Fatigue in patients with cancers of the breast or prostate undergoing radical radiotherapy

Multidisciplinary analysis of cancer-related fatigue at the time of diagnosis: preliminary results of the BIOCARE FActory cohort

PURPOSE

Cancer-related fatigue (CRF) is a common side effect of cancer and cancer treatment that significantly impairs the quality of life and can persist for years after treatment completion. Although fatigue is often associated with cancer treatment, it is also a result of the disease itself, even before intervention. CRF at the time of diagnosis may affect treatment timing or completion and is a consistent predictor of post-treatment fatigue at any time. The mechanisms underlying CRF are multidimensional and not well understood, particularly at the time of diagnosis.

METHODS

Sixty-five breast cancer patients at the time of diagnosis were included. The participants completed self-assessment questionnaires about CRF, sleep disturbances, and emotional symptoms and wore an accelerometer to assess levels of spontaneous physical activity and sleep quality. During the experimental session, the participants underwent cognitive, neuromuscular, and exercise metabolism evaluations.

RESULTS

Using augmented backward elimination regression, this study found that emotional symptoms and perceived sleep disturbances were the strongest predictors of CRF (adjusted r2 = 0.51). Neuromuscular fatigability and sleep disturbance were also associated with physical dimensions, whereas cognitive performance was associated with cognitive dimensions.

CONCLUSION

At the time of diagnosis, emotional and cognitive dimensions are over-represented compared to the general population, and specific subdimensions have specific predictors that support the idea of distinct mechanisms. Evaluating CRF subdimensions and their potential mechanisms at the time of diagnosis would be particularly relevant for identifying high-risk patients and offering them appropriate interventions.

TRIAL REGISTRATION

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

Autonomic function measurements for evaluating fatigue and quality of life in patients with breast cancer undergoing radiation therapy: a prospective longitudinal study

BACKGROUND

Fatigue during radiation therapy in women with breast cancer can decrease quality of life (QOL), yet it is often underestimated and needs to be evaluated objectively. This longitudinal study aimed to evaluate fatigue and QOL of women with breast cancer undergoing radiotherapy with a simple autonomic function measurement.

METHODS

Women with breast cancer who underwent postoperative radiotherapy in eight cancer care hospitals in Chubu and Kinki regions in Japan were recruited between October 2021 and June 2022. The women underwent a self-administered questionnaire that included the Cancer Fatigue Scale (CFS) and the Short Form-8 Health Survey (SF-8) and an autonomic nervous function measurement using a simple, non-invasive device before (T0, baseline), mid (T1), and at the end (T2) of treatment.

RESULTS

The 57 women showed similar trends, with CFS scores and log LF/HF ratio being the highest at T0 and significantly decreasing at T1 (both p < 0.05). The log LF/HF trends differed between those with high and low baseline log LF/HF values. Women with mental component summary (MCS) score improvement (T0 to T2) had the highest log LF/HF ratio at T0 and had significantly lower log LF/HF values at T1 and T2 than at T0 (p < 0.01 and p < 0.05, respectively). The change of (⊿) MCS from T0 to T1 was negatively correlated with ⊿log LF/HF from T0 to T1 (r = - 0.36, p < 0.01).

CONCLUSIONS

Measurement of autonomic nerve function with a simple device is useful for objective fatigue assessment during radiotherapy. Psychological support is important as improvement in mental health helps improve autonomic nerve function and, in turn, fatigue.

The Current Trend of Radiation Therapy for Patients with Localized Prostate Cancer

A recent approach to radiotherapy for prostate cancer is the administration of high doses of radiation to the prostate while minimizing the risk of side effects. Thus, image-guided radiotherapy utilizes advanced imaging techniques and is a feasible strategy for increasing the radiation dose. New radioactive particles are another approach to achieving high doses and safe procedures. Prostate brachytherapy is currently considered as a combination therapy. Spacers are useful to protect adjacent organs, specifically the rectum, from excessive radiation exposure.

Telehealth-Based Music Therapy Versus Cognitive Behavioral Therapy for Anxiety in Cancer Survivors: Rationale and Protocol for a Comparative Effectiveness Trial

BACKGROUND

Cancer survivors represent one of the fastest growing populations in the United States. Unfortunately, nearly 1 in 3 survivors experience anxiety symptoms as a long-term consequence of cancer and its treatment. Characterized by restlessness, muscle tension, and worry, anxiety worsens the quality of life; impairs daily functioning; and is associated with poor sleep, depressed mood, and fatigue. Although pharmacological treatment options are available, polypharmacy has become a growing concern for cancer survivors. Music therapy (MT) and cognitive behavioral therapy (CBT) are evidence-based, nonpharmacological treatments that have demonstrated effectiveness in treating anxiety symptoms in cancer populations and can be adapted for remote delivery to increase access to mental health treatments. However, the comparative effectiveness of these 2 interventions delivered via telehealth is unknown.

OBJECTIVE

The aims of the Music Therapy Versus Cognitive Behavioral Therapy for Cancer-related Anxiety (MELODY) study are to determine the comparative effectiveness of telehealth-based MT versus telehealth-based CBT for anxiety and comorbid symptoms in cancer survivors and to identify patient-level factors associated with greater anxiety symptom reduction for MT and CBT.

METHODS

The MELODY study is a 2-arm, parallel-group randomized clinical trial that aims to compare the effectiveness of MT versus CBT for anxiety and comorbid symptoms. The trial will enroll 300 English- or Spanish-speaking survivors of any cancer type or stage who have experienced anxiety symptoms for at least 1 month. Participants will receive 7 weekly sessions of MT or CBT delivered remotely via Zoom (Zoom Video Communications, Inc) over 7 weeks. Validated instruments to assess anxiety (primary outcome), comorbid symptoms (fatigue, depression, insomnia, pain, and cognitive dysfunction), and health-related quality of life will be administered at baseline and at weeks 4, 8 (end of treatment), 16, and 26. Semistructured interviews will be conducted at week 8 with a subsample of 60 participants (30 per treatment arm) to understand individual experiences with the treatment sessions and their impact.

RESULTS

The first study participant was enrolled in February 2022. As of January 2023, 151 participants have been enrolled. The trial is expected to be completed by September 2024.

CONCLUSIONS

This study is the first and largest randomized clinical trial to compare the short- and long-term effectiveness of remotely delivered MT and CBT for anxiety in cancer survivors. Limitations include the lack of usual care or placebo control groups and the lack of formal diagnostic assessments for psychiatric disorders among trial participants. The study findings will help guide treatment decisions for 2 evidence-based, scalable, and accessible interventions to promote mental well-being during cancer survivorship.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46281.

Efficacy of an asynchronous telerehabilitation program in post-COVID-19 patients: A protocol for a pilot randomized controlled trial

Background

About 40% of patients who have had COVID-19 still have symptoms three months later whereas a 10% may experience physical and/or psychological consequences two years later. Therefore, it is necessary to perform preventive interventions when patients are discharged from the hospital to decrease the aforementioned sequelae. The purpose of this pilot-controlled trial will be to determine the efficacy of a rehabilitation program on functional status and psychosocial factors for post-COVID-19 patients when it is delivered through a tele-care platform versus a booklet-based rehabilitation.

Methods

The estimated sample size will be of 50 participants who have been discharged after COVID-19 and have a level of fatigue equal or greater than 4 on the Fatigue Severity Scale. The primary outcome will be the severity of fatigue. Participants will be randomly allocated to an “asynchronous telerehabilitation group” or to a “booklet-based rehabilitation group”. Treatment in both groups will be the same and will consist of a combination of therapeutic exercise and an educative program. Treatment outcomes will be evaluated the last day of the intervention and at three- and six-months follow-up.

Discussion

The telerehabilitation intervention appears to be a viable and efficacy option in decreasing severe fatigue and other fitness variables such as strength and aerobic capacity, similar to other traditional rehabilitation formats such as through an explanatory booklet.

Clinical trial registration

This trial has been prospectively registered at clinialtrials.gov identifier: NCT04794036.

The association of personality traits with poststroke fatigue in daily life: An exploratory experience sampling method and cross-sectional study

Fatigue is a frequently occurring and persistent symptom after stroke. Many biological, psychosocial, and behavioural factors are associated with poststroke fatigue, but research into associations with personality traits is relatively sparse. In this study, we explored whether personality traits were related to poststroke fatigue measured with conventional fatigue questionnaires as well as experience sampling methodology (ESM). Twenty-four individuals with stroke completed 10 daily questionnaires about momentary (here-and-now) fatigue for six consecutive days using the mHealth ESM application PsyMate^TM. Further, they completed questionnaires assessing personality (NEO-FFI and LOR-T) and fatigue (FSS). Results showed that higher extraversion (ß = -.44, SE = .12, p = .001; 95% CI = -.67-.19) and optimism (ß = -.18, SE = .06, p = .007; 95% CI = -.30-.05) were associated with lower momentary fatigue. No association was found between neuroticism and momentary fatigue, but higher neuroticism (r = 0.531, p = .008, 95% CI = .160-.759; r = .574, p = .003, 95% CI = .245-.767) was associated with higher scores on the retrospective FSS scales. We conclude that personality traits differentially influence poststroke fatigue, but this also depends on the way fatigue is measured (with retrospective or with momentary measures). When functional gains are not in line with expected progress during the rehabilitation treatment of fatigue, it may be appropriate to take into account how person characteristics are related to momentary fatigue.

