Changes in and predictors of severity of fatigue in women with breast cancer: A longitudinal study

Prevalence and biopsychosocial indicators of fatigue in cancer patients

INTRODUCTION

Symptoms of cancer-related fatigue (CRF) can have a significant impact on patients' quality of life and treatment adherence. We aimed to investigate the relationship between CRF and multiple psychosocial and somatic indicators within a large mixed cancer sample.

METHODS

In this cross-sectional study, N = 1787 outpatients with cancer were assessed for CRF, pain, anxiety, and depression using validated screening instruments. We further obtained clinical parameters (Hb, CRP, creatinine, leukocytes, ASAT, and ALAT), sociodemographic data (age, gender, income, education level, marital status, parenthood, and living area), and lifestyle factors. Multivariate linear regression models were applied to estimate the impact of each indicator on CRF.

RESULTS

Overall, 90.6% of patients experienced some CRF, with 14.8% experiencing severe CRF. No gender difference was found in the prevalence of CRF. Patients with higher levels of pain, depressive symptoms, and lower Hb levels had significantly higher levels of CRF (ps <0.001). Lower levels of CRF were observed in patients who had children (p = 0.03), had less education (p < 0.001), and were physically active for more than 2 h per week before their oncological diagnosis (p = 0.014). The latter was only a significant indicator in the male subsample.

CONCLUSION

The present results demonstrate a high prevalence of CRF and highlight that not only somatic and psychosocial factors, but also lifestyle factors prior to diagnosis appear to be associated with the etiology and persistence of CRF. To effectively treat CRF, a biopsychosocial, personalized approach is recommended.

Effects of sleep disturbance, cancer-related fatigue, and psychological distress on breast cancer patients' quality of life: a prospective longitudinal observational study

More attention has gone to researching the cancer-related fatigue (CRF)-sleep disturbance (SD)-psychological distress (PD) symptom cluster in breast cancer patients during the chemotherapy period, but the change trend and heterogeneous development track in the whole treatment stage remain unclear, and it is also unclear whether the appearance of and changes in one symptom cause changes in other symptoms and quality of life (QoL). This study, using breast cancer patients' data collected through a validated questionnaire, examined the relationships between SD, CRF, PD, and QoL using latent growth modeling analyses. CRF developmental trajectories showed an upward trend over five surveys (slope = 0.649, P < 0.001); PD showed a significant weakening trend (slope = - 0.583, P < 0.001); SD showed an increasing trend (slope = 0.345, P < 0.001), and QoL showed a statistically significant weakening trend (slope = - 0.373, P < 0.001). The initial CRF (coefficient = - 0.233, P < 0.01), PD (coefficient = - 0.296, P < 0.01), and SD (coefficient = - 0.388, P < 0.001) levels had a statistically significant negative effect on initial QoL level. The linear development rate of PD was statistically significant and negatively affected that of QoL (coefficient = - 0.305, P < 0.05), whereas the quadratic development rate of SD negatively affected that of QoL (coefficient = - 0.391, P < 0.05). Medical staff should identify the change characteristics of different variables based on SD, CRF, PD, and QoL change trajectories, and advance the intervention time, as changes in variables affect other variables' subsequent changes.

Heterogeneity in resilience patterns and its prediction of 1-year quality of life outcomes among patients with newly diagnosed cancer: An exploratory piecewise growth mixture model analysis

PURPOSE

This study was designed to explore the impact of a new cancer diagnosis on resilience of patients and whether the resilience patterns could predict Quality of Life (QoL) in the first year.

METHODS

An exploratory linear piecewise growth mixture modeling (PGMM) with one hypothetical dot (3 months since diagnosis, T1) was employed to identify different resilience patterns and growth in 289 patients with different cancer diagnoses at five assessment occasions (T0-T4). Logistic regression analysis was performed to select potential predictors and receiver operating characteristic (ROC) curve analysis was utilized to test PGMM's discriminative ability against 1-year QoL.

RESULTS

Five discrete resilience trajectories with two growing trends were identified, including "Transcendence" (7.3%), "Resilient" (47.4%), "Recovery" (18.7%), "Damaged" (14.9%) and "Maladaption" (11.8%). Advanced stage, colorectal cancer, and receiving surgery therapy were significant predictors of negative resilience trajectories ("Damaged" or "Maladaption"). Discriminative ability was good for PGMM (AUC = 0.81, 95%CI, 0.76-0.85, P < 0.0001).

CONCLUSION

Heterogeneity is identified in resilience growth before and after 3 months since diagnosis. 26.7% newly diagnosed patients need additional attention especially for those with advanced colorectal cancer and receiving surgery therapy.

Fatigue and health-related quality of life in patients with immune thrombocytopenia: a longitudinal assessment in China

BACKGROUND

There is lacking studies of longitudinally assessment of fatigue and health-related quality of life (HRQoL) among Chinese immune thrombocytopenia (ITP) adults. We aimed to evaluate changes in fatigue and HRQoL and identify the associated factors.

METHODS

Patients' characteristics, Functional Assessment of Chronic Illness Therapy (FACIT-F) and the ITP-specific Patient Assessment Questionnaire (ITP-PAQ) scores at admission (T0), at discharge (T1), and three months after discharge (T2) were collected. Linear mixed effects models were used to examine changes over time.

RESULTS

We included 175 patients. The mean score of FACIT-F at T0 was 37.2 and increased at T1 (39.0), while then decreased at T2 (34.7). Patients who were single, retired, had persistent ITP, splenomegaly had more severe fatigue, whereas those who had not received any prior treatment and had a bleeding score of 0 at admission had milder fatigue. The mean score of ITP-PAQ was 57.7 at T0, then gradually increased to 60.3 at T1 and 62.8 at T2. Patients with persistent ITP and those who have never received treatment for ITP have better HRQoL.

