Fatigue, pain, and depression in pre-autotransplant breast cancer patients

Co-occurrence of symptoms after radiochemotherapy in locally advanced cervix cancer patients: a cluster analysis

BACKGROUND

State of the art combined radiochemotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) has shown improved disease control and survival as well as a significant reduction of organ related morbidity. However, LACC cancer survivors are still experiencing a spectrum of symptoms. The aim of this study was to identify co-occurring symptoms in cervix cancer survivors by using patient-reported outcome and physician assessed morbidity.

MATERIALS AND METHOD

EMBRACE I is a multicenter prospective observational study with 1416 LACC patients (2008-2015). Information on physician-assessed morbidity and patient-reported outcome was assessed at baseline and at regular follow-ups up with the CTCAE v.3 and EORTC-C30/CX24, respectively. Patients with at least 2 years of follow-up were included and data from 3 months to 2 years was used in the analysis. Factor analysis was used on both EORTC and CTCAE data with symptoms and follow-ups as observations. The extracted factors represent clusters of symptoms. Subsequently, regression models were built to investigate associations between the symptom clusters and QOL.

RESULTS

The analysis included 742 patients. Despite the differences in the definition of physician-assessed and patient-reported symptoms, similar clusters are identified by the two assessment methods. Three main organ-related clusters are recognized for urinary, gastro-intestinal and vaginal morbidity. Furthermore, a general symptoms cluster where fatigue, pain, insomnia, neuropathy, and hot flashes have large weights is found. Lastly, a cluster with nausea, vomit and lack of appetite is also identified. The general, gastrointestinal and nausea clusters show significant associations with general QOL.

CONCLUSIONS

This analysis on both PRO and physician-assessed morbidity found a cluster associated with general symptoms and organ-related symptom clusters (urinary, gastrointestinal, vaginal). This shows that LACC survivors experience a variety of co-occurring symptoms. Our analysis also shows that the cluster of general symptoms is associated with a decrease in QOL.

Depressive Symptoms and Quality of Life Associated With the Use of Monoclonal Antibodies in Breast Cancer Treatment

OBJECTIVES

To assess the relationship between (a) chemotherapy and monoclonal antibody (mAb) treatments and (b) depressive symptoms and quality of life (QOL) in patients with breast cancer.

SAMPLE & SETTING

182 women with breast cancer in Spain who were undergoing chemotherapy with or without mAbs.

METHODS & VARIABLES

An observational, cross-sectional study was carried out. The European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire-Core 30 and the EORTC QOL Questionnaire-Breast Cancer were used to assess QOL. Patients were screened for depressive symptoms using the Beck Depression Inventory-II.

RESULTS

No relationship was found between the use of mAbs with chemotherapy and QOL, except for incidence of diarrhea. However, depressive symptoms had a negative and highly significant influence on the majority of the QOL parameters.

IMPLICATIONS FOR NURSING

The presence of depressive symptoms negatively affects QOL. Used concurrently, mAbs and chemotherapy do not negatively influence QOL, but some adverse effects, such as diarrhea, are common.

Unwelcome Companions: Loneliness Associates with the Cluster of Pain, Fatigue, and Depression in Older Adults

Objective: Pain, fatigue, and depression commonly co-occur as a symptom cluster in pathological inflammatory states. Psychosocial stressors such as loneliness may lead to similar states through shared mechanisms. We investigated the association of loneliness with pain, fatigue, and depression in older adults. Methods: Using Health and Retirement Study data (N = 11,766), we measured cross-sectional prevalence of frequent, moderate to severe pain; severe fatigue; depressive symptoms; and co-occurrence of symptoms surpassing threshold levels (i.e., symptom cluster). Logistic regression models evaluated associations with loneliness. Results: Pain, fatigue, and depression were reported in 19.2%, 20.0%, and 15.3% of the total sample, respectively. The symptom cluster was seen in 4.9% overall; prevalence in lonely individuals was significantly increased (11.6% vs. 2.3%, p < .0001). After adjusting for demographic variables, loneliness associated with the symptom cluster (adjusted OR = 3.39, 95% CI = 2.91, 3.95) and each symptom (pain adjusted OR = 1.61, 95% CI = 1.48, 1.76; fatigue adjusted OR = 2.02, 95% CI = 1.85, 2.20; depression adjusted OR = 4.34, 95% CI = 3.93, 4.79). Discussion: Loneliness strongly associates with the symptom cluster of pain, fatigue, and depression. Further research should examine causal relationships and investigate whether interventions targeting loneliness mitigate pain, fatigue, and depression.

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.

Trajectories of Depressed Mood and Anxiety During Chemotherapy for Breast Cancer

BACKGROUND

Women are at risk of mood disturbance during treatment for breast cancer.

OBJECTIVE

The aims of this study were to identify classes of women experiencing similar trajectories of depressed mood and anxiety while receiving chemotherapy for breast cancer and to determine associated antecedents and outcomes. The specific aims were to (1) determine the distinct trajectory classes associated with severity of depressed mood and anxiety reported by women undergoing cycles 2 and 3 of chemotherapy for breast cancer, (2) determine if class membership is associated with various antecedent variables, and (3) determine if class membership is associated with days of missed work and hours spent lying down.

METHODS

In a secondary analysis, classes were identified using Latent Growth Mixture Modeling. Antecedents and outcomes related to class membership were explored.

RESULTS

Participants (n = 166; mean age, 53 [SD, 10.8] years) were mostly white (91.46%); half had early-stage disease. Two trajectories of depressed mood and anxiety were identified. Receipt of doxorubicin was associated with the higher severity class for depressed mood (P < .01) and anxiety (P = .04). No college education (P = .03) or spending more hours lying down (P = .03) was associated with the higher severity class for anxiety.

CONCLUSIONS

Distinct trajectories of mood disturbance are distinguished by baseline severity. Further study is needed to determine if biologic or genomic factors are associated with class membership.

IMPLICATIONS FOR PRACTICE

Identification of women at risk of mood disturbance may allow clinicians to intensify symptom management. Mood disturbance early in the treatment trajectory warrants management to improve outcomes.

Cancer-related fatigue among long-term survivors of breast, cervical, and colorectal cancer: a French registry-based controlled study

BACKGROUND

While several studies have documented fatigue during and after cancer treatment, long-term cancer survivor fatigue is underreported. In this study, we compare fatigue, quality of life (QoL), and anxiety between relapse-free cancer survivors 15 years after diagnosis and healthy controls.

METHODS

Cancer survivors (CS) were randomly selected from three large population-based cancer registries (Bas-Rhin, Calvados, and Doubs, France). Cancer-free controls were randomly selected from electoral lists with stratification on age group, residence area, and gender. All participants completed self-reported fatigue (MFI), QoL (EORTC QLQ-C30), and anxiety (STAI) questionnaires. Univariable and multivariable logistic regression were used to study the association between fatigue and cancer status, in three cancer subgroups: breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC).

RESULTS

Two hundred sixty-three CS and 688 controls (125/275, 45/153, 93/260 CS/controls for BC, CC, and CRC respectively) were included. The mean age was 66 years. In multivariable analyses, CS had higher general and mental fatigue than controls p = 0.04 and p = 0.02, respectively. No difference in QoL was observed between CS and controls. CS were more anxious than controls (p < 0.01). Anxiety was associated with general fatigue (p < 0.0001) and mental fatigue (p < 0.0001).