Cancer-related fatigue and depression: a monocentric, prospective, cross-sectional study in advanced solid tumors

Background

Cancer-related fatigue (CRF) is common in patients with advanced solid tumors and several risk factors are described. The possible role of depression is reported by clinicians despite the association with CRF being unclear.

Material and methods

In this monocentric, cross-sectional, prospective study we recruited patients with advanced solid tumors who were hospitalized at Fondazione IRCCS Istituto Nazionale dei Tumori of Milan. The primary objective was to assess the correlation between CRF and depression. Secondary objectives were the estimation of CRF and depression prevalence and the identification of associated clinical risk factors. CRF and depression were evaluated through the Functional Assessment of Cancer Therapy-Fatigue subscale and the Zung Self Depression Scale (ZSDS) questionnaires. The Cochran-Armitage trend test was used to demonstrate the primary hypothesis. Univariate and multivariate logistic regression models were used to investigate the impact of clinical variables.

Results

A total of 136 patients were enrolled. The primary analysis found a linear correlation (P < 0.0001) between CRF and depression. The prevalence of CRF and of moderate to severe depressive symptoms was 43.5% and 29.2%, respectively. In univariate analysis, patients with poor Eastern Cooperative Oncology Group performance status (ECOG PS), anemia, distress, pain, and receiving oncological treatment were at a significantly higher risk for CRF, whereas poor ECOG PS, pain, and distress were risk factors for depression. In multivariate analysis, high levels of ZSDS were confirmed to be correlated to CRF: odds ratio of 3.86 [95% confidence interval (CI) 0.98-15.20) and 11.20 (95% CI 2.35-53.36) for ZSDS of 50-59 and 60-100, respectively (P value for trend 0.002). Moreover, the ECOG PS score was confirmed to be significantly associated with CRF (OR 7.20; 95% CI 1.73-29.96; P = 0.007).

Conclusions

Our data suggest a strong correlation between CRF and depression in patients with advanced solid tumors. Further investigations are needed to better understand this relationship and if depressive disorder therapeutic strategies could also impact on CRF.

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Validated patient-reported outcome measures were used for screening CRF and depression in advanced cancer patients.

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A direct strong correlation between CRF and depression was found in these patients, often unconsidered by clinicians.

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Other different clinical risk factors for the onset and worsening of CRF were identified.

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A comprehensive evaluation of cancer patients, that should also consider mood disorders, could improve CRF management.

Feasibility and safety of physical exercise in men with prostate cancer receiving androgen deprivation therapy and radiotherapy: a study protocol

INTRODUCTION

Androgen deprivation therapy (ADT) and radiotherapy (RT) increase survival in selected patients with prostate cancer. Nevertheless, the side effects of these therapies are associated with an increased risk of accidental falls and fractures and a decreased quality of life. Preliminary evidence suggests that physical exercise can be a valid strategy to reduce the side effects of ADT and RT in men with prostate cancer. Despite this knowledge, most patients with prostate cancer are insufficiently active, and there is a lack of data on the safety and adherence to the recommended dose of physical exercise. This study protocol is designed to examine the feasibility and safety of a multicomponent experimental physical exercise intervention targeting psychophysical and cognitive functions and the quality of life in this population.

METHODS AND ANALYSIS

This is a pilot feasibility study. Twenty-five men currently treated with ADT and RT for prostate cancer will be invited to participate in a 20-week, multicomponent physical exercise intervention, including supervised and unsupervised exercise sessions and meeting the current recommendation for exercise in cancer. The primary outcomes are physical exercise feasibility (recruitment, adherence and drop-out rates) and safety (adverse events related and unrelated to the intervention). The secondary outcomes are muscle strength, balance, fatigue, symptoms of anxiety and depression, cognitive function, quality of life, and patient satisfaction. We will also record the number of accidental falls and fractures occurring during the intervention and at 1 year of follow-up.

ETHICS AND DISSEMINATION

The study has received ethics approval from The Area Vasta Nord Local Ethics Committee (Province of Reggio Emilia, 23 June 2020, Number 520/2020/SPER/IRCCSRE). Recruitment began in September 2020 and will be completed in September 2021. The results will be disseminated through scientific journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04500080.

Insomnia, Fatigue, and Depression: Theoretical and Clinical Implications of a Self-reinforcing Feedback Loop in Cancer

Introduction:

Insomnia is emerging as a modifiable major risk factor for mental and physical problems, including cancer, and it may contribute to cancer-related fatigue and depression. Since both fatigue and depression may favor insomnia as well, we may hypothesize a self-reinforcing feedback loop among these factors in cancer.

Methods:

With the aim of discussing this hypothesis, PubMed, PsycINFO, and Embase electronic databases were searched for literature published according to the PRISMA method with several combinations of terms such as “insomnia” and “cancer” and “fatigue” and “depression”. On this basis, we conducted a narrative review about theoretical aspects of insomnia in the context of cancer and about its role in cancer-related fatigue and depression.

Results:

Twenty-one papers were selected according to inclusion/exclusion criteria. Insomnia is frequent in cancer, and it is associated with cancer-related comorbid conditions such as emotional distress, depressive symptoms, and cancer-related fatigue. The hyperactivation of stress and inflammatory systems, which sustain insomnia, may contribute to cancer-related depression and fatigue. A deleterious feedback loop may be created, and it may perpetuate not only insomnia but also these cancer-related comorbid conditions.

Conclusion:

Although the understanding of the causal relationship between insomnia/ depression/fatigue in individuals with cancer is limited, we may hypothesize that these symptoms can exacerbate and maintain each other. When insomnia is established in cancer, it may lead to a vicious cycle with fatigue and depression and may contribute to adverse cancer outcomes. Interventions targeting insomnia could provide a promising approach not only for insomnia but also for cancer-related symptoms among cancer patients.

The Anti-Neuroinflammatory Effect of Fuzi and Ganjiang Extraction on LPS-Induced BV2 Microglia and Its Intervention Function on Depression-Like Behavior of Cancer-Related Fatigue Model Mice

The Chinese herb couple Fuzi and Ganjiang (FG) has been a classic combination of traditional Chinese medicine that is commonly used clinically in China for nearly 2000 years. Traditional Chinese medicine suggests that FG can treat various ailments, including heart failure, fatigue, gastrointestinal upset, and depression. Neuroinflammation is one of the main pathogenesis of many neurodegenerative diseases in which microglia cells play a critical role in the occurrence and development of neuroinflammation. FG has been clinically proven to have an efficient therapeutic effect on depression and other neurological disorders, but its mechanism remains unknown. Cancer-related fatigue (CRF) is a serious threat to the quality of life of cancer patients and is characterized by both physical and psychological fatigue. Recent studies have found that neuroinflammation is a key inducement leading to the occurrence and development of CRF. Traditional Chinese medicine theory believes that extreme fatigue and depressive symptoms of CRF are related to Yang deficiency, and the application of Yang tonic drugs such as Fuzi and Ganjiang can relieve CRF symptoms, but the underlying mechanisms remain unknown. In order to define whether FG can inhibit CRF depression-like behavior by suppressing neuroinflammation, we conducted a series of experimental studies in vitro and in vivo. According to the UPLC-Q-TOF/MS^E results, we speculated that there were 49 compounds in the FG extraction, among which 30 compounds were derived from Fuzi and 19 compounds were derived from Ganjiang. Our research data showed that FG can effectively reduce the production of pro-inflammatory mediators IL-6, TNF-α, ROS, NO, and PGE₂ and suppress the expression of iNOS and COX2, which were related to the inhibition of NF-κB/activation of Nrf2/HO-1 signaling pathways. In addition, our research results revealed that FG can improve the depression-like behavior performance of CRF model mice in the tail suspension test, open field test, elevated plus maze test, and forced swimming test, which were associated with the inhibition of the expression of inflammatory mediators iNOS and COX2 in the prefrontal cortex and hippocampus of CRF model mice. Those research results suggested that FG has a satisfactory effect on depression-like behavior of CRF, which was related to the inhibition of neuroinflammation.

Malignant Pleural Effusions Impact on Fatigue (IMPE-F): A Prospective Observational Cohort Pilot Study

Introduction: Cancer-related fatigue is well described. Fatigue in patients with a malignant pleural effusion (MPE) has not been directly studied. Methods: A prospective observational cohort pilot study ‘Do Interventions for Malignant Pleural Effusions (MPE) impact on patient reported fatigue levels (IMPE-F study)’ is planned to determine whether pleural interventions reduce fatigue in MPE. Fatigue will be assessed with a validated patient reported outcome measure, FACIT-F. Discussion: MPE-F has funding from Rocket Medical Plc, and is part of a Masters in Clinical Research at Newcastle University. Respondent fatigue will be addressed by the investigators going through the questionnaire with the participants. Inclusion criteria are all patients above 18 years of age with a presumed MPE undergoing a procedure and able to consent. The expected number of participants is 50. Trial registration: The IMPE-F study has Research Ethics Committee (REC) [20/YH/0224] and Health Research Authority (HRA) and Health and Care Research Wales (HCRW) approvals [IRAS project ID: 276451]. The study has been adopted on National Institute for Health Research portfolio [CPMS ID 46430].