CONCLUSION

ITP adults' fatigue and HRQoL were impaired. Patients' fatigue improved at discharge but worsened at three months after discharge, while HRQoL gradually improved over time.

Longitudinal comparison of health locus of control and subjective well-being in older women with breast cancer

OBJECTIVE

To investigate the dynamic changes in the health locus of control (HLC) and subjective well-being (SWB) of older women with breast cancer, to explore the relationship between the HLC and SWB of these patients at different time points.

DESIGN

The research method adopted was a longitudinal study. Convenience sampling was used to select older women with breast cancer and their HLC and SWB at different times were evaluated. The ages of the patients were ≥60 years. The survey was conducted starting from the day of admission and at 1 month, 3 months, and 6 months after surgery.

MAIN OUTCOME MEASURES

HLC and SWB.

RESULTS

The HLC and SWB of older women with breast cancer changed dynamically (P < 0.05), and the patients were in poor condition at T1. At each time point, the internal HLC (IHLC) for these patients was positively correlated with the total SWB score. Additionally, powerful others HLC (PHLC), chance HLC (CHLC), and SWB were negatively correlated (P < 0.05).

CONCLUSION

The HLC and SWB of older women with breast cancer change dynamically. Medical staff should pay more attention to the HLC and SWB of patients 1 month after surgery. SWB can be improved by improving the patients' IHLC and reducing their PHLC and CHLC.

Effects of Aromatherapy on Cancer Patients' Sleep and Fatigue: A Systematic Review and Meta-Analysis

Objective: This study aims at investigating the effectiveness of aromatherapy in enhancing sleep quality and reducing fatigue among cancer patients based on randomized controlled trials (RCTs) with a high level of evidence. Design: A systematic review and meta-analysis. Methods: Two reviewers screened and reviewed the full texts of search results obtained from six English databases and four Korean databases, and they extracted data from the selected studies independently. Risk of bias (RoB) was assessed using the revised Cochrane RoB tool for randomized trials. The review protocol was registered with the International Prospective Register of Systematic Reviews (CRD42021277515). Results: Eleven RCTs were included in this study. Aromatherapy significantly improved sleep quality among cancer patients compared with those in the control groups (routine care, no intervention, and placebo) (standardized mean difference [SMD] = -0.92, 95% confidence interval [CI]: -1.39 to -0.46; p < 0.001, I² = 89%). However, aromatherapy did not significantly reduce fatigue among such patients (SMD = -0.40, 95% CI: -0.81 to 0.01). The results of the meta-regression confirmed that increased intervention sessions resulted in the enhanced effectiveness of aromatherapy in improving sleep quality among cancer patients (Z = -3.86, p < 0.001). Conclusion: This study showed that aromatherapy significantly improves sleep quality among cancer patients. However, aromatherapy does not significantly reduce fatigue among cancer patients. It is possible that the statistical power of the meta-analysis was weak due to the small number of included studies. Therefore, in future studies, the effects of aromatherapy on fatigue among cancer patients should be assessed further using a larger number of included studies. Further, the effects of aromatherapy should be evaluated with a focus on specific subsets of patients, such as specific cancer diagnoses and specific modalities for cancer treatment.

Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial

Background

Breast cancer is the most common cancer type among women worldwide with over a million new cases each year. More than 40% of these women will struggle with chronic pain and fatigue after surgery, regardless of surgical procedure. These consequences are detrimental and result in distress and disability, including work disability. Few attempts have been made to prevent chronic pain and fatigue after surgery by applying a psychological approach, despite psychological risk factors being crucial in the development of both chronic pain and fatigue. In this study, we aim to develop and test an easily implementable strategy of preventing chronic pain and fatigue after breast cancer surgery. The intervention strategy involves a pre-operative hypnosis session and a web-based post-operative Acceptance and Commitment Therapy (ACT). The hypnosis has previously been found effective in alleviating acute post-operative pain and fatigue in breast cancer patients, while ACT is well suited to cancer populations as it offers a model of healthy adaptation to difficult circumstances. Together they form an intervention strategy with both a preventive and a rehabilitative focus.

Methods/Design

This randomized controlled trial aims to estimate the effects of the pre- and post- operative interventions compared to attentional control and treatment as usual (TAU) and will also include a qualitative process evaluation. Participants will be randomized to receive either a pre-operative brief hypnosis session and a post-operative web-based psychological intervention (iACT) or a pre-operative one-session mindfulness through an audio file and post-operative TAU. Self-reported questionnaire data and biomarker data will be assessed pre-surgery, post-surgery and 3 and 12 months after surgery. In addition, we will assess registry data on sick leave and prescriptions until 2-year follow-up. In the qualitative process evaluation, data will be collected from participants from both study arms (through interviews and a diary) and two different analyses performed (socio-narrative and Grounded Theory) with the objective to describe the development of chronic post-surgical pain and fatigue and the potential influence of the interventions on these processes. The study is set-up to demonstrate a minimum difference in pain of 1 point on NRS (0–10) and 3 points on FACIT-F (0–52) between the groups at 3-months follow-up by including 200 breast cancer patients in total.

Discussion

This trial will be the first study to estimate the effect of a combined pre-operative hypnosis with a post-operative iACT to prevent pain and fatigue after breast cancer surgery. The results from our study might i) help the large group of women affected by chronic pain and fatigue after breast cancer surgery, ii) shed light on the mechanisms involved in chronic pain and fatigue development, and iii) serve as a model for other surgical procedures.

Trial registration

Clinicaltrials.gov, registration number NCT04518085. Registered on January 29th, 2020. https://clinicaltrials.gov/ct2/show/NCT04518085.

