatigue is a major complaint among advanced cancer patients. Several instruments are available for measuring fatigue. The EORTC QLQ-C30 is one of the most frequently used health-related quality of life (HRQOL) instruments, and it includes a three-item fatigue subscale. Limited knowledge exists about the validity, performance and sensitivity of EORTC QLQ-C30 fatigue scale as compared with a fatigue-specific instrument. The aim of the present study was to validate the EORTC QLQ-C30 fatigue scale (FA) against the Fatigue Questionnaire (FQ). The FQ is frequently used and was developed to measure fatigue in both cancer and noncancer populations. The FQ measures physical (PF, seven items) and mental fatigue (MF, four items). The study population included two different cohorts: A) patients with advanced metastatic cancer included in a prospective randomized study of palliative radiotherapy (n = 238); B) patients with leukaemia and malignant lymphoma curatively treated with stem-cell transplantation and high-dose chemotherapy (n = 128). The analysis demonstrated that the FA correlated higher with the PF scale (r = 0.67-0.75) as compared with the MF scale (r = 0.49-0.61). The item scale correlations between FA items and the PF scale were consistently higher than between FA items and the MF scale. A factor analysis including all the items within the FA and the FQ identified two factors. All FA items loaded on a PF factor (0.70-0.85). A floor/ ceiling effect, indicating a high number of respondents with lowest, respectively, highest scores was observed more frequently in the FA as compared with the FQ. The PF discriminated better between diagnostic groups with different levels of fatigue than the FA did. In conclusion, the EORTC QLQ-C30 fatigue scale is measuring physical fatigue. A floor/ ceiling effect seems to appear for the EORTC QLQ-C30 fatigue scale. The validity of the EORTC QLQ-C30 fatigue scale is to be questioned for use in palliative care patients. In studies with fatigue as a defined end point, a domain-specific instrument should, therefore, be added.

Men's experiences and their resources from cancer diagnosis to recovery

This study describes the experiences and resources of male cancer patients in Finland during the trajectory of their illness. A semi-structured interview schedule was used to collect data on falling ill with cancer, on periods of treatment (surgery, chemotherapy, radiation therapy), and on convalescence. The participants (n=8), aged 42-64 (mean=53) were interviewed in a clinic setting in connection with a check-up visit. The interviews were tape-recorded and transcribed for qualitative content analysis. The male cancer patients described their experiences through the illness trajectory in terms of suspicions, their encounter with cancer, and the cancer becoming a reality. During treatment, men described their experiences in terms of changes in body image, individual illness experiences, and new social roles. Men's experiences during the convalescence period included physical restoration, anxiety following treatment regimes, reflection, and social roles at transition. The results also indicated that men did not consider their status as a chronic one, but rather as a passing and relatively short stage in their life. Both intra- and extrapersonal resources were described: the former included body image and capacity, self-understanding, social situation, and psychological resources; and the latter wives, children, colleagues, health-care personnel, fellow patients, health-care interventions and society. Extrapersonal resources included informational, emotional, and evaluative support, as well as concrete help.

Multidimensional independent predictors of cancer-related fatigue

The purpose of this study was to identify independent predictors of clinically significant fatigue based upon a multidimensional model. A total of 180 cancer patients completed the Brief Fatigue Inventory (BFI), Functional Assessment of Cancer Therapy-Fatigue (FACT-F), Memorial Symptom Assessment Scale Short Form (MSAS-SF), and the Zung Self-Rating Depression Scale (SDS). Additional data included Karnofsky Performance Status (KPS) score, laboratory tests, and demographic information. The BFI usual fatigue severity > or =3/10 was defined as clinically significant fatigue. Possible independent variables were identified from a biopsychosocial model of fatigue. Fisher's exact test was used to univariately assess the association of each variable with clinically significant fatigue. Multiple logistic regression analyses were used to identify independent predictors of fatigue within each dimension, and then across dimensions. Fatigue was present in 113 (62%) patients, and 80 (44.4%) patients had usual fatigue > or =3/10. The unidimensional independent predictors were use of analgesics (situation dimension); hemoglobin and serum sodium (biomedical dimension); feeling drowsy, dyspnea, pain and lack of appetite (physical symptom dimension); and feeling sad and feeling irritable (psychological symptom dimension). In a multidimensional model, dyspnea, pain, lack of appetite, feeling drowsy, feeling sad, and feeling irritable predicted fatigue independently with good calibration (Hosmer Lemeshow Chi Square=5.73, P=0.68) and discrimination (area under the receiver operating characteristic curve=0.88). Physical and psychological symptoms predict fatigue independently in the multidimensional model, and superseded laboratory data. These findings support a symptom-oriented approach to assessment of cancer-related fatigue.