Prevalence of Fatigue in Patients With Cancer: A Systematic Review and Meta-Analysis

CONTEXT

Fatigue is a particularly common and troubling symptom that has a negative impact on quality of life throughout all phases of treatment and stages of the illness among patients with cancer.

OBJECTIVES

The objective of this meta-analysis is to examine the present status of fatigue prevalence in patients with cancer.

METHODS

The following databases were searched: PubMed, MEDLINE, EMBASE, PsycINFO, Cochrane Library, from inception up to February 2020. Prevalence rates were pooled with meta-analysis using a random-effects model. Heterogeneity was tested using I-squared (I²) statistics.

RESULTS

A total of 129 studies (N = 71,568) published between 1993 and 2020 met the inclusion criteria. The overall prevalence of fatigue was 49% (34,947 of 71,656 participants, 95% CI = 45-53) with significant heterogeneity between studies (P < 0.000; τ² = 0.0000; I² = 98.88%). Subgroup analyses show that the prevalence of fatigue related to type of cancer ranged from 26.2% in patients with gynecological cancer to 56.3% in studies that included mixed types of cancer. In advanced cancer stage patients, the highest prevalence of fatigue (60.6%) was reported. Fatigue prevalence rates were 62% during treatment and 51% during mixed treatment status. The prevalence of fatigue decreased from 64% in studies published from 1996 to 2000 to 43% in studies published from 2016 to 2020. Metaregression identified female gender as a significant moderator for higher prevalence of fatigue, whereas mean age is not associated with fatigue.

CONCLUSION

This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce fatigue and improve the quality of life of patients with cancer.

Changes in Fatigue, Psychological Distress, and Quality of Life After Chemotherapy in Women with Breast Cancer: A Prospective Study

BACKGROUND

Chemotherapy leads to various symptoms and psychological distress, which contribute to a significant decrease in the quality of life of the patients.

OBJECTIVES

The aim of this study was to identify changes and interrelationships in the fatigue-depression-anxiety symptom cluster and quality of life during the cancer care trajectory in women with breast cancer.

METHODS

Fifty women participated in the study and completed questionnaires at 3 different times: prechemotherapy, postchemotherapy, and 6 months after the completion of chemotherapy. The assessment tools were the Functional Assessment of Cancer Therapy-Fatigue Scale, Hospital Anxiety and Depression Scale, and Functional Assessment of Cancer Therapy-Breast Cancer version 4 Scale. Data were analyzed using descriptive and repeated-measures analysis of variance statistics.

RESULTS

A significant increase in fatigue (F = 41.95, P < .001) and psychological distress (F = 26.55, P < .001) from prechemotherapy to postchemotherapy was noted. Improvement was observed 6 months after the completion of chemotherapy. A positive or negative change in fatigue was associated with the same in psychological distress. Quality of life (F = 65.22, P < .001) also showed similar change patterns as observed with fatigue and psychological distress. Fatigue had a greater impact on quality of life at postchemotherapy, but psychological distress had a greater impact at prechemotherapy and at the 6-month follow-up.

CONCLUSION

These results suggest that chemotherapy is highly associated with the fatigue-depression-anxiety symptom cluster and quality of life in women with breast cancer.

IMPLICATIONS FOR PRACTICE

Nursing intervention is needed to relieve the intensity of the fatigue-depression-anxiety symptom cluster and thus improve the quality of life of patients undergoing chemotherapy from before treatment to follow-up.

From fatigued to fit: an investigation of the impact of physical exercise in the management of radiotherapy-induced fatigue in prostate cancer patients

Aim:

The aim of this paper is to investigate the effectiveness of physical exercise in managing fatigue during radiotherapy for prostate cancer patients. It explores the impact of various physical exercise regimes and their role in the prevention and management of fatigue to help inform best practice.

Method:

A literature search was conducted on OVID Medline database with a follow-up search on google scholar to include relevant references found during the initial search. Relevant systematic reviews and randomised controlled trials (RCTs) arising from this search were reviewed.

Findings:

There is evidence to support the notion that physical exercise in all its forms is an effective and safe intervention for fatigue management for prostate cancer patients undergoing radiotherapy. Although widely studied, there is limited evidence of fatigue management strategies being clearly implemented into current radiotherapy practice for patients with prostate cancer. This information is essential to enable therapeutic radiographers to educate prostate cancer patients regarding effective exercise strategies and ensure that fatigue is managed optimally.

Conclusion:

Further research is required into the optimum physical exercise prescription to reduce radiation-induced fatigue, and standardised best practice guidelines should be developed nationally. A future move toward patient education into physical exercise and wellbeing should be a central component of the therapeutic radiographer role with specialist advice offered by review radiographers, empowering patients to become more physically active during treatment. Therapeutic radiographers have a unique opportunity to educate and promote physical exercise through a holistic wellbeing approach that aims to mitigate fatigue and improve quality of life.

Patient-reported acute fatigue in elderly breast cancer patients treated with and without regional nodal radiation

PURPOSE

Although regional nodal irradiation (RNI) improves outcomes in breast cancer (BC) patients, it is associated with increased toxicity. Therefore, controversy still exists surrounding its indications. The purpose of this study was to evaluate and compare patient-reported acute fatigue in elderly BC patients with and without regional nodal radiation (RNI).

METHODS

Elderly breast cancer patients (≥ 65 years) treated with adjuvant radiotherapy (RT) between 2012 and 2017 were identified from a prospective database. The validated Edmonton Symptom Assessment System-revised (ESAS-r) questionnaire, which assesses fatigue, was completed prior to (baseline), during, at end of RT and first follow-up (3-6 months). Symptoms were rated on a 10-point Likert scale, with higher scores indicating higher fatigue. Patient's treatment characteristics were also recorded prospectively. This was a retrospective study which identified elderly breast cancer patients who had received adjuvant radiation, completed ESAS-r prospectively and provided research consent for using ESAS-r. Patients were divided into two cohorts: those who received RNI (cohort 1) and those who did not (cohort 2). A minimal clinically important difference (MID) was defined using an anchor of ≥ 1-point compared to baseline. The proportion of patients reporting a change in fatigue at the end of RT was evaluated. To test the robustness of the results, dynamic changes of fatigue scores over time were further compared between the cohorts using a general linear mixed model (GLMM) after assuming individual patient with random effect. Univariate and multivariable logistic regression were conducted to assess the association between RNI and MID after adjusting for potential confounders. In addition to longitudinal analysis, a multivariable mixed effect model was developed to determine the association of RNI with fatigue after adjusting for potential confounders. A two-tailed p value ≤ 0.05 was considered statistically significant.

RESULTS

Of the 1198 patients, 859 had provided research consent and completed the ESAS-r at baseline and any other time-point and were included in the longitudinal analysis (cohort 1 = 159, cohort 2 = 700), while 637 (cohort 1 = 135, cohort 2 = 502) patients completed the ESAS-r at baseline and end of radiotherapy and were included in the anchor-based analysis. Mean age at diagnosis was similar between the groups: cohort 1; 71.5 ± 5.7 vs. cohort; 2 72 ± 5.4 years (total 71.8 ± 5.5). Overall, cohort 1 had higher stage (Stage 3: 32.7% vs 3.6%, p < 0.001) and reception of chemotherapy (68.6% vs. 16.1%, p < 0.001). Mean baseline fatigue was higher for cohort 1 vs. 2 (2.7 ± 2.5 vs. 2.1 ± 2.3, p = 0.006). On univariate and multivariable analyses, RNI was not associated with an increased odd of MID for fatigue at the end of RT (44% vs. 47%; OR 0.89, 95% CI 0.61-1.30, p = 0.56). After adjusting for confounders (age, duration of RT, endocrine therapy), treatment with RNI was not associated with increased odds of worse fatigue at the end of RT (OR 1.33, 95% CI 0.85-2.10, p = 0.22). Higher baseline fatigue (OR 0.86, 95% CI 0.79-0.92, p < 0.001) and receipt of chemotherapy had decreased odds (OR 0.50, 95% CI 0.32-0.86, p = 0.001) and were the only factors associated with decreased odds of MID. Dynamic changes showed a significant worsening of fatigue scores over time (p < 0.001) towards the end of RT and recovery at first follow-up (p < 0.001) with no difference between the cohorts (p = 0.38); both experienced parallel worsening of fatigue levels over time (cohort*time p = 0.71 and cohort*time²p = 0.78). On multivariable analysis earlier stage, the absence of chemotherapy and higher baseline depression were independent predictors of worse fatigue scores over time (p = 0.01, p = 0.003, and p = 0.02, respectively).

CONCLUSION

The addition of RNI in elderly BC patients is not associated with a significant worsening of patient-reported fatigue. Predictors of acute fatigue will enable shared decision making between patients and clinicians.