Reflexology and meditative practices for symptom management among people with cancer: Results from a sequential multiple assignment randomized trial

Optimal sequencing of complementary therapies can help improve symptom management through nonpharmacological approaches. A 12-week sequential multiple assignment randomized trial comparing home-based reflexology and meditative practices on severity of fatigue and other symptoms was conducted among patients with cancer and their informal caregivers. Dyads were initially randomized to reflexology (N = 150), meditative practices (N = 150), or control (N = 47). If patient's fatigue did not improve (nonresponse) after 4 weeks of reflexology or meditative practices, the dyad was rerandomized to either add the other therapy or continue with the original therapy for weeks 5-8. Four decision rules (DRs) were compared: (1) Initiating reflexology, and if nonresponse on fatigue after 4 weeks, continue with reflexology for another 4 weeks, thus providing a higher dose; (2) Initiating reflexology, and if nonresponse on fatigue after 4 weeks, add meditative practices for the next 4 weeks; (3) Initiating meditative practices, and if nonresponse on fatigue after 4 weeks, continue meditative practices for another 4 weeks, thus providing a higher dose; and (4) Initiating meditative practices, and if nonresponse on fatigue after 4 weeks, add reflexology for the next 4 weeks. Symptoms were evaluated weekly using the M.D. Anderson Symptom Inventory (MDASI). Clinically, nurses can recommend either therapy since no differences were found among the 4 DRs, with the exception of lower severity for summed MDASI symptoms at week 8 for the use of reflexology only (DR-1) versus DR-2 (sequencing reflexology to meditative practices). Adding the other therapy for nonresponders after 4 weeks may not be warranted.

Symptom Profiles of Latina Breast Cancer Survivors: A Latent Class Analysis

BACKGROUND

Symptom research among Latinas with breast cancer is limited-especially as it relates to multiple co-occurring symptoms.

OBJECTIVE

The aim of the study was to identify subgroups (latent classes) of Latinas who have distinct symptom profiles while receiving radiation, chemotherapy, and/or hormonal therapy for breast cancer.

METHODS

This secondary analysis included intake data from three randomized trials of supportive care psychosocial interventions for Latinas treated for breast cancer (n = 290). Prevalence of 12 symptoms-measured using the General Symptom Distress Scale-was entered into the latent class analysis to identify classes of women with different symptom profiles.

RESULTS

Most of the participants had Stage II or III disease, and 81% reported receiving chemotherapy. On average, women reported 4.2 (standard deviation [SD] = 3) symptoms with an overall symptom distress score of 6.4 (SD = 2.5) on a 1-10 scale, with 10 being most distressing. Latent class analysis resulted in three classes that were labeled based on symptoms with the highest prevalence. Class 1 (n = 192) was "Disrupted Sleep and Tired," Class 2 (n = 74) was "Tired," and Class 3 (n = 24) was "Pain, Disrupted Sleep, and Tired." Depression, anxiety, and difficulty concentrating had moderate prevalence in each of the three classes.

DISCUSSION

Beyond the core six symptoms (depression, anxiety, fatigue, pain, disrupted sleep, difficulty concentration), the classes differed in the prevalence of other burdensome symptoms (e.g., nausea, vomiting, constipation), which provide implications for treatment. Thus, it is important to assess for the full range of symptoms so that supportive care interventions can be tailored for the distinct symptom profiles of Latinas with breast cancer.

The long-term course of fatigue following breast cancer diagnosis

Purpose

Fatigue following breast cancer is a well-known problem, with both high and persistent prevalence. Previous studies suffer from lack of repeated measurements, late recruitment and short periods of follow-up. The course of fatigue from diagnosis and treatment to the long-time outcome status is unknown as well as differences in the level of fatigue between treatment regimens. The purpose of this study was to describe the long-time course of fatigue from the time of clinical suspicion of breast cancer, its dependence of patient characteristics and treatment regimens and the comparison with the course of fatigue among women with the same suspicion, but not diagnosed with breast cancer.

Methods

Three hundred thirty-two women referred to acute or subacute mammography was followed with questionnaires from before the mammography and up to 1500 days. Fatigue was measured by the Multidimensional Fatigue Inventory (MFI-20). The women reported their initial level of fatigue before the mammography and thus without knowledge of whether they had cancer or not. Both women with and without cancer were followed. Women with cancer were identified in the clinical database established by Danish Breast Cancer Cooperative Group (DBCG) to collect information on treatment regimen.

Results

Compared to fatigue scores before diagnosis, women with breast cancer reported a large increase of fatigue, especially in the first 6 months, followed by a slow decrease over time. Despite the long follow-up period, the women with breast cancer did not return to their level of fatigue at time of the mammography. Women without breast cancer, experienced a rapid decrease of fatigue after disproval of diagnosis followed by a steadier period.

Conclusions

Fatigue is a persistent problem in women diagnosed with breast cancer, even several years following diagnosis and treatment. The women with breast cancer were most affected by fatigue in the first 6 months after diagnosis.

Reliability, validity, and sensitivity of the Chinese Short-Form 36 Health Survey version 2 (SF-36v2) in women with breast cancer

RATIONALE, AIMS, AND OBJECTIVES

The psychometrics of the Short-Form 36 Health Survey version 2 (SF-36v2) in female breast cancer patients remains unknown. This study aimed to test the reliability, validity, and sensitivity of the Chinese SF-36v2 in women with breast cancer.

METHODS

The sample included 326 eligible participants. The reliability and the item convergent and discriminant validity were estimated using Cronbach α (≥0.70) and the multi-trait multi-item matrix analysis, respectively. The structural validity was tested using confirmatory factor analysis. Sensitivity was determined via an analysis of variance and the relative efficiency for initially diagnosed cases (yes vs no) as well as the time since diagnosis (years) before and after stratifying by initially diagnosed cases.