CONCLUSION

Fifteen years after diagnosis, cancer survivors reported more general and mental fatigue compared with controls. Our results reinforce guidelines, identifying fatigue as a persistent symptom.

The importance of physical function in patients with multiple myeloma for improving quality of life

PURPOSE

To investigate the relationship between physical function and quality of life in multiple myeloma patients.

METHODS

In this retrospective cross-sectional study, data from patients with multiple myeloma (N = 63), who were referred to the department of Rehabilitation Medicine from October 2017 to May 2018, were reviewed. Patients were excluded based on the following criteria: acute illness, unstable medical conditions, impaired cognition or communication, refusal, or inability to perform the assessment. Physical function was evaluated with the Mini-Balance Evaluation Systems Test (Mini-BESTest), and the European Organization for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-MY20 were used for the evaluation of quality of life. To evaluate fatigue and psychotic status, the Fatigue Severity Scale and Beck Depression Inventory were used. Patients were divided into two groups ("good-function group" and "poor-function group"), based on previously studied normative values of the Mini-BESTest. Clinical data was reviewed to interrogate the contributing factors of physical function.

RESULTS

Positive correlations were observed between Mini-BESTest scores and all domains of the QLQ-C30. The Mini-BESTest score was lower in patients with lower serum hemoglobin (r = 0.396, p = 0.001) and albumin levels (r = 0.440, p < 0.001), severe disease-related symptoms (r = - 0.39, p = 0.02), and depression (r = - 0.538, p < 0.001). Further, the poor-function group showed lower hemoglobin (p = 0.024) and albumin levels (p = 0.004).

CONCLUSION

In patients with multiple myeloma, physical function had a significant relationship with quality of life. Low hemoglobin and albumin levels, severe disease- or treatment-related symptoms, and depression were related to decreased physical function, and thus consequentially exert an effect on quality of life in multiple myeloma patients.

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.

A descriptive analysis of depression and pain complaints among patients with cancer in a low income country

BACKGROUND

In high income countries, cancer is one of the leading causes of death, with co-morbid depression contributing to the risk of increased mortality. However, both cancer and depression are neglected conditions in low income countries. The current study assessed the magnitude of depression and the association of pain complaints with depression among patients with cancer in a low income country.

METHOD

In this cross-sectional study participants were 390 patients with established diagnosis of cancer, who were recruited consecutively when visiting a tertiary treatment centre in Addis Ababa, Ethiopia. The occurrence of depression was determined using the nine items Patient Health Questionnaire (PHQ-9). Major depressive disorder was confirmed: (1) when five or more of the PHQ-9 symptoms were endorsed as occurring for at least 'more than seven days', with the exception of suicidal ideation item which counted as a positive rating if it had occurred even once in the previous fifteen days. (2) one of the symptoms has to be either depressed mood or loss of interest. Pain complaint was measured by Numeral Rating Scale (NRS) and severity of pain was assessed using Verbal Rating Scale (VRS).

RESULTS

The prevalence of major depressive disorder was 16.4% (95%CI: 13.1%, 20.4%), and subthreshold depression was 17.4% (95%CI: 14.0%, 21.5%). Pain complaints occurred in 69.0% (95%CI: 64.3%, 73.4%) of the participants. The odds of having a major depressive symptom was over four times higher among participants who had pain.

LIMITATIONS

The study was cross sectional and liable to recall bias. Recruitment was carried out in a tertiary referral hospital, which might lead to the selection of more economically well-off and educated participants limiting generalizability of the study. Moreover, we did not control for cancer types, which may be related to pain and the experience of depression. Some of the somatic symptoms in PHQ9 may also be related to the cancer itself.

CONCLUSIONS

This study highlights the clinical significance of both depression and pain complaints in patients with cancer in a low income country. Exploration of the impact of depressive disorders on quality of life and outcome of cancer is an important area for further research in low income countries.

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.

Exercise and cancer-related fatigue in adults: a systematic review of previous systematic reviews with meta-analyses

BACKGROUND

Conduct a systematic review of previous systematic reviews with meta-analysis to determine the effects of exercise (aerobic, strength or both) on cancer-related-fatigue (CRF) in adults with any type of cancer.

METHODS

Systematic reviews with meta-analyses of previous randomized controlled trials published through July of 2016 were included by searching six electronic databases and cross-referencing. Dual-selection and data abstraction were conducted. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Standardized mean differences (SMD) that were pooled using random-effects models were included as the effect size. In addition, 95% prediction intervals (PI), number needed-to-treat (NNT) and percentile improvements were calculated.

RESULTS

Sixteen studies representing 2 to 48 SMD effect sizes per analysis (mean ± SD, 7 ± 8, median = 5) and 37 to 3254 participants (mean ± SD, 633 ± 690, median = 400) were included. Length of training lasted from 3 to 52 weeks (mean ± SD, 14.6 ± 3.1, median = 14), frequency from 1 to 10 times per week (mean ± SD, 3.4 ± 0.8, median = 3), and duration from 10 to 120 min per session (mean ± SD, 44.3 ± 5.5, median = 45). Adjusted AMSTAR scores ranged from 44.4% to 80.0% (mean ± SD, 68.8% ± 12.0%, median = 72.5%). Overall, mean SMD improvements in CRF ranged from -1.05 to -0.01, with 22 of 55 meta-analytic results (52.7%) statistically significant (non-overlapping 95% CI). When PI were calculated for results with non-overlapping 95% CI, only 3 of 25 (12%) yielded non-overlapping 95% PI favoring reductions in CRF. Number needed-to-treat and percentile improvements ranged from 3 to 16 and 4.4 to 26.4, respectively.

CONCLUSIONS

A lack of certainty exists regarding the benefits of exercise on CRF in adults. However, exercise does not appear to increase CRF in adults.

TRIAL REGISTRATION

PROSPERO Registration # CRD42016045405 .

A review of the literature on symptom clusters in studies that included oncology patients receiving primary or adjuvant chemotherapy

AIMS AND OBJECTIVES

To summarise the current state of knowledge of symptom clusters research from studies that included, as part of their sample, patients who were receiving primary or adjuvant chemotherapy.

BACKGROUND

Since the concept of a symptom cluster was first introduced into the oncology literature in 2001, only four comprehensive reviews of symptom clusters research in oncology patients were identified that provide insights into this important concept in symptom management research.

DESIGN

A comprehensive review of the literature.

METHODS

A comprehensive literature search was conducted for the years 2000 to 2016. Only 19 studies met the inclusion criteria for this literature review. These studies were evaluated in terms of the symptom assessment instruments used; the statistical analysis methods used; the symptom dimension(s) used to create the symptom cluster(s); the number and types of symptom clusters identified; and whether the specific symptom clusters changed over time.

RESULTS

The number of symptom clusters identified ranged from one-seven. The majority of the studies used some type of factor analysis to create the symptom clusters. The most common symptom dimension used to create the clusters was symptom severity. A "gastrointestinal symptom cluster" was the most common symptom cluster identified. Across the eight longitudinal studies, for half of these studies the symptom clusters remained relatively stable over time.