Cancer-related fatigue and functional impairment - Towards an understanding of cognitive and behavioural factors

OBJECTIVE

Fatigue is a highly prevalent and debilitating problem in women with breast cancer. This study investigated the cognitive, behavioural, interpersonal and affective responses associated with fatigue and functional impairment for women with breast cancer undergoing chemotherapy. A nested prospective study examined factors predictive of cancer-related fatigue after three cycles of chemotherapy.

METHOD

159 women with breast cancer who were about to begin or undergoing chemotherapy completed a range of measures. Correlational and multiple regression analyses explored associations between fatigue severity, functioning and a range of psychological, behavioural, demographic and clinical variables. Forty-two patients were followed-up prospectively to examine the relationship between psychosocial variables, fatigue and functioning after three cycles of chemotherapy.

RESULTS

A range of cognitive, behavioural and affective variables were associated with increased fatigue severity and poorer functioning. Key cognitive and behavioural correlates included, all-or-nothing behaviour, avoidance behaviour, cancer-related catastrophising and critical/punishing responses from others. For the women in the nested prospective study, fatigue significantly increased after three cycles of chemotherapy. Increased fatigue was predicted by increased anxiety before starting chemotherapy.

CONCLUSIONS

Behavioural factors and cancer-specific cognitions make important contributions to cancer-related fatigue and associated impairments. Such factors are potentially amenable to change within the context of cognitive behavioural therapy.

Fatigue, Quality of Life, and Mood States during Chemotherapy in Italian Cancer Patients

Aims and background

In cancer patients, fatigue interferes with the individual's functioning and quality of life (QoL). We investigated the association between fatigue and the main QoL dimensions and mood states as well as the main sociodemographic and clinical variables.

Methods

A total of 105 inpatients undergoing chemotherapy were administered the Revised Piper Fatigue Scale and the EORTC QLQ-C30 and POMS questionnaires, along with a form for collecting personal and clinical data.

Results

Compared with patients reporting lower fatigue levels, patients with higher levels showed worse functioning (P <0.001) in every QoL domain (i.e., physical, role, emotional, social, cognitive functioning, pain, and general health) as well as in the assessed mood states (depression-dejection, tension-anxiety, confusion-bewilderment). Moreover, both QoL and mood states in the subgroup reporting intermediate fatigue levels were worse than those of the subgroup with lower fatigue levels (P <0.02), except for emotional functioning, general health and QoL, and tension-anxiety. In addition, fatigue was significantly associated with gender, age, education, performance status, but not with marital status, survival rate of cancer type, and current chemotherapy cycle.

Conclusions

The associations observed between fatigue, the main QoL domains, and negative mood states call for further active interventions to prevent and reduce fatigue.

The Revised Piper Fatigue Scale (PFS-R) for Italian Cancer Patients: A Validation Study

Background and aim

Fatigue is one of the most frequently reported symptoms by cancer patients. In recent years, much effort has been directed to designing fatigue measures which are psychometrically appropriate as well as easily administered. Among these, the Revised Piper Fatigue Scale (PFS-R) is widely used in assessing fatigue in cancer patients and other populations. Despite its large utilization in different national contexts and with different populations, its structure appears to vary across cultures, suggesting the need for its validation before use. The main aim of the present work was to verify the validity (i.e., dimensional structure and construct validity) and reliability (i.e., internal consistency) of an Italian translation of the PFS-R to reassure Italian oncology practitioners about its appropriate usage in practice and research.

Methods and study design

One-hundred ten Italian oncological inpatients were administered an Italian translation of the PFS-R together with a form for the collection of personal identification and clinical data and other fatigue and quality of life measures (POMS and EORTC QLQ-C30) already validated for Italy.

Results

Principal component exploratory factor analysis revealed a four-factor structure quite similar to (although not overlapping) the original described by Piper and colleagues; all four factors proved to be reliable and to correlate with one another and with previous validated measures of fatigue and quality of life. Preliminary descriptive statistics were also provided for data comparisons.

Conclusions

Despite the discussed limitations, PFS-R seems a valid and reliable multidimensional fatigue measure also adequate in Italian oncological settings.

Expression of Sestrin Genes in Radiotherapy for Prostate Cancer and Its Association With Fatigue: A Proof-of-Concept Study

Genetic factors that influence inflammation and energy production/expenditure in cells may affect patient outcomes following treatment with external beam radiation therapy (EBRT). Sestrins, stress-inducible genes with antioxidant properties, have recently been implicated in several behaviors including fatigue. This proof-of-concept study explored whether the sestrin family of genes ( SESN1, SESN2, and SESN3) were differentially expressed from baseline to the midpoint of EBRT in a sample of 26 Puerto Rican men with nonmetastatic prostate cancer. We also examined whether changes in expression of these genes were associated with changes in fatigue scores during EBRT.

METHOD

Participants completed the 13-item Functional Assessment of Cancer Therapy-Fatigue subscale, Spanish version. Whole blood samples were collected at baseline and at the midpoint of EBRT. Gene expression data were analyzed using the limma package in the R (version R 2.14.0.) statistical software. Linear models and empirical Bayes moderation, adjusted for radiation fraction (total number of days of prescribed radiation treatment), were used to examine potential associations between changes in gene expression and change in fatigue scores.

RESULTS

Expression of SESN3 (adjusted p < .01, log fold change -0.649) was significantly downregulated during EBRT, whereas the expressions of SESN1 and SESN2 remained unchanged. After adjustment for radiation fraction, change in SESN3 expression was associated with change in fatigue during EBRT (false discovery rate <.01).

CONCLUSIONS

Downregulation of SESN3, a novel pharmacoactive stress response gene, was associated with fatigue intensification during EBRT. SESN3 may serve as an interventional target and a biomarker for the cellular and molecular events associated with EBRT-related fatigue.

Experiences of the Breast Cancer Patients Undergoing Radiotherapy at a Public Hospital Peshawar Pakistan

Objective

This study aimed to explore the experiences of female breast cancer patients undergoing radiotherapy (RT) in a public hospital in Peshawar, Pakistan.

Methods

This study employed a descriptive exploratory method. A purposive sample of 14 breast cancer women undergoing RT was selected for this study. Data were collected over the period of 5 months, using a semi-structured interview guide and conducting in-depth face-to-face interviews. These interviews were audio taped and transcribed by a bilingual transcriber. The translated version of the interview was coded, and the analysis was done manually.

Results

Four main categories emerged from data analysis, which were: feelings and perceptions of the patients, their challenges, coping strategies, and teaching and informational needs.

Conclusions

Women undergoing RT in this culture experience more intense psychological effects, as compared to the physical effects. Keeping in mind, the magnitude of the emotional stress experienced by the participants, recommendations for policy reforms, and training for female RT staff are suggested based on findings of this research.

Implementation of evidence into practice for cancer-related fatigue management of hospitalized adult patients using the PARIHS framework

This study aimed to explore an evidence-based nursing practice model of CRF management in hospitalized adult patients using the PARIHS evidence-implementation framework as the theoretical structure to provide guidance for similar nursing practices. The implementation of guideline evidence into clinical practice was conducted on the oncology and radiotherapy wards of a university-affiliated hospital. The process of integrating the guideline into the symptom management system of cancer patients was described. The impact of the evidence implementation was evaluated from three aspects: organizational innovations and outcome measures associated with nurses and with patients pre- and post-evidence implementation. During the implementation of evidence into practice on the wards, a nursing process, health education, a quality control sheet and CRF training courses were established. Through this implementation, compliance with evidence related to CRF increased significantly on the two wards, with that of ward B being higher than that of ward A. Regarding nursing outcomes, nursing knowledge, attitude and behavior scores with respect to CRF nursing care increased substantially after its application on the two wards, and the ward B nurses’ scoring was higher than that of the ward A nurses. Qualitative analysis concerning the nurses suggested that leadership, patient concern about CRF management, and the need for professional development were the main motivators of the application, whereas the shortage and mobility of nursing human resources and insufficient communication between doctors and nurses were the main barriers. Additionally, most nurses felt more professional and confident about their work. Regarding patient outcomes, patient knowledge, attitude and behavior scores regarding CRF self-management increased significantly. Patients’ post-implementation CRF was alleviated compared with the pre-implementation treatment cycle. The PARIHS framework may provide instructive guidance for the incorporation of evidence into practice, and the process-oriented framework might provide greater operational utility of the application.

Association of Personality Profiles with Depressive, Anxiety, and Cancer-related Symptoms in Patients Undergoing Chemotherapy

Background

This study identified latent classes of cancer patients based on Big Five personality dimensions and evaluated for differences in demographic and clinical characteristics, depression, anxiety, and cancer-related symptoms.

Methods

Patients (n=1248) with breast, gastrointestinal, gynecological, or lung cancer completed the Center for Epidemiological Studies-Depression scale, Spielberger State-Trait Anxiety Inventories, NEO-Five Factor Inventory (NEO-FFI), and Memorial Symptom Assessment Scale (MSAS). Latent class profile analysis of NEO-FFI scores was used to identify patient subgroups.

Results

Three latent classes were identified. The "Distressed" class (14.3%) scored highest on neuroticism and lowest on extraversion, agreeableness, and conscientiousness. The "Resilient" class (31.9%) scored lowest on neuroticism and highest on extraversion, agreeableness, and conscientiousness. The "Normative" class (53.8%) was intermediate on all dimensions except openness. Compared to the Resilient class, patients in the Distressed class were younger, less educated, more likely to care for another adult, had more comorbidities, and exercised less. The three classes differed by performance status, marital and employment status, and income, but not by gender, time since diagnosis, or type of prior cancer treatment. The classes differed (Distressed > Normative > Resilient) in depression, anxiety, and cancer symptoms.