RESULTS

The overall Cronbach α was 0.91 (eight scales range: 0.72-0.92). All hypothesized item-scale correlations were greater than the alternatives (r ≥ 0.40). With acceptable model fit indices, the physical functioning, role-physical, bodily pain, and general health subscales had stronger contributions to the physical component summary (goodness-of-fit index [GFI]: 0.92, parsimony goodness-of-fit index [PGFI]: 0.60, comparative fit index [CFI]: 0.91, Tucker-Lewis index [TLI]: 0.93, adjusted goodness-of-fit index [AGFI]: 0.91, root mean square error of approximation [RMSEA]: 0.06, normed chi-squared [NC]: 2.65), while the vitality, social functioning, role-emotional, and mental health subscales contributed more to the mental component summary (GFI: 0.91, PGFI: 0.62, CFI: 0.91, TLI: 0.92, AGFI: 0.91, RMSEA: 0.07, NC: 2.76). The relative efficiencies with significant F-statistics were found for mental health (relative efficiency: 34.28; initially diagnosed cases), physical functioning (12.88; time since diagnosis), and physical functioning (5.80), role-physical (5.15), bodily pain (7.70), social functioning (4.62), role-emotional (4.72), mental health (4.75), and physical component summary (6.96; initially diagnosed cases with time since diagnosis; P < 0.05 for all variables).

CONCLUSIONS

Chinese SF-36v2 has acceptable psychometric properties and is suitable for women with breast cancer.

Factors of the evolution of fatigue dimensions in patients with breast cancer during the 2 years after surgery

Women with breast cancer are increasingly being cured of the disease but fatigue remains the most frequently reported symptom. The aims of our study were to identify distinct trajectories in four fatigue dimensions during 2 years after breast cancer surgery and to explore the demographic, clinical and personality characteristics associated with these profiles. We included women from the prospective longitudinal multicenter FATSEIN cohort in France. They completed the Multidimensional Fatigue Inventory for nine follow-ups over 24 months after surgery. A group-based trajectory model identified distinct trajectories in each fatigue dimension. Multinomial logistic regression determined the factors associated with each profile. From the 459 women followed, 3-5 fatigue trajectories were revealed in each fatigue dimension, from its absence to its severest degree. In our multivariate analysis, the risk of severe fatigue was decreased in all dimensions by a high quality of life before surgery (measured by the European Organization for Research and Treatment of Cancer 30-item QoL questionnaire; e.g., for general and physical fatigue: OR = 0.93, 95% CI 0.91, 0.96), especially a high physical and emotional functions for general and physical fatigue, and a high cognitive function for mental fatigue. Both severe mental fatigue and severely reduced motivation worsened with low optimism before surgery (e.g., for mental fatigue: OR = 0.93, 95% CI 0.89, 0.97). Severely reduced activities increased by having chemotherapy (OR = 9.41, 95% CI 2.28, 38.79). Targeting women at risk for severe fatigue can provide early preventive and curative treatment and appropriate psychological support.

The effect of a 12-week home-based walking program on reducing fatigue in women with breast cancer undergoing chemotherapy: A randomized controlled study

BACKGROUND

Fatigue is the most common symptom experienced by cancer patients during treatment and can last long after completing treatment. Fatigue in cancer patients who have completed treatment is well known to be reduced by exercise, but the effect of exercise on reducing fatigue in patients under treatment has been inconsistent.

OBJECTIVES

The purposes of this study were to examine short-term and long-term effects of an individually tailored, home-based brisk walking program on reducing fatigue in breast cancer patients under chemotherapy.

DESIGN, SETTING, PARTICIPANTS

For this randomized controlled trial, women were recruited from a medical center in northern Taiwan if they were diagnosed with stages I-III breast cancer and experienced insomnia, fatigue, pain, or depressive symptoms after their first cycle of chemotherapy. Consenting participants (N = 159) were randomly assigned to either an exercise (12-week home-based walking program) group (n = 81) or an attention-control group (n = 78).

METHODS

The 12-week, home-based brisk walking program started on the first day of the third chemotherapy cycle. Fatigue was measured by the Brief Fatigue Inventory. Covariates, i.e., functional performance, sleep disturbance, anxiety, depression, and exercise-related variables, were also measured. Data were collected at baseline, two times during the exercise intervention, and five times after the exercise intervention (eight times in total). The effects of time-varying and time-invariant predictors on fatigue were analyzed by multilevel modeling.

RESULTS

Fatigue levels increased over time for both groups, even after completing treatment. At the end of the 12-week exercise program, the exercise group had less fatigue than the attention-control group, and this group difference was maintained for the whole study period. At the end of exercise program, women who had spent more time exercising before diagnosis had less fatigue than those who had exercised less often. In addition, patients' fatigue levels at various time points fluctuated along with their functional performance, sleep disturbance, and depression.

CONCLUSIONS

Our tailored, home-based brisk walking program effectively reduced fatigue in breast cancer patients under chemotherapy, and this effect lasted after completing treatment.

Symptom Trajectories Are Associated With Co-occurring Symptoms During Chemotherapy for Breast Cancer

CONTEXT

Symptoms are reported to co-occur during treatment for breast cancer. We previously identified three patterns of fatigue and two patterns of disturbed sleep, depressed mood, and anxiety in women undergoing chemotherapy for breast cancer using a Latent Growth Mixture Model.

OBJECTIVES

The purpose of this study was to explore whether membership in symptom classes of fatigue, disturbed sleep, depressed mood, and anxiety is associated with other symptoms at moderate-to-severe levels.

METHODS

Using data from three longitudinal studies, Wilcoxon rank-sum tests and Jonckheere-Terpstra tests for trend were used to distinguish between classes of women on co-occurring symptoms. Summative scores were calculated, including the number of days subjects reported moderate-to-severe levels (4 or higher on a 0-10 scale) of seven symptoms during two cycles of chemotherapy and compared to class membership.