CONCLUSIONS

Additional research is needed in oncology patients to address the assessment of symptom clusters, the specific nature of symptom clusters and whether symptom clusters change over time.

Translation and validation of the Cancer-Related Fatigue Scale in Greek in a sample of patients with advanced prostate cancer

OBJECTIVE

To translate and validate the Cancer-Related Fatigue (CRF) Scale in the Greek language.

DESIGN

A cross-sectional descriptive design was used in order to translate and validate the CRF Scale in Greek. Factor analyses were performed to understand the psychometric properties of the scale and to establish construct, criterion and convergent validity.

SETTING

Outpatients' oncology clinics of two public hospitals in Cyprus.

PARTICIPANTS

148 patients with advanced prostate cancer undergoing chemotherapy.

RESULTS

The Cancer Fatigue Scale (CFS) had good stability (test-retest reliability r=0.79, p<0.001) and good internal consistency (Cronbach's α coefficient for all 15 items α=0.916). Furthermore, the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value) was found to be 0.743 and considered to be satisfactory (>0.5). The correlations between the CFS physical scale (CFS-FS scale) and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 physical subscales were found to be significant (r=-0.715). The same occurred between CFS cognitive and EORTC cognitive subscale (r=-0.579). Overall, the criterion validity was verified. The same occurs for the convergent validity of the CFS since all correlations with the Global Health Status (q29-q30) were found to be significant.

CONCLUSIONS

This is the first validation study of the CRF Scale in Greek and warrant of its use in the assessment of prostate cancer patient's related fatigue. However, further testing and validation is needed in the early stages of the disease and in patients in later chemotherapy cycles.

Is cancer survival associated with cancer symptom awareness and barriers to seeking medical help in England? An ecological study

BACKGROUND

Campaigns aimed at raising cancer awareness and encouraging early presentation have been implemented in England. However, little is known about whether people with low cancer awareness and increased barriers to seeking medical help have worse cancer survival, and whether there is a geographical variation in cancer awareness and barriers in England.

METHODS

From population-based surveys (n=35 308), using the Cancer Research UK Cancer Awareness Measure, we calculated the age- and sex-standardised symptom awareness and barriers scores for 52 primary care trusts (PCTs). These measures were evaluated in relation to the sex-, age-, and type of cancer-standardised cancer survival index of the corresponding PCT, from the National Cancer Registry, using linear regression. Breast, lung, and bowel cancer survival were analysed separately.

RESULTS

Cancer symptom awareness and barriers scores varied greatly between geographical regions in England, with the worst scores observed in socioeconomically deprived parts of East London. Low cancer awareness score was associated with poor cancer survival at PCT level (estimated slope=1.56, 95% CI: 0.56; 2.57). The barriers score was not associated with overall cancer survival, but it was associated with breast cancer survival (estimated slope=-0.66, 95% CI: -1.20; -0.11). Specific barriers, such as embarrassment and difficulties in arranging transport to the doctor's surgery, were associated with worse breast cancer survival.

CONCLUSIONS

Cancer symptom awareness and cancer survival are associated. Campaigns should focus on improving awareness about cancer symptoms, especially in socioeconomically deprived areas. Efforts should be made to alleviate barriers to seeking medical help in women with symptoms of breast cancer.

Breast Cancer Symptom Clusters Derived from Social Media and Research Study Data Using Improved K-Medoid Clustering

Most cancer patients, including patients with breast cancer, experience multiple symptoms simultaneously while receiving active treatment. Some symptoms tend to occur together and may be related, such as hot flashes and night sweats. Co-occurring symptoms may have a multiplicative effect on patients' functioning, mental health, and quality of life. Symptom clusters in the context of oncology were originally described as groups of three or more related symptoms. Some authors have suggested symptom clusters may have practical applications, such as the formulation of more effective therapeutic interventions that address the combined effects of symptoms rather than treating each symptom separately. Most studies that have sought to identify clusters in breast cancer survivors have relied on traditional research studies. Social media, such as online health-related forums, contain a bevy of user-generated content in the form of threads and posts, and could be used as a data source to identify and characterize symptom clusters among cancer patients. The present study seeks to determine patterns of symptom clusters in breast cancer survivors derived from both social media and research study data using improved K-Medoid clustering. A total of 50,426 publicly available messages were collected from Medhelp.com and 653 questionnaires were collected as part of a research study. The network of symptoms built from social media was sparse compared to that of the research study data, making the social media data easier to partition. The proposed revised K-Medoid clustering helps to improve the clustering performance by re-assigning some of the negative-ASW (average silhouette width) symptoms to other clusters after initial K-Medoid clustering. This retains an overall non-decreasing ASW and avoids the problem of trapping in local optima. The overall ASW, individual ASW, and improved interpretation of the final clustering solution suggest improvement. The clustering results suggest that some symptom clusters are consistent across social media data and clinical data, such as gastrointestinal (GI) related symptoms, menopausal symptoms, mood-change symptoms, cognitive impairment and pain-related symptoms. We recommend an integrative approach taking advantage of both data sources. Social media data could provide context for the interpretation of clustering results derived from research study data, while research study data could compensate for the risk of lower precision and recall found using social media data.

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1,073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.

This guideline was developed through a collaboration between the American Cancer Society and the American Society of Clinical Oncology and has been published jointly by invitation and consent in both CA: A Cancer Journal for Clinicians and Journal of Clinical Oncology. Copyright © 2015 American Cancer Society and American Society of Clinical Oncology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Cancer Society or the American Society of Clinical Oncology.

Should we cluster patients or symptoms? The myth of symptom clusters based on 'depression, insomnia, pain' and 'depression, fatigue, pain'

CONTEXT

'Depression, fatigue, pain' (DFP) and 'depression, insomnia, pain' (DIP) symptom clusters (SCs) have been proposed in cancer. These symptoms are common and co-occur, that is, they constitute clusters of patients rather than symptoms.

OBJECTIVES

The following research questions were addressed: (1) What is the frequency of co-occurrence of two symptom groups (DFP and DIP) in advanced cancer? (2) What is the degree of symptom item association within each symptom group? (3) Were either of these symptom trios associated with prognosis?

METHODS

We reanalysed a symptom data set of 1000 patients with advanced cancer. We identified the frequency of co-occurrence of two symptom groups: DFP and DIP, using both prevalence and severity data. The symptom associations were tested by χ(2) and Spearman correlations. We also determined whether either of these symptom trios were associated with a major biological outcome, that is, survival by time-to-event analyses.

RESULTS

(1) Although DFP and DIP co-occured in about a quarter of the population, they were not SCs, but rather patient clusters. (2) Many persons had only one symptom from any symptom pair, and correlation coefficients were low for all symptom pairs. (3) Neither DFP nor DIP were associated with survival.

CONCLUSIONS

Neither DFP nor DIP symptom item combinations constituted a specific cancer SC contrary to prior reports. DFP co-occurred in 27% and DIP in only 20%. Additionally, these symptom combinations were not associated with a biological outcome, that is, poor prognosis. Patient subgroups identified by shared symptom experiences alone do not identify SCs.

American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

Answer questions and earn CME/CNE The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.