Conclusions

Personality is associated with psychological and physical symptoms in cancer patients.

The course of cancer related fatigue up to ten years in early breast cancer patients: What impact in clinical practice?

Little is known about the cancer related fatigue (CRF) along cancer course and risk factors that could predict CRF development and persistence in breast cancer (BC) survivors. This prospective study detected incidence, timing of onset, duration of CRF, impact on QoL and psychological distress. Seventy-eight early BC patients, undergoing chemotherapy (CT) followed or not by hormonal therapy were assessed for QoL and psychological distress by EORTC QLQC30 and HADs questionnaires. Fatigue was investigated with mix methods, structured interview and psychometric measures. A qualitative analysis was added to assess the behavioral pattern of CRF. Low fatigue levels were identified after surgery (9%), increasing during (49%) and at the end of CT (47%), maintaining after 1 year (31%) and declining up to ten years of follow-up. Prevalence of CRF was higher at the end of CT and lower at follow-up. At the end and after 1 and 2 years from CT, persistence of CRF was associated to anxiety in 20%, 11% and 5% and to depression in 15%, 10% and 5% respectively. A relationship between CRF and psychological distress was observed; patients presenting depression and anxiety before CT were at higher risk for fatigue onset at a later period. A relationship between fatigue and QoL was noted at the end of CT. Our study shows the fatigue timely trend in early BC patients from surgery, CT and follow-up. Identification of biological, psychological, social predictor factors related to fatigue could be helpful for early interventions in patients at higher risk of developing fatigue.

Assessment of fatigue using the Identity-Consequence Fatigue Scale in patients with lung cancer

OBJECTIVE:

To evaluate the properties of the Identity-Consequence Fatigue Scale (ICFS) in patients with lung cancer (LC), assessing the intensity of fatigue and associated factors.

METHODS:

This was a cross-sectional study involving LC patients, treated at a teaching hospital in Brazil, who completed the ICFS. Patients with chronic heart disease (CHD) and healthy controls, matched for age and gender, also completed the scale. Initially, a Brazilian Portuguese-language version of the ICFS was administered to 50 LC patients by two independent interviewers; to test for reproducibility, it was readministered to those same patients. At baseline, the LC patients were submitted to spirometry and the six-minute walk test, as well as completing the Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), and Fatigue Severity Scale (FSS). Inflammatory status was assessed by blood C-reactive protein (CRP) levels. To validate the ICFS, we assessed the correlations of its scores with those variables.

RESULTS:

The sample comprised 50 patients in each group (LC, CHD, and control). In the LC group, the intraclass correlation coefficients for intra-rater and inter-rater reliability regarding ICFS summary variables ranged from 0.94 to 0.76 and from 0.94 to 0.79, respectively. The ICFS presented excellent internal consistency, and Bland-Altman plots showed good test-retest reliability. The ICFS correlated significantly with FSS, HADS, and SF-36 scores, as well as with CRP levels. Mean ICFS scores in the LC group differed significantly from those in the CHD and control groups.

CONCLUSIONS:

The ICFS is a valid, reliable instrument for evaluating LC patients, in whom depression, quality of life, and CRP levels seem to be significantly associated with fatigue.

OBJETIVO:

Avaliar as propriedades da Escala de Identificação e Consequências da Fadiga (EICF) em pacientes com câncer de pulmão (CP), analisando a intensidade da fadiga e fatores associados.

MÉTODOS:

Estudo transversal com pacientes com CP, atendidos em um hospital-escola no Brasil, que preencheram a EICF. Pacientes com doenças cardíacas crônicas (DCC) e controles saudáveis, pareados por idade e sexo, também preencheram a escala. Inicialmente, uma versão brasileira da escala foi aplicada a 50 pacientes com CP por dois entrevistadores independentes; para testar a reprodutibilidade, ela foi reaplicada aos mesmos pacientes. No momento basal, os pacientes com CP realizaram espirometria e teste de caminhada de seis minutos, bem como preencheram a Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) e Fatigue Severity Scale (FSS). O estado inflamatório foi avaliado pelos níveis de proteína C reativa (PCR) no sangue. Para validar a EICF, avaliamos as correlações entre as pontuações na mesma e essas variáveis.

RESULTADOS:

A amostra foi composta por 50 pacientes em cada grupo (CP, DCC e controle). No grupo CP, os coeficientes de correlação intraclasse para confiabilidade intra e interobservador para as variáveis resumidas da EICF variaram de 0,94 a 0,76 e de 0,94 a 0,79, respectivamente. A EICF apresentou excelente consistência interna, e as disposições gráficas de Bland-Altman demonstraram boa confiabilidade teste-reteste. A EICF apresentou correlações significativas com as pontuações na FSS, HADS e SF-36, bem como com os níveis de PCR. As médias das pontuações na EICF do grupo CP diferiram significativamente das dos grupos DCC e controle.

CONCLUSÕES:

A EICF é um instrumento válido e confiável para a avaliação de pacientes com CP, nos quais depressão, qualidade de vida e níveis de PCR parecem estar significativamente associados à fadiga.

Effects of a Short-Term Dance Movement Therapy Program on Symptoms and Stress in Patients With Breast Cancer Undergoing Radiotherapy: A Randomized, Controlled, Single-Blind Trial

CONTEXT

Integrated interventions with combined elements of body movement and psychotherapy on treatment-related symptoms in cancer patients are relatively scarce.

OBJECTIVES

The aim of the present study is to investigate the effectiveness of dance movement therapy (DMT) on improving treatment-related symptoms in a randomized controlled trial.

METHODS

A total of 139 Chinese patients with breast cancer awaiting adjuvant radiotherapy were randomized to DMT or control group. The intervention included six 1.5-hour DMT sessions provided twice a week over the course of radiotherapy. Self-report measures on perceived stress, anxiety, depression, fatigue, pain, sleep disturbance, and quality of life were completed before and after the three-week program.

RESULTS

DMT showed significant effects on buffering the deterioration in perceived stress, pain severity, and pain interference (Cohen d = 0.34-0.36, P < 0.05). No significant intervention effects were found on anxiety, depression, fatigue, sleep disturbance, and quality of life (Cohen d = 0.01-0.20, P > 0.05).

CONCLUSION

The short-term DMT program can counter the anticipated worsening of stress and pain in women with breast cancer during radiotherapy.

Clinical Indicators of Psychosocial Distress Predict for Acute Radiation-Induced Fatigue in Patients Receiving Adjuvant Radiation Therapy for Breast Cancer: An Analysis of Patient-Reported Outcomes

PURPOSE

To assess the magnitude and predictors of patient-reported fatigue among breast cancer patients receiving radiation therapy (RT).

METHODS AND MATERIALS

Patients receiving breast RT completed a survey querying fatigue at each weekly on-treatment visit. Patient-reported fatigue severity and interference was assessed on an ordinal scale of 0 to 4, using a validated scoring system. Baseline anxiety and depression scores were also obtained. The kinetics of mean fatigue scores per week and the maximum fatigue scores over the course of the entire treatment were assessed, and clinical predictors were identified by univariate and multivariate regression.

RESULTS

The average fatigue severity and interference scores were 0.6 and 0.46. The average fatigue scores increased to an equivalent extent from week to week, with expected increases of 0.99 in fatigue severity and 0.85 in interference over 7 weeks. Patients treated with hypofractionated RT (HF-RT) versus conventionally fractionated RT (CF-RT) had significantly fewer maximum fatigue severity or interference scores that were >2 (ie, severe or very severe; 29% vs 10% for severity, and 26% vs 8% for interference, P<.01). Age ≤45 years, presence of psychiatric/pain-related comorbidities, and baseline sadness and anxiety severity were predictive of average and maximum fatigue scores (P<.05), but variables related to treatment intensity (eg, mastectomy vs lumpectomy, chemotherapy use, radiation target volumes) and other host factors (working, children, marital status, proximity to RT facility) were not.

CONCLUSION

Patient-reported fatigue modestly increases over RT courses, with less maximum fatigue reported with HF-RT. Younger age and baseline sadness, anxiety, and psychiatric/pain-related comorbidities are powerful predictors of fatigue, whereas other factors, such as treatment intensity, are not. Future studies will investigate interventions for patients at high risk for fatigue.

Cancer-related fatigue and associated disability in post-treatment cancer survivors

PURPOSE

Cancer-related fatigue (CRF) is the most prevalent and distressing symptom among cancer patients and survivors. However, research on its prevalence and related disability in the post-treatment survivorship period remains limited. We sought to describe the occurrence of CRF within three time points in the post-treatment survivorship trajectory.

METHODS

A self-administered mail-based questionnaire which included the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) and the World Health Organisation Disability Assessment Schedule 2.0 was sent to three cohorts of disease-free breast, prostate or colorectal cancer survivors (6-18 months; 2-3 years; and 5-6 years post-treatment). Clinical information was extracted from chart review. Frequencies of significant fatigue by diagnostic group and time cohorts were studied and compared. Multivariate logistic regressions were conducted to examine the associations between CRF and demographic, clinical, and psychosocial variables.