RESULTS

Participants (n = 166) in the higher fatigue severity class reported more days with moderate-to-severe disturbed sleep, depressed mood, anxiety, nausea, and trouble thinking. Women in the higher severity disturbed sleep class reported more days with moderate-to-severe fatigue, depressed mood, anxiety, and trouble thinking. Women in the higher depressed mood severity class reported more days with moderate-to-severe fatigue, disturbed sleep, anxiety, and nausea. Women in the higher anxiety severity class reported more days with moderate-to-severe fatigue, disturbed sleep, and depressed mood.

CONCLUSION

Moderate-to-severe symptoms co-occur during cancer treatment for breast cancer. The dynamic process of multiple symptoms may be altered by future identification of a shared etiology.

Psychological Resilience as a Protective Factor for the Body Image in Post-Mastectomy Women with Breast Cancer

European statistics confirm a rise in breast cancer among contemporary women. Those suffering from cancer and undergoing a surgery (mastectomy) are undoubtedly considered to be in difficult situations. The range of the numerous negative and/or positive emotions, thoughts, and behaviours depend on many psychological factors such as psychological resilience. The authors are currently drawing a report on their own studies where they are trying to determine factors that protect body image resilience in women suffering from breast cancer after mastectomies. The research group consisted of 120 women after a short (up to 2 years) or a long (over 2 years) duration having elapsed since their mastectomy. The results of the research groups show that psychological resilience is a significant protecting factor for the body image that prevents the excessive development of negative self-esteem in post-mastectomy women. Female patients ought to be provided aid in the short time immediately after the procedure and afterwards, when they are less capable of tolerating negative emotions. In order to significantly improve the general body image resilience to emotional and cognitive distortions in post-mastectomy women who experienced breast cancer, it is recommended that psychological interventions (from psychoeducation to psychological assistance and specialist psychotherapy) are conducted systematically throughout the course of treatment.

Distinct Trajectories of Fatigue and Sleep Disturbance in Women Receiving Chemotherapy for Breast Cancer

PURPOSE/OBJECTIVES

To examine self-reported severity of fatigue and disturbed sleep experienced daily by women with breast cancer during multiple cycles of chemotherapy, exploring potential classes of women experiencing similar symptom trajectories.
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DESIGN

In a secondary analysis, classes of women experiencing similar patterns of fatigue and disturbed sleep were identified.
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SETTING

Oncology clinics in the United States.
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SAMPLE

166 women with breast cancer receiving chemotherapy. 
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METHODS

Severity scores were self-reported daily using an automated system. Classes of fatigue and disturbed sleep severity were identified using latent growth mixture modeling.
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MAIN RESEARCH VARIABLES

Fatigue, disturbed sleep, age, stage of disease, education, employment, marital status, chemotherapy regimen, hours lying down, and missed work.
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FINDINGS

Three fatigue classes were identified.

CONCLUSIONS

Patterns of symptom trajectories for fatigue and disturbed sleep were distinguished by baseline symptom severity.
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IMPLICATIONS FOR NURSING

Identification of women at risk for fatigue and disturbed sleep may allow clinicians to intensify symptom management.

Effects of zinc supplementation on fatigue and quality of life in patients with colorectal cancer

Objective

To investigate the effects of oral zinc supplementation on fatigue intensity and quality of life of patients during chemotherapy for colorectal cancer.

Methods

A prospective, randomized, double-blinded, placebo-controlled study was conducted with 24 patients on chemotherapy for colorectal adenocarcinoma in a tertiary care public hospital. The study patients received zinc capsules 35mg (Zinc Group, n=10) or placebo (Placebo Group, n=14) orally, twice daily (70mg/day), for 16 weeks, from the immediate postoperative period to the fourth chemotherapy cycle. Approximately 45 days after surgical resection of the tumor, all patients received a chemotherapeutic regimen. Before each of the four cycles of chemotherapy, the Functional Assessment of Chronic Illness Therapy-Fatigue scale was completed. We used a linear mixed model for longitudinal data for statistical analysis.

Results

The scores of quality of life and fatigue questionnaires were similar between the groups during the chemotherapy cycles. The Placebo Group presented worsening of quality of life and increased fatigue between the first and fourth cycles of chemotherapy, but there were no changes in the scores of quality of life or fatigue in the Zinc Group.

Conclusion

Zinc supplementation prevented fatigue and maintained quality of life of patients with colorectal cancer on chemotherapy.

Symptom Cluster Trajectories During Chemotherapy in Breast Cancer Outpatients

CONTEXT

Breast cancer patients often experience multiple symptoms and substantial discomfort. Some symptoms may occur simultaneously and throughout the duration of chemotherapy treatment.

OBJECTIVES

The aim of this study was to investigate symptom severity and symptom cluster trajectories during chemotherapy in outpatients with breast cancer in Taiwan.

METHODS

This prospective, longitudinal, repeated measures study administered a standardized questionnaire (M. D. Anderson Symptom Inventory Taiwan version) to 103 breast cancer patients during each day of the third 21-day cycle of chemotherapy. Latent class growth analysis was performed to examine symptom cluster trajectories.

RESULTS

Three symptom clusters were identified within the first 14 days of the 21-day chemotherapy cycle: the neurocognition cluster (pain, shortness of breath, vomiting, memory problems, and numbness/tingling) with a trajectory of Y = 2.09 - 0.11 (days), the emotion-nausea cluster (nausea, disturbed sleep, distress/upset, drowsiness, and sadness) with a trajectory ofY = 3.57 - 0.20 (days), and the fatigue-anorexia cluster (fatigue, lack of appetite, and dry mouth) with a trajectory of Y = 4.22 - 0.21 (days). The "fatigue-anorexia cluster" and "emotion-nausea cluster" peaked at moderate levels on chemotherapy days 3-5, and then gradually decreased to mild levels within the first 14 days of the 21-day chemotherapy cycle.