Symptom clusters in women with breast cancer: an analysis of data from social media and a research study

PURPOSE

User-generated content on social media sites, such as health-related online forums, offers researchers a tantalizing amount of information, but concerns regarding scientific application of such data remain. This paper compares and contrasts symptom cluster patterns derived from messages on a breast cancer forum with those from a symptom checklist completed by breast cancer survivors participating in a research study.

METHODS

Over 50,000 messages generated by 12,991 users of the breast cancer forum on MedHelp.org were transformed into a standard form and examined for the co-occurrence of 25 symptoms. The k-medoid clustering method was used to determine appropriate placement of symptoms within clusters. Findings were compared with a similar analysis of a symptom checklist administered to 653 breast cancer survivors participating in a research study.

RESULTS

The following clusters were identified using forum data: menopausal/psychological, pain/fatigue, gastrointestinal, and miscellaneous. Study data generated the clusters: menopausal, pain, fatigue/sleep/gastrointestinal, psychological, and increased weight/appetite. Although the clusters are somewhat different, many symptoms that clustered together in the social media analysis remained together in the analysis of the study participants. Density of connections between symptoms, as reflected by rates of co-occurrence and similarity, was higher in the study data.

CONCLUSIONS

The copious amount of data generated by social media outlets can augment findings from traditional data sources. When different sources of information are combined, areas of overlap and discrepancy can be detected, perhaps giving researchers a more accurate picture of reality. However, data derived from social media must be used carefully and with understanding of its limitations.

Ongoing Screening and Treatment to Potentially Reduce Tyrosine Kinase Inhibitor-Related Fatigue in Renal Cell Carcinoma

CONTEXT

Renal cell carcinoma (RCC) represents 1% to 4% of adult malignancies, and approximately 33% of patients with RCC present with metastatic disease and have a poor prognosis. Better understanding of RCC tumor biology has led to the development of several molecularly targeted agents, such as tyrosine kinase inhibitors (TKIs), to manage advanced disease. Although evolving data suggest these drugs may be beneficial in RCC, they are associated with significant toxicities. Cancer-related fatigue (CRF) is one of the most common toxicities associated with the TKIs used in RCC.

OBJECTIVES

To review the incidence, pathophysiology, and management of CRF in patients with RCC who are undergoing targeted therapy with TKIs.

METHODS

A comprehensive database search was performed using PubMed, Ovid, Embase, and MEDLINE. References of all cited articles also were reviewed. Data from articles published between 1975 and June 2014 were considered. A narrative review regarding the incidence, pathophysiology, and management of CRF in patients with RCC undergoing targeted therapy with TKIs was performed.

RESULTS

CRF is one of the most common TKI toxicities in patients with metastatic RCC and often is the dose-limiting toxicity. Management of TKI-related CRF can be difficult and may necessitate various nonpharmacologic and pharmacologic interventions.

CONCLUSION

TKI-related CRF in patients with RCC is a highly distressing complication of cancer therapy. CRF can substantially influence drug compliance, the ability to maximally treat, and quality of life. It is important to recognize this common, yet frequently underdiagnosed complication and initiate appropriate management strategies, to increase the likelihood for optimal outcomes.

Efficacy and safety of an amino acid jelly containing coenzyme Q10 and L-carnitine in controlling fatigue in breast cancer patients receiving chemotherapy: a multi-institutional, randomized, exploratory trial (JORTC-CAM01)

PURPOSE

Cancer-related fatigue (CRF) is one of the most common symptoms reported by cancer patients. This randomized trial investigated the efficacy of the amino acid jelly Inner Power(®) (IP), a semi-solid, orally administrable dietary supplement containing coenzyme Q10 and L-carnitine, in controlling CRF in breast cancer patients in Japan.

METHODS

Breast cancer patients with CRF undergoing chemotherapy were randomly assigned to receive IP once daily or regular care for 21 days. The primary endpoint was the change in the worst level of fatigue during the past 24 h (Brief Fatigue Inventory [BFI] item 3 score) from day 1 (baseline) to day 22. Secondary endpoints were change in global fatigue score (GFS; the average of all BFI items), anxiety and depression assessed by the Hospital Anxiety and Depression Scale (HADS), quality of life assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and EORTC Breast Cancer-Specific QLQ (EORTC QLQ-BR23), and adverse events.

RESULTS

Fifty-nine patients were enrolled in the study, of whom 57 were included in the efficacy analysis. Median patient age was 50 years. Changes in the worst level of fatigue, GFS, and current feeling of fatigue were significantly different between the intervention and control groups, whereas the change in the average feeling of fatigue was not significantly different between groups. HADS, EORTC QLQ-C30, and EORTC QLQ-BR23 scores were not significantly different between the two groups. No severe adverse events were observed.

CONCLUSION

IP may control moderate-severe CRF in breast cancer patients.

TRIAL REGISTRATION

The registration number of this study in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) is UMIN000008646.

Occurrence and predictors of the fatigue in high-grade glioma patients

A better knowledge of the fatigue could be of the greatest importance for the high-grade glioma (HGG) patients, who are a unique and vulnerable population. The aim of this study was to evaluate the occurrence and the predictors of the fatigue in HGG patients, using a specific fatigue scale. The study was designed as a cross-sectional study. The study population included sixty-seven consecutive outpatients with HGG. We used these measures: Brief Fatigue Inventory, Karnofsky Performance Scale, Functional Independence Measure, Brief Psychiatric Rating Scale and Psychological Distress Inventory and SF-36, EORTC QLQ-30 and EORTC QLQ-BN20 for quality of life (QoL). Sixteen out of sixty-seven (23.9 %) patients were affected by Anaplastic Astrocytoma and 51/67 (76.1 %) by Glioblastoma Multiforme. About one-third (36.2 %) of patients had a clinically relevant fatigue (Brief Fatigue Inventory ≥3). In regression analysis, physical and mental aspects of QoL were statistically significant related with fatigue (p < 0.01 and p < 0.02, respectively). Our data underlined the relevant occurrence of fatigue in HGG patients and support the development of further studies exploring a tailored rehabilitation program.

Prevalence and predictors of fatigue in glioblastoma: a prospective study

BACKGROUND

The main goal of this study was to assess frequency, clinical correlates, and independent predictors of fatigue in a homogeneous cohort of well-defined glioblastoma patients at baseline prior to combined radio-chemotherapy.

METHODS

We prospectively included 65 glioblastoma patients at postsurgical baseline and assessed fatigue, sleepiness, mean bedtimes, mood disturbances, and clinical characteristics such as clinical performance status, presenting symptomatology, details on neurosurgical procedure, and tumor location and diameter as well as pharmacological treatment including antiepileptic drugs, antidepressants, and use of corticosteroids. Data on fatigue and sleepiness were measured with the Fatigue Severity Scale and the Epworth Sleepiness Scale, respectively, and compared with 130 age- and sex-matched healthy controls.

RESULTS

We observed a significant correlation between fatigue and sleepiness scores in both patients (r = 0.26; P = .04) and controls (r = 0.36; P < .001). Only fatigue appeared to be more common in glioblastoma patients than in healthy controls (48% vs 11%; P < .001) but not the frequency of sleepiness (22% vs 19%; P = .43). Female sex was associated with increased fatigue frequency among glioblastoma patients but not among control participants. Multiple linear regression analyses identified depression, left-sided tumor location, and female sex as strongest associates of baseline fatigue severity.