RESULTS

One thousand two hundred ninety-four questionnaire packages were returned (63 % response rate). A total of 29 % (95 % CI [27 % to 32 %]) of the sample reported significant fatigue (FACT-F ≤34), and this was associated with much higher levels of disability (p < 0.0001). Breast (40 % [35 % to 44 %]) and colorectal (33 % [27 % to 38 %]) cancer survivors had significantly higher rates of fatigue compared with the prostate group (17 % [14 % to 21 %]) (p < 0.0001). Fatigue levels did not differ between the three time cohorts. The main factors associated with CRF included physical symptom burden, depression, and co-morbidity (AUC, 0.919 [0.903 to 0.936]).

CONCLUSIONS

Clinically relevant levels of CRF are present in approximately 1/3 of cancer survivors up to 6 years post-treatment, and this is associated with high levels of disability.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians need to be aware of the chronicity of CRF and assess for it routinely in medical practice. While there is no gold standard treatment, non-pharmacological interventions with established efficacy can reduce its severity and possibly minimize its disabling impact on patient functioning. Attention must be paid to the co-occurrence and need for possible treatment of depression and other co-occurring physical symptoms as contributing factors.

Cancer-related fatigue--mechanisms, risk factors, and treatments

Fatigue is one of the most common adverse effects of cancer that might persist for years after treatment completion in otherwise healthy survivors. Cancer-related fatigue causes disruption in all aspects of quality of life and might be a risk factor of reduced survival. The prevalence and course of fatigue in patients with cancer have been well characterized and there is growing understanding of the underlying biological mechanisms. Inflammation seems to have a key role in fatigue before, during, and after cancer-treatment. However, there is a considerable variability in the presentation of cancer-related fatigue, much of which is not explained by disease-related or treatment-related characteristics, suggesting that host factors might be important in the development and persistence of this symptom. Indeed, longitudinal studies have identified genetic, biological, psychosocial, and behavioural risk factors associated with cancer-related fatigue. Although no current gold-standard treatment for fatigue is available, a variety of intervention approaches have shown beneficial effects in randomized controlled trials, including physical activity, psychosocial, mind-body, and pharmacological treatments. This Review describes the mechanisms, risk factors, and possible interventions for cancer-related fatigue, focusing on recent longitudinal studies and randomized trials that have targeted fatigued patients.

Toxicity profile of temozolomide in the treatment of 300 malignant glioma patients in Korea

This study evaluated the toxicity profiles of temozolomide in the treatment of malignant glioma as either concurrent or adjuvant chemotherapy. We retrospectively reviewed the medical records of 300 malignant glioma patients treated with temozolomide in two medical institutions in Korea between 2004 and 2010. Two hundred nine patients experienced a total of 618 toxicities during temozolomide therapy. A total of 84.8% of the 618 toxicities were Common Terminology Criteria for Adverse Events (CTCAE) grade 1 or 2, while 15.2% were grade 3 or 4. Among the hematologic toxicities, thrombocytopenia (13.7%), anemia (11.0%), and AST/ALT increases (7.0%) were common. Among the non-hematologic toxicities, nausea (44.3%), vomiting (37.0%), and anorexia (14.3%) were the three most common toxicities. There was no mortality due to temozolomide. Although temozolomide showed many types of toxicities, the majority of the toxicities were tolerable and of lower grade. Gastrointestinal troubles are the most common toxicities in Korean patients treated with temozolomide.

Impact of anemia management with EPO on psychologic distress in cancer patients: results of a multicenter patient survey

ABSTRACT: Aim: We investigated the role of erythropoietin (EPO) in reducing anemia and preventing the development of psychological distress in patients treated with chemotherapy. Patients & methods: This prospective observational study enrolled 591 adult patients receiving EPO at a dose of 30,000 IU administered once weekly for chemotherapy-induced anemia (mean baseline hemoglobin [Hb] level was 9.55 g/dl) over a 12-month period. Results: The majority of patients (371 [71%] patients) achieved a Hb increase >2 g/dl after 4 weeks of treatment. Interestingly, the nonresponder group had a statistically significant deterioration of their psychological conditions as indicated by psychological distress score (p = 0.01). However, within the group of responders to EPO, the Psychological Distress Inventory score remained unchanged. In the present study, severe side effects associated with EPO were not recorded. Conclusion: Hb increase, induced by EPO, ameliorates the psychological conditions of cancer patients.

Longitudinal relationships between fatigue and depression in cancer patients with depression and/or pain

OBJECTIVE

Fatigue is one of the most common and debilitating symptoms reported by cancer patients, yet relatively little is understood about its etiology. Recently, as researchers have begun to focus attention on cancer-related fatigue (CRF), depression has emerged as its strongest correlate. Few longitudinal studies, however, have examined directionality of the relationship between the two symptoms. Our aim was to evaluate the directionality of the association between depression and CRF.

METHOD

The study used a single-group cohort design of longitudinal data (N = 329) from a randomized controlled trial of an intervention for pain and depression in a heterogeneous sample of cancer patients. Participants met criteria for clinically significant pain and/or depression. Our hypothesis that depression would predict change in fatigue over 3 months was tested using latent variable cross-lagged panel analysis.

RESULTS

Depressive symptoms and fatigue were strongly correlated in the sample (baseline correlation of latent variables = 0.71). Although the model showed good fit to the data, χ(2) (66, N = 329) = 88.16, p = .04, SRMR = 0.030, RMSEA = 0.032, and CFI = 1.00, neither structural path linking depression and fatigue was significant, suggesting neither symptom preceded and predicted the other.

CONCLUSIONS

Our findings did not support hypotheses regarding the directionality of the relationship between depressive symptoms and fatigue. The clinical implication is that depression-specific treatments may not be sufficient to treat CRF and that instead, interventions specifically targeting fatigue are needed.

C-reactive protein predicts fatigue independently of depression in breast cancer patients prior to chemotherapy

Heightened inflammatory activity has been proposed as a mechanism for the development of cancer-related fatigue (CRF), a common and distressing condition that can negatively affect quality of life. Inflammation is also implicated in the pathogenesis of depression, and depression is a strong predictor of CRF. Thus, the role of the pro-inflammatory cytokine network in CRF may be mediated by depression or both conditions may share similar underlying physiological processes. The current study investigated associations between fatigue, depression and inflammatory cytokine (IFN-γ, IL-6, TNF-α) and CRP concentrations, as well as kynurenine pathway (KP) activation, in 61 breast cancer patients prior to chemotherapy. Changes in inflammatory markers and KP activation over time were also explored, and associations with changes in fatigue and depression were examined. Higher levels of CRP were significantly correlated with fatigue and depression before chemotherapy; nevertheless, CRP predicted fatigue independently of depression. Although greater kynurenine concentrations were associated with increased immune activation, there was no evidence that the KP played a role in fatigue or depression. Furthermore, no relationships emerged between either fatigue or depression and IFN-γ, IL-6, or TNF-α before chemotherapy. Nevertheless, kynurenine levels pre- and post-treatment significantly predicted changes in depression, suggesting that heightened KP activation may contribute to depressive symptoms in patients treated for cancer. In addition, IL-6 significantly covaried with fatigue. These preliminary findings provide some support for the idea that low-grade inflammation contributes to the development of CRF, independently of depression; however, there was no evidence that this is mediated by KP activity.

Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period

BACKGROUND

Anxiety, depression, insomnia, fatigue, and pain are frequently reported by cancer patients. These symptoms are highly interrelated. However, few prospective studies have documented the sequence with which symptoms occur during cancer care.

PURPOSE

This longitudinal study explored the temporal relationships between anxiety, depression, insomnia, fatigue, and pain over an 18-month period in a large population-based sample of nonmetastatic cancer patients (N = 828), using structural equation modeling.

METHODS

The patients completed a battery of self-report scales at baseline and 2, 6, 10, 14, and 18 months later.

RESULTS

The relationships between the same symptom at two consecutive assessments showed the highest coefficients (β = 0.29 to 0.78; all ps ≤ 0.05). Cross-loading parameters (β = 0.06 to 0.19; ps ≤ 0.05) revealed that fatigue frequently predicted subsequent depression, insomnia, and pain, whereas anxiety predicted insomnia.

CONCLUSIONS

Fatigue and anxiety appear to constitute important risk factors of other cancer-related symptoms and should be managed appropriately early during the cancer care trajectory.

Evolution of cancer-related symptoms over an 18-month period

CONTEXT

Previous studies have revealed inconsistent findings about the longitudinal evolution of cancer-related symptoms. In addition, the contribution of medical factors (e.g., cancer site, and treatments) in explaining the changes in these symptoms is yet to be established.

OBJECTIVES

This prospective study investigated longitudinal changes of five symptoms (i.e., depression, anxiety, insomnia, fatigue, and pain) in patients scheduled to undergo surgery for cancer (N=828).

METHODS

The patients completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, the Multidimensional Fatigue Inventory, and a pain questionnaire at baseline and after 2, 6, 10, 14 and 18 months.