CONCLUSION

Distinct symptom clusters were observed during the third cycle of chemotherapy. Systematic and ongoing evaluation of symptom cluster trajectories during cancer treatment is essential. Healthcare providers can use these findings to enhance communication with their breast cancer patients and to prioritize symptoms that require attention and intervention.

Distinct Evening Fatigue Profiles in Oncology Outpatients Receiving Chemotherapy

Background

Fatigue is the most common and debilitating symptom experienced by oncology patients during chemotherapy (CTX). Fatigue severity demonstrates a large amount of inter-individual and diurnal variability.

Purpose

Study purposes were to evaluate for subgroups of patients with distinct evening fatigue profiles and evaluate how these subgroups differed on demographic, clinical, and symptom characteristics.

Methods

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (n=1332) completed questionnaires six times over two cycles of CTX. Lee Fatigue Scale (LFS) evaluated evening fatigue severity. Latent profile analysis was used to identify distinct evening fatigue profiles.

Results

Four distinct evening fatigue classes (i.e., Low (14.0%), Moderate (17.2%), High (36.0%), Very High (32.8%)) were identified. Compared to the Low class, patients in the Very High evening fatigue class were: younger, female, had childcare responsibilities, had more years of education, had a lower functional status, had a higher comorbidity burden, and were diagnosed with breast cancer. Patients in the Very High class reported higher levels of depressive symptoms, sleep disturbance, and evening fatigue at enrollment.

Conclusions

Findings provide new insights into modifiable risk factors for higher levels of evening fatigue. Clinicians can use this information to identify higher risk patients and plan appropriate interventions.

The experience of breast cancer survivors’ participation in important activities during and after treatments

Introduction

This study compares breast cancer survivors’ experiences of participating in activities important to them, both during and after breast cancer treatment.

Method

Eight survivors between the ages of 41 and 60 years with Stage I, II, or III breast cancer who had been treated consecutively with surgery, chemotherapy, and radiation therapy were recruited for the study. Participants completed the Activity Card Sort-modified and a semi-structured interview at the end of radiation therapy and 6 months post treatment.

Findings

Interpretative phenomenological analysis was used to analyze the transcripts. The themes identified differed at each time point. At the end of treatment, themes were (a) personal and treatment stress changes activity participation, (b) strategies increase activity participation, (c) fatigue, fear of infection or other side effects reduces activity participation, (d) family and friends assist with completing activities, and (e) plans for participating in activities after treatment ends. At 6 months post treatment, themes were: (a) emotions influence activity participation, (b) activities after cancer have changed, and (c) side effects influence activity participation.

Conclusions

During treatment, survivors may be focusing more on “needed” activities; later on, survivors may want to participate in leisure activities, including ones that they have been wanting to pursue.

Surgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity

BACKGROUND

Fatigue has been reported by many patients undergoing surgery and is associated with a negative prognosis. The factors associated with postoperative fatigue and its evolution during the postoperative period are unclear. Adequate fatigue measurement instruments are necessary to obtain reliable evaluations and to direct effective care to control fatigue in this patient population.

OBJECTIVES

This article describes the evolution of postoperative fatigue in patients with cancer as well as related factors.

METHODS

A review of the literature using the CINAHL® and PubMed databases was undertaken.

FINDINGS

The prevalence of moderate and severe fatigue varies during the postoperative period, with a reduction in the 12 months after surgery. Various factors (e.g., stress, anxiety, depression, pain, changes in sleep patterns) seem to influence the severity of fatigue. More evidence is needed to explore the relationship between immediate postoperative fatigue and the evolution of fatigue during the period following surgical treatment for cancer.

Inflammatory pathway genes associated with inter-individual variability in the trajectories of morning and evening fatigue in patients receiving chemotherapy

Fatigue, a highly prevalent and distressing symptom during chemotherapy (CTX), demonstrates diurnal and interindividual variability in severity. Little is known about the associations between variations in genes involved in inflammatory processes and morning and evening fatigue severity during CTX. The purposes of this study, in a sample of oncology patients (N=543) with breast, gastrointestinal (GI), gynecological (GYN), or lung cancer who received two cycles of CTX, were to determine whether variations in genes involved in inflammatory processes were associated with inter-individual variability in initial levels as well as in the trajectories of morning and evening fatigue. Patients completed the Lee Fatigue Scale to determine morning and evening fatigue severity a total of six times over two cycles of CTX. Using a whole exome array, 309 single nucleotide polymorphisms SNPs among the 64 candidate genes that passed all quality control filters were evaluated using hierarchical linear modeling (HLM). Based on the results of the HLM analyses, the final SNPs were evaluated for their potential impact on protein function using two bioinformational tools. The following inflammatory pathways were represented: chemokines (3 genes); cytokines (12 genes); inflammasome (11 genes); Janus kinase/signal transducers and activators of transcription (JAK/STAT, 10 genes); mitogen-activated protein kinase/jun amino-terminal kinases (MAPK/JNK, 3 genes); nuclear factor-kappa beta (NFkB, 18 genes); and NFkB and MAP/JNK (7 genes). After controlling for self-reported and genomic estimates of race and ethnicity, polymorphisms in six genes from the cytokine (2 genes); inflammasome (2 genes); and NFkB (2 genes) pathways were associated with both morning and evening fatigue. Polymorphisms in six genes from the inflammasome (1 gene); JAK/STAT (1 gene); and NFkB (4 genes) pathways were associated with only morning fatigue. Polymorphisms in three genes from the inflammasome (2 genes) and the NFkB (1 gene) pathways were associated with only evening fatigue. Taken together, these findings add to the growing body of evidence that suggests that morning and evening fatigue are distinct symptoms.

Associations Between Neurotransmitter Genes and Fatigue and Energy Levels in Women After Breast Cancer Surgery

CONTEXT

Fatigue is a common problem in oncology patients. Less is known about decrements in energy levels and the mechanisms that underlie both fatigue and energy.