CONCLUSIONS

Our findings indicate that glioblastoma patients are frequently affected by fatigue at baseline, suggesting that factors other than those related to radio- or chemotherapy have significant impact, particularly depression and tumor localization.

Symptoms, clusters and quality of life prior to surgery for breast cancer

AIMS AND OBJECTIVES

To examine the pretreatment symptoms and symptom clusters that women awaiting breast cancer surgery are experiencing and the impact of these symptoms on their quality of life.

BACKGROUND

Most women diagnosed with breast cancer will have surgery as a first-line treatment. The presence of presurgery symptoms may be significant in contributing to distress and impaired quality of life. While it seems that women with breast cancer may experience the symptoms of fatigue, pain, depression and sleep disturbance as a cluster, this has not yet been confirmed by empirical research in the presurgery time period.

DESIGN

A multiple-point prospective longitudinal cohort panel design is used.

METHODS

Presurgery symptoms and quality of life were assessed using the Hospital Anxiety and Depression Scale, Insomnia Severity Index, Functional Assessment of Cancer Therapy-Fatigue, Brief Pain Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30(3).

RESULTS

Participants (n = 94, age range 30-92) experienced symptoms prior to surgery, with pain being a more prevalent symptom (35%) than fatigue (32%), sleep disturbances (25·5%) or depression (11%). global quality of life was significantly impacted on by fatigue and showed a moderate correlation with emotional functioning and a weak correlation with physical and social functioning. Hierarchical cluster analysis identified the presence of five clusters with symptoms present in differing intensities in each cluster.

CONCLUSION

In this cohort of women, healthy other than having a diagnosis of breast cancer, symptoms were impacting on quality of life. It is evident that clusters of symptoms are present presurgery that must be assessed and managed.

RELEVANCE TO PRACTICE

Healthcare delivery systems must ensure that early symptoms are addressed effectively in the presurgery period to improve quality of life and reduce adverse outcomes postsurgery.

Association between the prevalence of symptoms and health-related quality of life in adult survivors of childhood cancer: a report from the St Jude Lifetime Cohort study

PURPOSE

We investigated the association between prevalence of symptoms and health-related quality of life (HRQOL) in adult survivors of childhood cancer enrolled in the St Jude Lifetime Cohort study.

METHODS

Eligibility criteria include childhood malignancy treated at St Jude, survival ≥ 10 years from diagnosis, and current age ≥ 18 years. Study participants were 1,667 survivors (response rate = 65%). Symptoms were self-reported by using a comprehensive health questionnaire and categorized into 12 classes: cardiac; pulmonary; motor/movement; pain in head; pain in back/neck; pain involving sites other than head, neck, and back; sensation abnormalities; disfigurement; learning/memory; anxiety; depression; and somatization. HRQOL was measured by using physical/mental component summary (PCS/MCS) and six domain scores of the Medical Outcomes Study 36-Item Short-Form Health Survey. Multivariable regression analysis was performed to investigate associations between symptom classes and HRQOL. Cumulative prevalence of symptom classes in relation to time from diagnosis was estimated.

RESULTS

Pain involving sites other than head, neck and back, and disfigurement represented the most frequent symptom classes, endorsed by 58.7% and 56.3% of survivors, respectively. Approximately 87% of survivors reported multiple symptom classes. Greater symptom prevalence was associated with poorer HRQOL. In multivariable analysis, symptom classes explained up to 60% of the variance in PCS and 56% of the variance in MCS; demographic and clinical variables explained up to 15% of the variance in PCS and 10% of the variance in MCS. Longer time since diagnosis was associated with higher cumulative prevalence in all symptom classes.

CONCLUSION

A large proportion of survivors suffered from many symptom classes, which was associated with HRQOL impairment.

Common biological pathways underlying the psychoneurological symptom cluster in cancer patients

BACKGROUND

A symptom cluster is a group of symptoms that occur together and are interrelated. The clinical implication of symptom cluster research is to use the clustering patterns of symptoms to understand the mechanisms for these symptoms and develop management strategies targeted at multiple symptoms.

OBJECTIVE

The purposes of this review were to summarize the evidence for a psychoneurological symptom cluster in cancer patients, to provide information regarding the underlying biological mechanisms for each of the psychoneurological symptoms within the cluster, and to propose possible common biological pathways that may underlie this cluster.

METHODS

A systematic review of the literature was conducted.

RESULTS

Empirical evidence exists to support a cluster of psychoneurological symptoms (ie, depressive symptoms, cognitive disturbance, fatigue, sleep disturbance, pain). At a molecular level, common biological pathways (ie, proinflammatory cytokines, hypothalamic-pituitary-adrenal axis, and monoamine neurotransmission system) may underlie the development of symptoms within this cluster. Activation of proinflammatory cytokines is proposed as a first stage of mechanistic pathway. However, other biological factors, such as lowered estrogen or hemoglobin levels, may influence psychoneurological cluster.

CONCLUSION

Additional studies are needed to confirm the roles of cytokines as well as other biological factors in the development of the psychoneurological cluster and to determine the biomarkers to identify the subgroups of cancer patients who are at greatest risk for this cluster.

IMPLICATIONS FOR PRACTICE

This information can be used by researchers and clinicians to guide the selection of symptom management strategies that are ideally targeted to the biological mechanisms that underlie this symptom cluster.

Functional impairments as symptoms in the symptom cluster analysis of patients newly diagnosed with advanced cancer

CONTEXT

Symptoms and subsequent functional impairment have been associated with the biological processes of disease, including the interaction between disease and treatment in a measurement model of symptoms. However, hitherto cluster analysis has primarily focused on symptoms.

OBJECTIVES

This study among patients within 100 days of diagnosis with advanced cancer explored whether self-reported physical symptoms and functional impairments formed clusters at the time of diagnosis.

METHODS

We applied cluster analysis to self-reported symptoms and activities of daily living of 111 patients newly diagnosed with advanced gastrointestinal (GI), gynecological, head and neck, and lung cancers. Based on content expert evaluations, the best techniques and variables were identified, yielding the best solution.

RESULTS

The best cluster solution used a K-means algorithm and cosine similarity and yielded five clusters of physical as well as emotional symptoms and functional impairments. Cancer site formed the predominant organizing principle of composition for each cluster. The top five symptoms and functional impairments in each cluster were Cluster 1 (GI): outlook, insomnia, appearance, concentration, and eating/feeding; Cluster 2 (GI): appetite, bowel, insomnia, eating/feeding, and appearance; Cluster 3 (gynecological): nausea, insomnia, eating/feeding, concentration, and pain; Cluster 4 (head and neck): dressing, eating/feeding, bathing, toileting, and walking; and Cluster 5 (lung): cough, walking, eating/feeding, breathing, and insomnia.

CONCLUSION

Functional impairments in patients newly diagnosed with late-stage cancers behave as symptoms during the diagnostic phase. Health care providers need to expand their assessments to include both symptoms and functional impairments. Early recognition of functional changes may accelerate diagnosis at an earlier cancer stage.