RESULTS

Several time changes were statistically significant but effect sizes only revealed one change of a medium magnitude, that is, a reduction of anxiety from T1 to T2 (d=-0.58). Women with breast or gynecological cancer were the only subgroups to exhibit significant changes (i.e., reduction of a small magnitude of anxiety symptoms from T1 to T2; ds=-0.27 and -0.30, respectively). However, numerous differences were found across adjuvant treatments, including greater variations in depression and insomnia scores in the chemotherapy group (ds=-0.71 to 0.20) and a transient increase in fatigue symptoms in patients receiving "all" adjuvant treatments (ds=-0.24 to 0.37).

CONCLUSION

The severity of cancer-related symptoms varies during the cancer care trajectory, especially anxiety scores, which importantly decrease during the first few months after the surgery. This study also suggests that treatment regimens better account for individual differences than cancer site in the evolution of symptoms.

Predictors of fatigue in cancer patients before and after chemotherapy

Fatigue is a debilitating and common condition in cancer patients. This study examined pretreatment predictors of fatigue before chemotherapy and also assessed whether these could prospectively predict fatigue posttreatment. A total of 100 patients completed questionnaires assessing psychological factors, physical activity and sleep. A subsample of 26 participants wore actigraphs to objectively assess sleep/wake and activity/rest. Fatigue was measured pretreatment and posttreatment and at follow-up several months later. Greater pretreatment pain, depression, stress and sleep disruption significantly predicted greater fatigue before chemotherapy, explaining 55 percent of the variance. Pretreatment fatigue significantly predicted post-treatment fatigue. No other significant prospective predictors of posttreatment fatigue emerged.

Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer

CONTEXT

Pain, fatigue, and sleep disturbance commonly co-occur in patients receiving treatment for advanced cancer.

OBJECTIVES

A pilot randomized controlled trial was conducted to assess initial efficacy of a patient-controlled cognitive-behavioral (CB) intervention for the pain, fatigue, and sleep disturbance symptom cluster.

METHODS

Eighty-six patients with advanced lung, prostate, colorectal, or gynecologic cancers receiving treatment at a comprehensive cancer center were stratified by recruitment clinics (chemotherapy and radiation therapy) and randomized to intervention or control groups. Forty-three patients were assigned to receive training in and use of up to 12 relaxation, imagery, or distraction exercises delivered via an MP3 player for two weeks during cancer treatment. Forty-three patients were assigned to a waitlist control condition for the same two week period. Outcomes included symptom cluster severity and overall symptom interference with daily life measured at baseline (Time 1) and two weeks later (Time 2).

RESULTS

Eight participants dropped out; 78 completed the study and were analyzed (36 intervention and 42 control subjects). Participants used the CB strategies an average of 13.65 times (SD=6.98). Controlling for baseline symptom cluster severity and other relevant covariates, it was found that the symptom cluster severity at Time 2 was lower in the intervention group (M(Adj)=2.99, SE=0.29) than in the waitlist group (M(Adj)=3.87, SE=0.36), F(1, 65)=3.57, P=0.032. Symptom interference with daily life did not differ between groups. No significant adverse events were noted with the CB intervention.

CONCLUSION

Findings suggest that the CB intervention may be an efficacious approach to treating the pain, fatigue, and sleep disturbance symptom cluster. Future research is planned to confirm efficacy and test mediators and moderators of intervention effects.

Low incidence of fatigue after hypofractionated stereotactic body radiation therapy for localized prostate cancer

Background: Fatigue is a common side effect of conventional prostate cancer radiation therapy. The increased delivery precision necessitated by the high dose per fraction of stereotactic body radiation therapy (SBRT) offers the potential of reduce target volumes and hence the exposure of normal tissues to high radiation doses. Herein, we examine the level of fatigue associated with SBRT treatment. Methods: Forty patients with localized prostate cancer treated with hypofractionated SBRT, and a minimum of 12 months follow-up were included in this analysis. Self-reported fatigue and other quality of life measures were assessed at baseline and at 1, 3, 6, 9, and 12 months post-SBRT. Results: Mean levels of fatigue were elevated at 1 month post-SBRT compared to baseline values (P = 0.02). Fatigue at the 3-month follow-up and later were higher but not statistically significantly different compared to baseline. African-American patients reported higher fatigue post-SBRT than Caucasian patients. Fatigue was correlated with hormonal symptoms as measured by the Expanded Prostate Cancer Index Composite (EPIC) quality of life questionnaire, but not with urinary, bowel, or sexual symptoms. Age, co-morbidities, smoking, prostate specific antigen (PSA) levels, testosterone levels, tumor stage, and treatment variables were not associated with fatigue. Conclusion: This is the first study to investigate fatigue as a side effect of SBRT. In contrast to standard radiation therapy, results suggest SBRT-related fatigue is short-term rather than a long-term side effect of SBRT. These results also suggest post-SBRT fatigue to be a more frequent complication in African-Americans than Caucasians.

Identification of factors associated with cancer related fatigue syndrome in disease-free breast cancer patients after completing primary treatment

This study is an analysis of variables associated with women who meet the criteria for after completion of successful primary treatment for breast cancer. This analysis was conducted to identify factors independently associated with cancer related fatigue syndrome using a combined dataset from two non-overlapping studies conducted on similar populations. Participants who were clinically (and radiologically) disease-free, between 3 months and 2 years after treatment, were recruited from a single centre. A diagnostic interview was conducted to ascertain whether they met the criteria for cancer related fatigue syndrome. We analysed a number of treatment, laboratory and questionnaire variables between groups. Those that were significantly different were entered into a logistic model. A total of 278 subjects (105 cases of cancer related fatigue syndrome and 173 controls who did not meet the criteria) were analysed. A number of questionnaire responses were significantly different including all of the European Organisation for the Research and Treatment of Cancer core 30 item quality of life questionnaire (EORTC QLQ c30) and Breast questionnaire 23 item subgroup scores. 11 variables were entered into the final model and 5 were independently associated with cancer related fatigue syndrome: Hospital anxiety and depression scale score, EORTC pain and insomnia scales, breast systemic side effects and plasma sodium. There was, however, no association with demographic or treatment variables. As a conclusion, cancer related fatigue syndrome after treatment is linked with sub-clinical mood pain and subjective sleep disturbance and with the side effects of systemic treatment. This study is unable to determine whether these associations are causal, but they provide a potential target for interventions to manage the symptoms of cancer related fatigue syndrome.

Symptom prevalence and management of cancer patients in Lebanon

CONTEXT

Cancer patients experience a great number of distressing physical and psychological symptoms. In Lebanon, there are no available data on symptom prevalence and symptom management in adults with cancer.

OBJECTIVES

The aim of this study was to determine the prevalence of symptoms and the effectiveness of treatment received as reported by patients.

METHODS

The study used a cross-sectional, descriptive survey design. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the Memorial Symptom Assessment Scale were translated to Arabic and used; data were collected from adult Lebanese cancer patients at the American University of Beirut Medical Center.

RESULTS

A total of 200 cancer patients participated in the study; the majority were female with breast cancer and mean age was 54 years. The cognitive functioning domain of the EORTC QLQ-C30 scale was found to have the highest score and social functioning the lowest. The most prevalent symptom was lack of energy. Nausea and pain were the symptoms most treated. Males reported better quality of life (QoL), physical functioning, and role functioning than females; females reported more fatigue, pain, and appetite loss than males. Higher physical and psychological symptoms were correlated with lower health status, QoL, and functioning.

CONCLUSION

Although this sample reported a fair QoL and social functioning, many symptoms were highly prevalent and inadequately treated. Symptoms were found to negatively affect QoL and functioning. Based on these results, providing adequate symptom management and social support to Lebanese cancer patients is highly recommended.

When breast cancer survivors report cognitive problems at work

OBJECTIVE

Breast cancer survivors (BCS) who wish to stay actively employed following primary treatment of cancer may experience cognitive problems at work. Management of these cognitive problems may need to focus on associated symptoms. The current study determined whether fatigue and depressive symptoms, which can co-occur with one another, are independently and/or interactively related to cognitive limitations at work.

METHOD

A cross-sectional study was conducted. BCS (n = 133) and a non-cancer comparison group (NCCG; n = 122) completed measures of work-related cognitive limitations, fatigue, and depression.

RESULTS

Three years post primary treatment, BCS reported higher levels of fatigue (p = 0.001), depressive symptoms (p = 0.001), and work related cognitive limitations (p = 0.001) than the NCCG. Fatigue and depressive symptoms were each independently associated with cognitive limitations in both those with and without a history of cancer.

CONCLUSIONS

When BCS report problems with cognitive abilities at work along with fatigue and depressive symptoms, it is important to recognize that these symptoms can be independently related to cognitive limitations. This study also suggests that management of symptoms of fatigue and depression may benefit from different approaches when improvement in cognitive function at work is a desired outcome.

Examining a therapeutic yoga program for prostate cancer survivors

BACKGROUND

In the earlier stages of prostate cancer, effective treatments have created a need for research to focus on practices that may improve quality of life throughout survivorship. Physical activity is a significant supportive care management strategy for prostate cancer survivors, though the optimal modality is not yet understood.