OBJECTIVES

In patients with breast cancer, variations in neurotransmitter genes between lower and higher fatigue latent classes and between the higher and lower energy latent classes were evaluated.

METHODS

Patients completed assessments before and monthly for six months after surgery. Growth mixture modeling was used to identify distinct latent classes for fatigue severity and energy levels. Thirty candidate genes involved in various aspects of neurotransmission were evaluated.

RESULTS

Eleven single-nucleotide polymorphisms or haplotypes (i.e., ADRB2 rs1042718, BDNF rs6265, COMT rs9332377, CYP3A4 rs4646437, GALR1 rs949060, GCH1 rs3783642, NOS1 rs9658498, NOS1 rs2293052, NPY1R Haplotype A04, SLC6A2 rs17841327, and 5HTTLPR + rs25531 in SLC6A4) were associated with latent class membership for fatigue. Seven single-nucleotide polymorphisms or haplotypes (i.e., NOS1 rs471871, SLC6A1 rs2675163, SLC6A1 Haplotype D01, SLC6A2 rs36027, SLC6A3 rs37022, SLC6A4 rs2020942, and TAC1 rs2072100) were associated with latent class membership for energy. Three of 13 genes (i.e., NOS1, SLC6A2, and SLC6A4) were associated with latent class membership for both fatigue and energy.

CONCLUSIONS

Molecular findings support the hypothesis that fatigue and energy are distinct, yet related symptoms. Results suggest that a large number of neurotransmitters play a role in the development and maintenance of fatigue and energy levels in breast cancer patients.

Polymorphisms in Cytokine Genes Are Associated With Higher Levels of Fatigue and Lower Levels of Energy in Women After Breast Cancer Surgery

CONTEXT

Little is known about the phenotypic and molecular characteristics associated with changes over time in fatigue and lack of energy in patients with breast cancer.

OBJECTIVES

The aim of this study was to identify subgroups (i.e., latent classes) of women with distinct fatigue and energy trajectories; evaluate for differences in phenotypic characteristics between the latent classes for fatigue and energy; and evaluate for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators and latent class membership.

METHODS

Patients were enrolled before and followed for six months after breast cancer surgery. Latent class analyses were done to identify subgroups of patients with distinct fatigue and energy trajectories. Candidate gene analyses were done to identify cytokine genes associated with these two symptoms.

RESULTS

For both fatigue and lack of energy, two distinct latent classes were identified. Phenotypic characteristics associated with the higher fatigue class were younger age, higher education, lower Karnofsky Performance Status score, higher comorbidity, higher number of lymph nodes removed, and receipt of chemotherapy (CTX). Polymorphisms in interleukin (IL) 1β and IL10 were associated with membership in the higher fatigue class. Phenotypic characteristics associated with the lower energy class included: a lower Karnofsky Performance Status score and a higher comorbidity score. A polymorphism in IL1R1 was associated with membership in the lower energy class.

CONCLUSION

Within each latent class, the severity of fatigue and decrements in energy were relatively stable over the first six months after breast cancer surgery. Distinct phenotypic characteristics and genetic polymorphisms were associated with membership in the higher fatigue and lower energy classes.

Gender Differences in Predictors of Quality of Life at the Initiation of Radiation Therapy

PURPOSE/OBJECTIVES

To evaluate gender differences in quality of life (QOL), demographic, clinical, and symptom characteristics.


DESIGN

Prospective, observational.


SETTING

Two radiation oncology departments in northern California.


SAMPLE

185 patients before initiation of radiation therapy (RT).


METHODS

At their RT simulation visit, patients completed a demographic questionnaire, a measure of QOL, and symptom-specific scales. Backward elimination regression analyses were conducted to determine the significant predictors of QOL
.

MAIN RESEARCH VARIABLES

QOL, gender, and 20 potential predictors
.

FINDINGS

In women, depressive symptoms, functional status, age, and having children at home explained 64% of the variance in QOL. In men, depressive symptoms, state anxiety, number of comorbidities, being a member of a racial or ethnic minority, and age explained 70% of the variance in QOL
.

CONCLUSIONS

Predictors of QOL differed by gender. Depressive symptom score was the greatest contributor to QOL in both genders.
.

IMPLICATIONS FOR NURSING

Nurses need to assess for QOL and depression at the initiation of RT. Knowledge of the different predictors of QOL may be useful in the design of gender-specific interventions to improve QOL.

Burden of symptoms associated with development of metastatic bone disease in patients with breast cancer

Purpose

Women with breast cancer frequently develop painful bone metastases. This retrospective study was designed to longitudinally characterize patterns of patient-reported symptoms among patients with breast cancer relative to the diagnosis of bone metastases.

Methods

Patient records were identified from the Oncology Services Comprehensive Electronic Records (OSCER) database which includes outpatient oncology practices across the USA. Symptom burden was assessed by Patient Care Monitor (PCM) assessments, which are administered as part of routine care in a subset of these practices. Eligible patients were women diagnosed with breast cancer (ICD-9-CM 174.xx) who developed bone metastases (ICD-9-CM 198.5) and had ≥1 PCM assessment between January 2007 and December 2012. The pre-specified endpoint was the occurrence of moderate to severe symptom burden, defined as PCM score ≥4 (0–10 scale).

Results

One thousand one hundred five women (median age, 61) met the eligibility criteria. Worsening of symptoms, particularly fatigue and pain, occurred in the months leading up to the diagnosis of bone metastases. After bone metastases diagnosis, the rate of increase in the proportion of patients experiencing moderate/severe symptoms slowed, but continued to climb during follow-up. Median time to moderate/severe symptoms was 0.9 month for fatigue, 1 month for pain, 2.9 months for trouble sleeping, and 7.7 months for numbness/tingling. Half of the patients received bone-targeted agents after diagnosis of bone metastases.