Cluster analysis of clinical data identifies fibromyalgia subgroups

INTRODUCTION

Fibromyalgia (FM) is mainly characterized by widespread pain and multiple accompanying symptoms, which hinder FM assessment and management. In order to reduce FM heterogeneity we classified clinical data into simplified dimensions that were used to define FM subgroups.

MATERIAL AND METHODS

48 variables were evaluated in 1,446 Spanish FM cases fulfilling 1990 ACR FM criteria. A partitioning analysis was performed to find groups of variables similar to each other. Similarities between variables were identified and the variables were grouped into dimensions. This was performed in a subset of 559 patients, and cross-validated in the remaining 887 patients. For each sample and dimension, a composite index was obtained based on the weights of the variables included in the dimension. Finally, a clustering procedure was applied to the indexes, resulting in FM subgroups.

RESULTS

VARIABLES CLUSTERED INTO THREE INDEPENDENT DIMENSIONS: "symptomatology", "comorbidities" and "clinical scales". Only the two first dimensions were considered for the construction of FM subgroups. Resulting scores classified FM samples into three subgroups: low symptomatology and comorbidities (Cluster 1), high symptomatology and comorbidities (Cluster 2), and high symptomatology but low comorbidities (Cluster 3), showing differences in measures of disease severity.

CONCLUSIONS

We have identified three subgroups of FM samples in a large cohort of FM by clustering clinical data. Our analysis stresses the importance of family and personal history of FM comorbidities. Also, the resulting patient clusters could indicate different forms of the disease, relevant to future research, and might have an impact on clinical assessment.

Adaptation of the illness trajectory framework to describe the work of transitional cancer survivorship

PURPOSE/OBJECTIVES

To examine and refine the Illness Trajectory Framework, and to address transitional cancer survivorship.

DATA SOURCES

CINAHL®, PubMed, and relevant Institute of Medicine reports were searched for survivors' experiences during the year following treatment.

DATA SYNTHESIS

Using an abstraction tool, 68 articles were selected from the initial search (N > 700). Abstracted data were placed into a priori categories refined according to recommended procedures for theory derivation, followed by expert review.

CONCLUSIONS

Derivation resulted in a framework describing the work of transitional cancer survivorship, defined as survivor tasks, performed alone or with others, to carry out a plan of action for managing one or more aspects of life following primary cancer treatment. Theoretically, survivors engage in three reciprocally interactive lines of work: (a) illness-related, (b) biographical, and (c) everyday life work. Adaptation resulted in refinement of these domains and the addition of survivorship care planning under "illness-related work."

IMPLICATIONS FOR NURSING

Understanding this process of work may allow survivors and those who support them to better prepare for the post-treatment period. This adaptation provides a framework for future testing and development. Validity and utility of this framework within specific survivor populations also should be explored.

Employment outcomes among survivors of common cancers: the Symptom Outcomes and Practice Patterns (SOAPP) study

INTRODUCTION

Risk factors for employment difficulties after cancer diagnosis are incompletely understood, and interventions to improve post-cancer employment remain few. New targets for intervention are needed.

METHODS

We assessed a cohort of 530 nonmetastatic cancer patients (aged ≤ 65 years, >6 months from diagnosis, off chemo- or radiotherapy) from the observational multi-site Symptom Outcomes and Practice Patterns study. Participants reported employment change, current employment, and symptoms. Groups were based on employment at survey (working full- or part-time versus not working) and whether there had been a change due to illness (yes versus no). The predictive power of symptom interference with work was evaluated for employment group (working stably versus no longer working). Race/ethnicity, gender, cancer type, therapy, and time since diagnosis were also assessed. Association between employment group and specific symptoms was examined.

RESULTS

The cohort was largely non-Hispanic white (76 %), female (85 %), and diagnosed with breast cancer (75 %); 24 % reported a change in employment. On multivariable analysis, participants with at least moderate symptom interference were more likely to report no longer working than their less effected counterparts (odds ratio (OR) = 8.0, 95 % CI, 4.2-15.4), as were minority participants compared with their non-Hispanic white counterparts (OR = 3.2, 95 % CI, 1.8-5.6). Results from the multiple regression model indicated the combination of fatigue (OR = 2.3, 95 % CI, 1.1-4.7), distress (OR = 3.9, 95 % CI, 1.7-9.0), and dry mouth (OR = 2.6, 95 % CI, 1.1-6.2) together with race/ethnicity and time since diagnosis adequately accounted for employment group.

CONCLUSIONS

Our findings support the hypothesis that residual symptom burden is related to post-cancer employment: Residual symptoms may be targets for intervention to improve work outcomes among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

This analysis examines whether increased symptom burden is associated with a change to not working following a cancer diagnosis. We also examined individual symptoms to assess which symptoms were most strongly associated with not working after a cancer diagnosis. Our hope is that we will be able to use this information to both screen survivors post-active treatment as well as target high-risk symptoms for further and more aggressive intervention, in an attempt to improve post-cancer work outcomes.

Pain, movement, and mind: does physical activity mediate the relationship between pain and mental health among survivors of breast cancer?

OBJECTIVES

This study examined the relationship between pain and mental health outcomes of depression and affect among survivors of breast cancer. The mediating role of physical activity was also tested.

METHODS

Survivors of breast cancer (N=145) completed self-report measures of pain symptoms at baseline, wore an accelerometer for 7 days, and reported levels of depression symptoms and negative and positive affect 3 months later. Hierarchical linear regression analyses, controlling for personal and cancer-related demographics, were used to test the association between pain symptoms and each mental health outcome, as well as the mediation effect of physical activity.

RESULTS

Pain positively predicted depression symptoms [F(6,139)=4.31, P<0.01, R=0.15] and negative affect [F(5,140)=4.17, P<0.01, R=0.13], and negatively predicted positive affect [F(6,139)=2.12, P=0.03, R=0.08]. Physical activity was a significant (P<0.01) partial mediator of the relationship between pain and depression and between pain and positive affect.

DISCUSSION

Participation in physical activity is one pathway through which pain influences mental health. Efforts are needed to help survivors of breast cancer manage pain symptoms and increase their level of physical activity to help improve mental health.

Symptom clusters and quality of life in older adult breast cancer survivors

PURPOSE/OBJECTIVES

To identify symptom clusters in older adult breast cancer survivors (ages 65-97 years) and examine whether symptom clusters are related to demographic, health, and quality-of-life variables.

DESIGN

Factor analysis to identify possible symptom clusters. The resulting clusters then were correlated with quality-of-life measures.

SETTING

Phone interviews between the participants and a trained research nurse.

SAMPLE

192 breast cancer survivors (X age = 70).

METHODS

This was a secondary data analysis of the baseline measures of demographics, health history, symptom bother, and physical, mental, and existential dimensions of quality of life. Exploratory and confirmatory factor analyses were conducted as well as multiple indicator multiple cause modeling and partial correlation analyses to assess the relationships among clusters and demographic, health history, and quality-of-life measures.

MAIN RESEARCH VARIABLES

Self-reported symptom bother, demographics such as age and education level, health history, and quality of life.