Validation evidence for the French Canadian adaptation of the Multidimensional Fatigue Inventory as a measure of cancer-related fatigue

Cancer-related fatigue is the most reported symptom among patients with cancer. Researchers in the field of psychooncology have encouraged the development of short instruments, which allow for easier completion by clinical populations while still maintaining solid psychometric properties. The current study examined the validity and reliability of the French Canadian adaptation of the Multidimensional Fatigue Inventory (MFI) among women (n = 277) and men (n = 327) undergoing therapy for breast or prostate cancer, respectively. An exploratory factor analysis of the selected 15-item MFI yielded the following four factors: general/physical, mental, reduced motivation, and reduced activity. This was supported by a confirmatory factor analysis. The reliability, as evaluated by test-retest and Cronbach alpha internal consistency reliability coefficients of the French Canadian shortened MFI, was acceptable. In addition, the four factor-based scores correlated in a theoretically meaningful manner with existing measures of mood disturbance (Profile of Mood States and Hospital Anxiety and Depression Scale), cancer-related stressors (Inventory of Recent Life Experiences), coping with illness (Coping with Health Injuries and Problems Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), and insomnia (Insomnia Severity Index), suggesting good construct, convergent, and concurrent criterion validity. Although further validation is recommended, the results for the French Canadian MFI in assessing cancer-related fatigue in both women and men undergoing cancer treatments showed good psychometric qualities.

No excess fatigue in young adult survivors of childhood cancer

Clinical reports suggest that many survivors of childhood cancer experience fatigue as a long-term effect of their treatment. To investigate this issue further, we assessed the level of fatigue in young adult survivors of childhood cancer. We compared the results with a group of young adults with no history of cancer. The impact of demographic, medical and treatment factors and depressive symptoms on survivors' fatigue was studied. Participants were 416 long-term survivors of childhood cancer (age range 16-49 years, 48% of whom were female) who had completed treatment an average of 15 years previously and 1026 persons (age range 16-53 years, 55% female) with no history of cancer. All participants completed the Multidimensional Fatigue Inventory (MFI-20), a self-report instrument consisting of five scales (general fatigue, physical fatigue, mental fatigue, reduced activity, reduced motivation) and the Center for Epidemiologic Studies Depression Scale (CES-D). Small differences were found in the mean scores for the different dimensions of fatigue between the long-term survivors and controls (range effect sizes -0.34 to 0.34). Women experienced more fatigue than men. Logistic regression revealed that being female and unemployed were the only demographic characteristics explaining the various dimensions of fatigue. With regard to medical and treatment factors, diagnosis and severe late effects/health problems were associated with fatigue. Finally, depression was significantly associated with fatigue on all subscales. Our clinical practice suggests a difference in fatigue in young adult childhood cancer survivors and their peers. This could not be confirmed in this study using the MFI-20. The well known correlation between fatigue and depression was confirmed in our study. Further research is needed to clarify the undoubtedly complex somatic and psychological mechanisms responsible for the development, maintenance and treatment of fatigue in childhood cancer survivors.

Patient-related barriers to fatigue communication: initial validation of the fatigue management barriers questionnaire

Fatigue is a highly prevalent and distressing symptom of cancer and its treatment. However, cancer patients often fail to communicate with their oncologists about fatigue. In this study, we attempted to identify the patient-related barriers to communication about fatigue, as cited by patients. Two hundred patients were sampled across the Community Cancer Care, Inc. (CCC) network of Indiana using the Cancer Behavior Inventory-Brief scale (CBI-B), the Zung Self-Rating Depression Scale (ZSDS), the Functional Assessment of Cancer Inventory-Fatigue scale (FACT-F), and the Fatigue Management Barriers Questionnaire (FMBQ), a questionnaire devised by experts in the field of cancer-related fatigue. There were no significant correlations between the instrument scores and demographic variables. Scores on the instruments did not differ significantly based on whether the patient was from a rural or urban site. One hundred thirty-two patients (66%) reported that they had never spoken to their doctor about fatigue. The most frequently reported reasons for this lack of patient communication about fatigue included the doctor's failure to offer interventions (47%), patients' lack of awareness of effective treatments for fatigue (43%), a desire on the patient's part to treat fatigue without medications (40%), and not wanting to complain to the doctor (28%). Patients reported that medical staff offered a mean of 11.63 recommendations for dealing with fatigue. The FMBQ was found to correlate significantly with self-efficacy (CBI-B, r = -0.20, P < 0.01) and correlate weakly with the number of recommendations made (r = -0.15, P < 0.05). The FMBQ was noted to have acceptable internal consistency (alpha = 0.88) and validity and may prove to be a useful instrument for understanding why patients do not communicate about fatigue. Multiple barriers contribute to why cancer patients do not comment about fatigue but may be overcome if physicians screen and assess for this symptom.