Conclusions

Symptom burden, especially pain and fatigue, increased both before and after the diagnosis of bone metastases, highlighting the need for proactive monitoring and management of symptoms in breast cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3154-x) contains supplementary material, which is available to authorized users.

Predictors and Trajectories of Morning Fatigue Are Distinct From Evening Fatigue

CONTEXT

Fatigue is the most common symptom in oncology patients during chemotherapy. Little is known about the predictors of interindividual variability in initial levels and trajectories of morning fatigue severity in these patients.

OBJECTIVES

An evaluation was done to determine which demographic, clinical, and symptom characteristics were associated with initial levels as well as the trajectories of morning fatigue and to compare findings with our companion paper on evening fatigue.

METHODS

A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (n = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives.

RESULTS

A large amount of interindividual variability was found in the morning fatigue trajectories. A piecewise model fit the data best. Patients with higher body mass index, who did not exercise regularly, with a lower functional status, and who had higher levels of state anxiety, sleep disturbance, and depressive symptoms reported higher levels of morning fatigue at enrollment. Variations in the trajectories of morning fatigue were predicted by the patients' ethnicity and younger age.

CONCLUSION

The modifiable risk factors that were associated with only morning fatigue were body mass index, exercise, and state anxiety. Modifiable risk factors that were associated with both morning and evening fatigue included functional status, depressive symptoms, and sleep disturbance. Using this information, clinicians can identify patients at higher risk for more severe morning fatigue and evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Trajectories of Evening Fatigue in Oncology Outpatients Receiving Chemotherapy

CONTEXT

Fatigue is a distressing persistent sense of physical tiredness that is not proportional to a person's recent activity. Fatigue impacts patients' treatment decisions and can limit their self-care activities. Although significant interindividual variability in fatigue severity has been noted, little is known about predictors of interindividual variability in initial levels and trajectories of evening fatigue severity in oncology patients receiving chemotherapy.

OBJECTIVES

To determine whether demographic, clinical, and symptom characteristics were associated with initial levels and the trajectories of evening fatigue.

METHODS

A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (N = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives.

RESULTS

A large amount of interindividual variability was found in the evening fatigue trajectories. A piecewise model fit the data best. Patients who were white, diagnosed with breast, gynecological, or lung cancer, and who had more years of education, childcare responsibilities, lower functional status, and higher levels of sleep disturbance and depression reported higher levels of evening fatigue at enrollment.

CONCLUSION

This study identified both nonmodifiable (e.g., ethnicity) and modifiable (e.g., childcare responsibilities, depressive symptoms, sleep disturbance) risk factors for more severe evening fatigue. Using this information, clinicians can identify patients at higher risk for more severe evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Trajectories of fear of recurrence in women with breast cancer

PURPOSE

Although fear of recurrence (FCR) is common among cancer survivors, it remains unclear what factors predict initial levels (e.g., prior to surgery) or changes in FCR in the post-treatment period. Among women treated for breast cancer, this study evaluated the effects of demographic, clinical, symptom, and psychosocial adjustment characteristics on the initial (preoperative) levels of FCR and trajectories of FCR over 6 months following surgery.

METHODS

Prior to and for 6 months following breast cancer surgery, 396 women were assessed for demographic and clinical (disease and treatment) characteristics, symptoms, psychological adjustment characteristics, and quality of life (QOL). FCR was assessed using a four-item subscale from the QOL instrument. Hierarchical linear modeling was used to examine changes in FCR scores and to identify predictors of inter-individual differences in preoperative FCR levels and trajectories over 6 months.

RESULTS

From before surgery to 6 months post-operatively, women with breast cancer showed a high degree of inter-individual variability in FCR. Preoperatively, women who lived with someone, experienced greater changes in spiritual life, had higher state anxiety, had more difficulty coping, or experienced more distress due to diagnosis or distress to family members reported higher FCR scores. Patients who reported better overall physical health and higher FCR scores at enrollment demonstrated a steeper decrease in FCR scores over time.

CONCLUSIONS

These findings highlight inter-individual heterogeneity in initial levels and changes in FCR over time among women undergoing breast cancer surgery. Further work is needed to identify and provide interventions for women experiencing FCR during and after breast cancer treatment.

Presurgical symptom profiles predict quality of life 2 years after surgery in women with breast cancer

PURPOSE

Higher symptom burden in oncology patients is associated with poorer quality of life (QOL). However, the long-term predictive relationship between pre-treatment symptom profiles and QOL is unknown. The aim of this study was to identify subgroups of breast cancer patients based on their presurgical symptom profiles and to examine the predictive effect of group membership on QOL 2 years after surgery.

METHODS

Data were analyzed from a longitudinal study of women's (N = 198) symptoms after breast cancer surgery. Patient subgroups were identified by latent class analysis based on presurgical severity of five symptoms (i.e., attentional and physical fatigue, sleep disturbance, depression, and anxiety). Among these 198 women, quality of life 2 years after surgery was available for 97. Group differences in QOL were examined by general linear models.

RESULTS

We identified four distinct patient groups. Group A (All Low) had low levels of all symptoms. Group B (Low Fatigue and Moderate Mood) was characterized by low attentional and physical fatigue but moderate sleep disturbance, depression, and anxiety. Group C (All Moderate) was characterized by moderate levels of all five symptoms. Group D was characterized by moderate attentional and physical fatigue and severe sleep disturbance, depression, and anxiety (Moderate Fatigue and High Mood). Group D had significantly lower overall QOL scores 2 years after surgery than Group A (p = 0.002).

CONCLUSIONS

Breast cancer patients' presurgical symptom profile had a long-term predictive effect on QOL. Routine assessment of patients' pre-treatment symptom is suggested to identify high risk group.