HYPOTHESES

The authors hypothesized that yoga would be a feasible physical activity option for prostate cancer survivors and their support persons and that the incorporation of social support would increase physical activity adherence.

METHODS

This 14-week feasibility study involved a 7-week class-based yoga program (adherence phase), followed by 7 weeks of self-selected physical activity (maintenance phase). Demographic information, physical activity behavior, quality of life, fatigue, stress, mood, and fitness variables were assessed at 3 time points. Prostate cancer survivors' perceived social support was rated during yoga and after yoga.

RESULTS

Class attendance was 6.1 and 5.8 for prostate cancer survivors (n = 15) and their support persons (n = 10), respectively, for the 7 classes. Levels of perceived social support were higher for those who brought a support person. Significant improvements with regard to stress, fatigue, and mood before and after yoga class (all Ps < .05) were reported by all participants. No clinically significant changes were noted on prostate cancer survivor's quality of life or fatigue over the course of the 14-week study.

CONCLUSIONS

Yoga is a feasible physical activity option for prostate cancer survivors. The program had a promising uptake rate, high program adherence rate, and there were acute program benefits with regard to stress, fatigue, and mood for all participants. Future examination is warranted with regard to chronic benefits and group cohesion influences on levels of perceived social support.

Sleep-wake circadian activity rhythms and fatigue in family caregivers of oncology patients

BACKGROUND

Little is known about the relationships between sleep/wake circadian activity rhythms and fatigue in family caregivers (FCs) of oncology patients.

OBJECTIVES

The objectives of this study were to describe values for nocturnal sleep/rest, daytime wake/activity, and circadian activity rhythm parameters measured using actigraphy and to evaluate the relationships between these subjective and objective measures of sleep disturbance and self-reported fatigue severity, in a sample of FCs of oncology patients.

METHODS

Family caregivers (n = 103) completed self-report measures for sleep disturbance (ie, Pittsburgh Sleep Quality Index, General Sleep Disturbance Scale) and fatigue (Lee Fatigue Scale) and wore wrist actigraphs for 48 hours prior to beginning radiation therapy. Spearman rank correlations were calculated between variables.

RESULTS

Approximately 40% to 60% of FCs experienced sleep disturbance depending on whether clinically significant cutoffs for the subjective or objective measures were used to calculate occurrence rates. In addition, these FCs reported moderate levels of fatigue. Only a limited number of significant correlations were found between the subjective and objective measures of sleep disturbance. Significant positive correlations were found between fatigue and subjective, but not objective measures of sleep disturbance. The amplitude of circadian activity rhythm was not related to any objective sleep measure but was correlated with self-report of longer sleep-onset latency.

CONCLUSIONS

A significant percentage of FCs experience clinically meaningful disturbances in sleep-wake circadian activity rhythms. These disturbances occur primarily in sleep maintenance.

IMPLICATIONS FOR PRACTICE

Family caregivers need to be assessed, along with patients, for sleep disturbance, and appropriate interventions initiated for them and for the patient.

Sleep-wake circadian activity rhythm parameters and fatigue in oncology patients before the initiation of radiation therapy

BACKGROUND

Little is known about the relationships between sleep parameters and fatigue in patients at the initiation of radiation therapy (RT).

OBJECTIVES

The objectives of this study were to describe values for nocturnal sleep/rest, daytime wake/activity, and circadian activity rhythm parameters measured using actigraphy and to evaluate the relationships between these objective parameters and subjective ratings of sleep disturbance and fatigue severity, in a sample of patients at the initiation of RT.

METHODS

Patients (n = 185) with breast, prostate, lung, or brain cancer completed self-report measures for sleep disturbance (ie, Pittsburgh Sleep Quality Index, General Sleep Disturbance Scale) and fatigue (Lee Fatigue Scale) and wore wrist actigraphs for a total of 48 hours prior to beginning RT. Actigraphy data were analyzed using the Cole-Kripke algorithm. Spearman rank correlations were calculated between variables.

RESULTS

Approximately 30% to 50% of patients experienced sleep disturbance, depending on whether clinically significant cutoffs for the subjective or objective measures were used to calculate occurrence rates. In addition, these patients reported moderate levels of fatigue. Only a limited number of significant correlations were found between the subjective and objective measures of sleep disturbance. Significant positive correlations were found between the subjective, but not the objective measures of sleep disturbance and fatigue.

CONCLUSIONS

A significant percentage of oncology patients experience significant disturbances in sleep-wake circadian activity rhythms at the initiation of RT. The disturbances occur in both sleep initiation and sleep maintenance.

IMPLICATIONS FOR PRACTICE

Patients need to be assessed at the initiation of RT for sleep disturbance, so appropriate treatment is initiated.

Systematic review and meta-analysis of the correlates of cancer-related fatigue

BACKGROUND

Fatigue is one of the most common problems experienced by cancer patients. The factors most frequently reported to correlate with cancer-related fatigue are symptom distress (pain, nausea/vomiting, dyspnea, and lack of appetite) and psychological distress (depression and anxiety).

AIMS

This study was performed to examine the overall association of symptom and psychological distress with cancer-related fatigue using systematic literature review and meta-analysis. This study also aimed to determine which factors have a higher correlation with fatigue, and therefore should receive nursing priority.

METHODS

A meta-analysis of 30 primary studies identified by searching computer databases, which included MEDLINE, PubMed, and CINAHL.

RESULTS

Results showed that all symptoms (pain, dyspnea, nausea/vomiting, and lack of appetite) and psychological distress (depression and anxiety) included had a significant association with cancer-related fatigue with medium-to-large effect sizes, which were estimated using correlation coefficients. The overall correlations of psychological distress with cancer-related fatigue were found to be higher than those of symptom distress. The correlation of nausea/vomiting with cancer-related fatigue was higher than those of pain and dyspnea.

CONCLUSIONS AND IMPLICATIONS

Our findings highlight the importance of psychological distress in dealing with cancer-related fatigue in addition to the need to be attentive to a patient's symptom distress. Of the symptom distress, nausea/vomiting should be prioritized by nurses when managing cancer-related fatigue. This study provides sound empirical evidence that can be used to draft guidelines for the management of cancer-related fatigue.

Health-related quality of life in long-term survivors after high-dose chemoradiotherapy followed by surgery in esophageal cancer

Curative treatment of esophageal cancer with definitive or preoperative high-dose chemoradiotherapy inflicts a major strain on the patients with potentially severe physical, emotional, and social consequences. The aim of this study was to assess various aspects of quality of life and fatigue in long-term survivors following such a treatment. Patients undergoing a potentially curative treatment between 1996 and 2007, and still alive (n= 41) completed quality of life questionnaires of the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal cancer module (QLQ-OES18). Twenty patients were treated by surgery alone, and 21 patients were scheduled for high-dose chemoradiotherapy followed by surgery. Five of those patients did not undergo planned surgery. Preoperative chemoradiotherapy consisted of three courses of chemotherapy, cisplatin 100 mg/m(2) and 5-fluorouracil 5000 mg/m(2) in each course and concomitant radiotherapy of a median dose 66 Gy. Quality of life in esophageal cancer patients receiving high-dose chemoradiotherapy was compared with that for esophageal cancer patients who received only surgery, head and neck cancer patients, laryngectomized patients, and a random sample of the general Norwegian population. Esophageal cancer patients treated by high-dose chemoradiotherapy had significantly worse global quality of life as reflected by almost all functional scales and higher fatigue compared with esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. There were no significant differences in quality of life between the esophageal cancer patients receiving high-dose chemoradiotherapy and the laryngectomy patients. Further, the esophageal cancer patients receiving high-dose chemoradiotherapy had higher intensity of other symptoms like general pain, insomnia, nausea/vomiting, diarrhea, and constipation compared with the esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. High-dose chemoradiotherapy with cisplatin and 5-fluorouracil had a considerable negative long-term effect on global quality of life in patients with resectable esophageal cancer. Fatigue was a prominent long-lasting symptom in these patients.

The mediating effects of depression on sleep disturbance and fatigue: symptom clusters in patients with hepatocellular carcinoma

The purposes of this study were to (a) explore the relationships among sleep disturbance, fatigue, and depression and (b) test whether depression mediates the effect of sleep disturbance on fatigue in patients with hepatocellular carcinoma (HCC). A cross-sectional study was conducted with a total of 77 patients with HCC. All participants completed questionnaires that included the Brief Fatigue Inventory-Taiwan Form, the Pittsburgh Sleep Quality Index-Taiwan Form, and the depression subscale of the Taiwanese version of the Hospital Depression and Anxiety Scale. Path analysis was used to test the mediation role of depression. Fatigue, sleep disturbance, and depression are positively interrelated and co-occur in patients with HCC. Moreover, depression completely mediates the effects of sleep disturbance on fatigue. These findings suggest that depression is an important mechanism underlying the relationship between sleep disturbance and fatigue for patients with HCC. This is the first study to explore the phenomenon of symptom clustering in sleep disturbance, fatigue, and depression in patients with HCC and to investigate the mediating role of depression that underlies the relationship between sleep disturbance and fatigue. The current findings are of clinical importance because they suggest the need to consider simultaneous management of sleep disturbance, fatigue, and depression.