Sleep disturbance in cancer patients

Sleep difficulty is a prominent concern of cancer patients, yet there has been no large study of the prevalence and nature of sleep disturbance in cancer patients. This cross-sectional survey study examined: (a) the prevalence of reported sleep problems in patients attending six clinics at a regional cancer centre; (b) sleep problem prevalence in relation to cancer treatment; and (c) the nature of reported insomnia (type, duration, and associated factors). For three months, all patients attending clinics for breast, gastrointestinal, genitourinary, gynecologic, lung, and non-melanoma skin cancers were offered a brief sleep questionnaire. Response rate was 87%; the final sample size was 982. Mean age of respondents was 64.9 years (SD 12.5). The most prevalent problems were excessive fatigue (44% of patients), leg restlessness (41%). insomnia (31%), and excessive sleepiness (28%). Chi square tests showed significant variation among clinics in the prevalence of most sleep problems. The lung clinic had the highest or second-highest prevalence of problems. The breast clinic had a high prevalence of insomnia and fatigue. Recent cancer treatment was associated with excessive fatigue and hypersomnolence. Insomnia commonly involved multiple awakenings (76% of cases) and duration > or = 6 months (75% of cases). In 48% of cases, insomnia onset was reported to occur around the time of cancer diagnosis (falling within the period 6 months pre-diagnosis to 18 months post-diagnosis). The most frequently identified contributors to insomnia were thoughts, concerns, and pain/discomfort. In a multivariate logistic regression analysis, variables associated with increased odds of insomnia were fatigue, age (inverse relationship), leg restlessness, sedative/hypnotic use, low or variable mood, dreams, concerns, and recent cancer surgery. This study provides new information about sleep-related phenomena in cancer patients, information which will be useful in planning supportive care services for cancer patients.

Preliminary evaluation of a clinical syndrome approach to assessing cancer-related fatigue

The objectives of this study were to evaluate the reliability, validity, and utility of a newly developed clinical syndrome approach to assessing cancer-related fatigue. Fifty-one patients who underwent blood or marrow transplantation an average of 6.9 months previously were administered a standardized interview designed to identify the presence of a clinical syndrome of cancer-related fatigue. Patients also completed self-report measures of fatigue, depression, and health-related quality of life. Comparisons among independent raters demonstrated high rates of reliability for the presence or absence of a cancer-related fatigue syndrome and its symptoms. Twenty-one percent of patients (n = 11) were found to meet criteria for diagnosis of a cancer-related fatigue syndrome. Compared to patients not meeting the diagnostic criteria, patients meeting the criteria reported fatigue that was greater (P < or = 0.05) in its severity, frequency, pervasiveness, and interference with quality of life. Patients who met criteria also demonstrated poorer role functioning, less vitality, and more depressive symptomatology (P < or = 0.05). These findings provide preliminary evidence of the reliability and validity of the methods used to assess the proposed clinical syndrome and suggest their utility in identifying patients experiencing clinically significant cancer-related fatigue.

Fatigue as an important aspect of quality of life in patients with acute myeloid leukemia

Quality of life (QL) was evaluated in 101 patients with AML undergoing intensive and prolonged treatment at 12 sequential time points by using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C 30 questionnaire and the profile of mood states scale (POMS). For those patients having completed the course of inpatient treatment (n=37), QL improved from the beginning of chemotherapy to the end of inpatient treatment. Patients who subsequently went off protocol did not differ significantly in their self-assessed QL when compared with patients who completed therapy. Fatigue was more closely related to QL than nausea/emesis or appetite loss, but did not correlate with hemoglobin levels.

Self-assessment in cancer patients referred to palliative care: a study of feasibility and symptom epidemiology

BACKGROUND

Research in palliative care is considered difficult due to the poor health of patients. However, patient-provided data are essential for a thorough description of patient symptomatology and for the evaluation of care.

METHODS

The authors examined the feasibility of a questionnaire-based study using the European Organization for Research and Treatment of Cancer quality-of-life instrument EORTC QLQ-C30, the Edmonton Symptom Assessment System (ESAS), and the Hospital Anxiety and Depression Scale (HADS) in cancer patients who were receiving palliative care. This report describes the symptomatology of participating patients and examines differences in symptomatology between patients in three palliative care functions: inpatient, outpatient, and palliative home care.