FINDINGS

Seven clinically distinct symptom clusters tapping 36 different symptoms in older adult breast cancer survivors were found. These symptom clusters were significantly related to multiple dimensions of quality of life.

CONCLUSIONS

Older adult breast cancer survivors experience multiple concurrent symptoms that appear to cluster. Identifying symptom clusters helps to elucidate possible intersymptom relationships which may lead to the design of more effective symptom management interventions for older adult breast cancer survivors.

IMPLICATIONS FOR NURSING

Older adult breast cancer survivors should be assessed for a wide variety of symptoms if clinicians hope to identify and understand intersymptom relationships. Such assessment would enable more comprehensive symptom management.

A literature review of symptom clusters in patients with breast cancer

The aim of this article is to present a review reporting empirically determined symptom clusters in breast cancer patients. We conducted a literature search on symptom clusters in breast cancer patients using PubMed, MEDLINE, EMBASE and CINAHL. Studies examining the presence of predetermined clusters were excluded. The five relevant studies identified were published between 2005 and 2009. The five studies differed from each other by statistical methodology, by the number of symptom clusters produced and by the symptoms comprising the clusters. Symptom clusters extracted between the five studies varied from one to four, while the number of symptoms in a cluster ranged from two to five. One study examining symptom clusters between different patient groups and a second study examining clusters across a time trajectory had certain reproducible clusters comprising similar symptoms. There were no clusters across different studies that contained the same symptoms, although the single symptom of fatigue was present in a cluster in all five studies and depression/psychological distress was noted in four of the studies. Nausea and appetite were the only two symptoms that associated together across three of the five studies; however, they were not the only two symptoms in those clusters. Methodological disparities include different patient populations between and within studies, different statistical methods, varying assessment tools and time points, with the majority of studies employing more than one symptom tool. Although there were common symptoms assessed across the five studies, no common symptom clusters could be derived from these reports. This lack of commonality may result from the disparities in subpopulations of patients, assessment tools, and analytical and methodological approaches. As symptom cluster research continues to develop towards a clearer consensus on guidelines, the findings of symptom clusters may provide clinically valuable information regarding diagnosis, prognostication, prioritizing and managing symptoms in breast cancer patients.

Long-term effect of the self-management comprehensive coping strategy program on quality of life in patients with breast cancer treated with high-dose chemotherapy

BACKGROUND

This study aims to examine the effectiveness of a self-management multimodal comprehensive coping strategy program (CCSP) on quality of life (QOL) among breast cancer patients 1 year after treatment.

METHODS

Patients (n = 110) with stage II, III, or IV breast cancer scheduled to receive high dose chemotherapy and autologous hematopoietic stem cell transplantation were randomized to either CCSP treatment or control group. The CCSP intervention was taught 2 week before hospital admission with reinforcement at specified times during treatment and 3 months after discharge. The CCSP components included educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery. Instruments administered at baseline included the following: Quality of Life Index-Cancer Version (QOLI-CV), State-Trait Anxiety Inventory, Beck Depression Inventory, and Coping Strategies Questionnaire. At 1-year follow-up, patients (n = 73) completed and returned the follow-up QOLI-CV.

RESULTS

Patients were mainly ≥ 40 years of age, married, Caucasian, and diagnosed with advanced breast cancer. A model measuring effectiveness of CCSP on QOL (total and subscale) at 1-year follow-up showed that the CCSP group (n = 38) had significant improvement in overall QOL (p < 0.01), health and functioning (p < 0.05), and socioeconomic (p < 0.05) and psychological/spiritual well-being (p < 0.01) compared with the control group (n = 35). The CCSP patients frequently used the CCSP to manage psychological (51%) and sleep problems (60%).

CONCLUSIONS

The CCSP improved QOL for patients at 1-year follow-up. Patients overwhelmingly reported that CCSP was beneficial. The CCSP as an effective coping intervention has potential as a self-management program for breast cancer survivors.

Cancer-related fatigue: prevalence, assessment and treatment strategies

Cancer-related fatigue (CRF) is one of the most common symptoms reported by patients and is defined as the feeling of extraordinary exhaustion associated with a high level of distress, disproportionate to the patients' activity, and is not relieved by sleep or rest. Prevalence rates range from 59 to nearly 100% depending on the clinical status of the cancer. Except for chemotherapy-induced anemia, the mechanisms responsible for CRF are not yet completely understood. Therefore, CRF may be influenced by multiple possible somatic and psychosocial factors. CRF has been shown as either a short-term side effect of adjuvant cancer therapy or a chronic long-term late effect. Compared with other symptoms, such as pain or nausea, CRF is more distressing and often long lasting, with a strong impact on daily living and quality of life. The concept of fatigue has been widely elaborated and operationalized in different dimensions within the last few decades and specific instruments assessing fatigue in cancer populations have been developed. To support patients and alleviate CRF symptoms various treatment strategies are discussed in this article, including information and counseling, enhancement of activities, exercise and sports therapy, psychosocial interventions as well as pharmacological treatment. In most Western countries, treatment of CRF has been identified as a priority for advancing cancer patient care. This article gives an overview of the concept of CRF, its pathogenesis, assessment and treatment strategies.

Exercise may reduce depression but not anxiety in self-referred cancer patients undergoing chemotherapy. Post-hoc analysis of data from the 'Body & Cancer' trial

Abstract Background. The diagnosis and treatment of cancer may cause clinically significant and persistent psychological morbidity. The objective of this study was to determine the short-term effect of a six week exercise intervention on anxiety and depression in cancer patients undergoing chemotherapy (The 'Body & Cancer' trial). Methods. Two hundred and nine self-referred patients (52 males, 157 females, mean age 47 years) were randomised into an intervention group and a waiting-list control group. Anxiety and depression was measured by the Hospital Anxiety and Depression Scale. Results. At baseline, 23.5% and 11.5% of the population scored >8 on the HADS and were classified as suspicious or definite cases of anxiety and depression, respectively. Adjusted for baseline score, disease and demographic covariates the estimated intervention effect showed improvement at six weeks for depression of -0.7 points (95% confidence interval [CI] -1.27 to -0.14, p = 0.0153). No significant effect was seen on anxiety. Further subanalysis, including only suspicious or definite cases of depression, resulted in an estimated intervention effect of -2.53 points (95% CI, -0.64 to -0.42, p = 0.021). Conclusion. Anti-depressant effects could be caused by exercise in self-referred cancer patients undergoing chemotherapy. Dedicated trials and follow-up studies are needed to clarify the optimal duration and content of exercise interventions to meet the needs of clinically depressive or anxious patients.

Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters

To investigate prevalence and severity of symptoms and symptom clustering in breast cancer survivors who attended MBSR(BC). Women were randomly assigned into MBSR(BC) or Usual Care (UC). Eligible women were ≥ 21 years, had been diagnosed with breast cancer and completed treatment within 18 months of enrollment. Symptoms and interference with daily living were measured pre- and post-MBSR(BC) using the M.D. Anderson Symptom Inventory. Symptoms were reported as highly prevalent but severity was low. Fatigue was the most frequently reported and severe symptom among groups. Symptoms clustered into 3 groups and improved in both groups. At baseline, both MBSR(BC) and the control groups showed similar mean symptom severity and interference; however, after the 6-week post-intervention, the MBSR(BC) group showed statistically-significant reduction for fatigue and disturbed sleep (P < 0.01) and improved symptom interference items, compared to the control group. For the between-group comparisons, 11 of 13 symptoms and 5 of 6 interference items had lower means in the MBSR(BC) condition than the control condition. These results suggest that MBSR(BC) modestly decreases fatigue and sleep disturbances, but has a greater effect on the degree to which symptoms interfere with many facets of life. Although these results are preliminary, MBSR intervention post-treatment may effectively reduce fatigue and related interference in QOL of breast cancer survivors.

Prevalência e comorbidade de dor e fadiga em mulheres com câncer de mama

O estudo analisou a prevalência e a comorbidade de dor e fadiga em mulheres com câncer de mama. Trata-se de estudo transversal, com amostra, não probabilística de 182 mulheres em tratamento ambulatorial para câncer de mama, entrevistadas no período de julho 2006 a março de 2007. Fadiga, avaliada pela Escala de Fadiga de Piper, foi dividida em duas categorias (escore 0,1-4,9 e >5-10). Dor, avaliada pela escala de 0-10, foi categorizada do mesmo modo que fadiga. Fadiga ocorreu em 94 mulheres (51,6%), sendo >5 em 44 (46,8%) delas. Dor ocorreu em 86 mulheres (47,2%), sendo >5 em 50 (58,1%). Fadiga e dor correlacionaram-se (r=0,38, p=0,003) e a comorbidade fadiga e dor foi de 38,3%. Dor intensa acentuou a fadiga (p=0,089) e fadiga intensa acentuou a dor (p=0,016). Tais dados são inéditos em nosso meio, confirmam a existência de um cluster de sintoma e dos prejuízos decorrentes dessa comorbidade.

Late effects of breast cancer treatment and potentials for rehabilitation

BACKGROUND

Breast cancer is the most frequent malignant disease among women world wide. Survival has been improving leading to an increasing number of breast cancer survivors, in the US estimated to about 2.6 million.

MATERIAL AND METHODS

The literature was reviewed with focus on data from the Nordic countries.

RESULTS

Local therapies such as breast cancer surgery and radiotherapy may cause persistent pain in the breast area, arm, and shoulder reported by 30-50% of patients after three to five years, lymphedema in 15-25% of patients, and restrictions of arm and shoulder movement in 35%. Physiotherapy is the standard treatment for the latter while no pain intervention trials have been published. Chemotherapy may cause infertility and premature menopause, resulting in vasomotor symptoms, sexual dysfunction, and osteoporosis, which are similar to the side effects of endocrine treatment in postmenopausal women. Awareness of cardiotoxicity is needed since anthracyclines, trastuzumab, and radiotherapy can damage the heart. Breast cancer survivors have an increased risk of a major depression and far from all receive adequate anti-depressive treatment. Other psychological symptoms include fear of recurrence, sleep disturbances, cognitive problems, fatigue, and sexual problems.

DISCUSSION

To improve rehabilitation, specific goals have to be formulated into national guidelines and high priority directed towards research into developing and testing new interventions for alleviating symptoms and side effects experienced by breast cancer survivors.

Is increasing physical activity necessary to diminish fatigue during cancer treatment? Comparing cognitive behavior therapy and a brief nursing intervention with usual care in a multicenter randomized controlled trial

BACKGROUND

Two interventions for fatigue were given during curative cancer treatment. The aim of this multicenter randomized controlled trial (RCT) with three conditions was to demonstrate the efficacy and to determine the contribution of physical activity.

METHODS

Recruited from seven hospitals, 220 patients with various malignancies participated in a RCT. The brief nursing intervention (BNI) consisted of two 1-hour sessions, 3 months apart, given by 12 trained nurses, focusing only on physical activity. Cognitive behavior therapy (CBT) consisted of up to ten 1-hour sessions, within 6 months, provided by two therapists, focusing on physical activity and psychosocial elements. The control group received only usual care (UC). Assessments took place before and at least 2 months after cancer treatment, when patients had recovered from acute fatigue. Fatigue was the primary outcome. Efficacy was tested using analyses of covariance. A nonparametric bootstrap approach was used to test whether the effect on fatigue was mediated by physical activity.

RESULTS

The CBT group was significantly less fatigued than the UC group. Between the BNI and the UC groups, no significant difference was found in fatigue. The mediation hypothesis was rejected.

DISCUSSION

CBT given during curative cancer treatment proved to be an effective intervention to reduce fatigue at least 2 months after cancer treatment. The BNI was not effective. Contrary to what was expected, physical activity did not mediate the effect of CBT on fatigue. Thus, the reduction in fatigue elicited by CBT was realized without a lasting increase in physical activity.

Symptom management in palliative care and end of life care

There is a need for generalist- and specialist-level palliative care clinicians proficient in symptom management and care coordination. Major factors contributing to this need include changed disease processes and trajectories, improved medical techniques and diagnostic testing, successful screening for chronic conditions, and drugs that often prolong life. The rapid progressive illnesses and deaths that plagued the first half of the twentieth century have been replaced in the twenty-first century by increased survival rates. Conditions that require ongoing medical care beyond a year define the current chronic illness population. Long years of survival are often accompanied by a reduced quality of life that requires more medical and nursing care and longer home care. This article reviews the management of selected symptoms in palliative and end of life care.

A phase 3 randomized, placebo-controlled, double-blind, clinical trial of the effect of modafinil on cancer-related fatigue among 631 patients receiving chemotherapy: a University of Rochester Cancer Center Community Clinical Oncology Program Research base study

BACKGROUND

Cancer-related fatigue is a debilitating symptom affecting psychosocial functioning and quality of life in 70% to 100% of cancer patients during and after treatment. The authors examined the effect of 200 mg of modafinil daily on the severity of cancer-related fatigue.

METHODS

The authors conducted a multicenter, randomized, double-blind, placebo-controlled, phase 3, clinical trial to examine the effect of modafinil on patient-reported fatigue in cancer patients undergoing chemotherapy. A sample of 877 cancer patients beginning chemotherapy at 23 geographically separate University of Rochester Cancer Center (URCC) Community Clinical Oncology Program (CCOP) affiliates were assessed for fatigue. Patients who reported fatigue (N=867) were randomly assigned to receive either 200 mg of oral modafinil (Provigil) daily or a placebo. Treatment began on Day 5 of Cycle 2 and ended after Day 7 of Cycle 4. Fatigue and depression were assessed during Cycles 2 to 4 by using psychometrically valid measures. Group differences (treatment vs control) in the worst level of fatigue during the previous week at Cycle 4 were examined by using an analysis of covariance (ANCOVA) adjusting for baseline fatigue (Cycle 2).

RESULTS

There were 631 patients (315 modafinil, 316 placebo) who provided evaluable data. ANCOVA showed a significant interaction between treatment condition and baseline fatigue (P=.017), where patients with severe baseline fatigue (n=458) benefited from modafinil, whereas patients with mild or moderate fatigue did not. Modafinil had no statistically significant effect on depression (P>.05).

CONCLUSIONS

Modafinil may be useful in controlling cancer-related fatigue in patients who present with severe fatigue but is not useful in patients with mild or moderate fatigue.