RESULTS

Of 267 eligible patients who were referred to a department of palliative medicine, initial self-assessment questionnaires were obtained from 176 patients (65.9%). The 91 nonparticipants were older and had lower Karnofsky Performance status (KPS) values than the participants. Almost all participating patients suffered from impaired role function and physical function and had high levels of pain, fatigue, and other symptoms. According to the HADS, 47% of patients suffered from depression. Outpatients had better scores than inpatients and patients in palliative home care for physical function, role function, cognitive function, depression, and inactivity.

CONCLUSIONS

It is possible to carry out a questionnaire-based study of symptomatology in consecutive cancer patients in palliative care, achieving rather complete data from the participants. The symptomatology in these patients was very pronounced. The questionnaires were able to detect clinically important differences between places of service.

I get tired for no reason: a single item screening for cancer-related fatigue

This study examined the criterion validity and sensitivity and specificity of a single item to rapidly screen patients in ambulatory oncology clinics for cancer-related fatigue. In an effort to expand the utility of the Zung Self-Rating Depression Scale (ZSDS) as a screen for other symptoms, the utility of the single fatigue item was examined. The fatigue item reads "I get tired for no reason" and is rated on a four-point scale ranging from "none or a little of the time" to "most or all of the time." Fifty-two subjects were administered the Zung, the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale, and the Fatigue Symptom Inventory (FSI). The Zung item was highly correlated with the ZSDS (r= 0.63, p < 0.0001) and the FACT-An (r = -0.70, p < 0.0001), as well as to the individual items of the FSI, ranging from 0.41 (p < 0.003) to 0.71 (p < 0.0001). All 10 subjects considered to be depressed based on the ZSDS were also considered to fatigued on the FACT-An. Setting the ZSDS item cutoff point at level 3--"A good part of the time"--yielded a sensitivity of 78.95% and a specificity of 87.88%. It is concluded that a single item can be a fast and accurate way of screening cancer patients for fatigue to trigger additional follow-up, thus expanding the utility of a depression screening tool for problems other than the purely psychiatric.

Fatigue in ambulatory patients with advanced lung cancer: prevalence, correlated factors, and screening

Although it has been indicated that patients with lung cancer experience higher level of fatigue than patients with other cancers, few published studies have focused on the characteristics of this fatigue and how it interferes with daily activities. The purpose of this study was to clarify fatigue prevalence and the factors correlated with fatigue, and to develop a screening method for fatigue in patients with advanced lung cancer. One hundred fifty-seven patients completed two fatigue scales (Cancer Fatigue Scale [CFS], and Fatigue Numerical Scale [FNS]) plus other measures, along with a self-administered questionnaire asking whether fatigue had interfered with any of 7 areas of daily activities. Fifty-nine percent of patients had experienced clinical fatigue, which was defined as fatigue that interfered with any daily activities. Logistic regression analysis demonstrated that symptoms of dyspnea on walking, appetite loss, and depression were significant correlated factors. Both CFS and FNS were found to have sufficient sensitivity and specificity for use as a screening tool. The results indicated that fatigue is a frequent and important symptom, which is associated with both physical and psychological distress in this population. The CFS and FNS were confirmed to have sufficient screening ability.

Methylphenidate for fatigue in advanced cancer: a prospective open-label pilot study

Psychostimulants such as methylphenidate are used for fatigue in cancer patients. We report a prospective, open-label, pilot study of the successful use of methylphenidate to treat fatigue in nine of 11 consecutive patients with advanced cancer. Seven had received radiation or chemotherapy, a median of three weeks (range from one to 30 weeks) prior to methylphenidate. A rapid onset of benefit was noted, even in the presence of mild anemia. Sedation and pain also improved in some. Only one patient had side effects severe enough to stop the medication.

Fatigue patterns observed in patients receiving chemotherapy and radiotherapy

The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.

Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates

This study investigated the characteristics, course, and correlates of fatigue in women receiving adjuvant chemotherapy for breast cancer. Fifty-four patients were assessed before the start of chemotherapy and during the first three treatment cycles. An age-matched sample of women with no cancer history was assessed at similar time intervals for comparison purposes. Results indicated that breast cancer patients experienced worse fatigue than women with no cancer history. These differences were evident before and after patients started chemotherapy. In addition, fatigue worsened among patients after treatment started. More severe fatigue before treatment was associated with poorer performance status and the presence of fatigue-related symptoms (e.g., sleep problems and muscle weakness). Increases in fatigue after chemotherapy started were associated with continued fatigue-related symptoms and the development of chemotherapy side effects (e.g., nausea and mouth sores). These findings demonstrate the clinical significance of fatigue in breast cancer patients before and during adjuvant chemotherapy treatment. Results also suggest that aggressive management of common side effects, such as nausea and pain, may be useful in relieving chemotherapy-related fatigue.