Fatigue, inflammation, and ω-3 and ω-6 fatty acid intake among breast cancer survivors

Metabolites, Healthy Lifestyle, and Polygenic Risk Score Associated with Upper Gastrointestinal Cancer: Findings from the UK Biobank Study

Previous metabolomics studies have highlighted the predictive value of metabolites on upper gastrointestinal (UGI) cancer, while most of them ignored the potential effects of lifestyle and genetic risk on plasma metabolites. This study aimed to evaluate the role of lifestyle and genetic risk in the metabolic mechanism of UGI cancer. Differential metabolites of UGI cancer were identified using partial least-squares discriminant analysis and the Wilcoxon test. Then, we calculated the healthy lifestyle index (HLI) score and polygenic risk score (PRS) and divided them into three groups, respectively. A total of 15 metabolites were identified as UGI-cancer-related differential metabolites. The metabolite model (AUC = 0.699) exhibited superior discrimination ability compared to those of the HLI model (AUC = 0.615) and the PRS model (AUC = 0.593). Moreover, subgroup analysis revealed that the metabolite model showed higher discrimination ability for individuals with unhealthy lifestyles compared to that with healthy individuals (AUC = 0.783 vs 0.684). Furthermore, in the genetic risk subgroup analysis, individuals with a genetic predisposition to UGI cancer exhibited the best discriminative performance in the metabolite model (AUC = 0.770). These findings demonstrated the clinical significance of metabolic biomarkers in UGI cancer discrimination, especially in individuals with unhealthy lifestyles and a high genetic risk.

Cancer-related fatigue: Towards a more targeted approach based on classification by biomarkers and psychological factors

Cancer-related fatigue is a frequent, burdensome and often insufficiently treated symptom. A more targeted treatment of fatigue is urgently needed. Therefore, we examined biomarkers and clinical factors to identify fatigue subtypes with potentially different pathophysiologies. The study population comprised disease-free breast cancer survivors of a German population-based case-control study who were re-assessed on average 6 (FU1, n = 1871) and 11 years (FU2, n = 1295) after diagnosis. At FU1 and FU2, we assessed fatigue with the 20-item multidimensional Fatigue Assessment Questionnaire and further factors by structured telephone-interviews. Serum samples collected at FU1 were analyzed for IL-1ß, IL-2, IL-4, IL-6, IL-10, TNF-a, GM-CSF, IL-5, VEGF-A, SAA, CRP, VCAM-1, ICAM-1, leptin, adiponectin and resistin. Exploratory cluster analyses among survivors with fatigue at FU1 and no history of depression yielded three clusters (CL1, CL2 and CL3). CL1 (n = 195) on average had high levels of TNF-α, IL1-β, IL-6, resistin, VEGF-A and GM-CSF, and showed high BMI and pain levels. Fatigue in CL1 manifested rather in physical dimensions. Contrarily, CL2 (n = 78) was characterized by high leptin level and had highest cognitive fatigue. CL3 (n = 318) did not show any prominent characteristics. Fatigued survivors with a history of depression (n = 214) had significantly higher physical, emotional and cognitive fatigue and showed significantly less amelioration of fatigue from FU1 to FU2 than survivors without depression. In conclusion, from the broad phenotype "cancer-related fatigue" we were able to delineate subgroups characterized by biomarkers or history of depression. Future investigations may take these subtypes into account, ultimately enabling a better targeted therapy of fatigue.

Top Ten Tips Palliative Care Clinicians Should Know About Integrative Palliative Care

Integrative medicine (IM) use is widespread among individuals living with serious illness. There is a natural alignment between the fields of IM and palliative care (PC) rooted in their shared core values. Integrative palliative care (IPC) is an emerging focus within the field of PC that aims to broaden the healing toolkit available to patients with serious illness by combining standard-of-care biomedical treatments with evidence-informed integrative and complementary medicine practices with the goal of enhancing quality of life at every stage of a person's health journey. This article is an evidence-based guide to incorporating IPC practices into the care of seriously ill individuals.

Biological mechanisms of cancer-related fatigue in breast cancer survivors after treatment: a scoping review

PURPOSE

Cancer-related fatigue (CRF) is the most common symptom experienced by cancer survivors. It is a multidimensional symptom affecting physical, emotional, and/or cognitive spheres, different from other types of fatigue. Characteristically is not alleviated by sleep or rest. CRF could have specific features in breast cancer survivors (BCS), because of sex, hormones, and distinct treatments. On the other hand, more than 25% of BCS report persistent CRF for 10 years or more after the diagnosis. The present study aims to recapitulate the knowledge about the biological mechanisms that potentially drive CRF in BCS after treatment.

METHODS

To answer a broad question, a scoping review methodology was used. Data were collated from three bibliographic databases: PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies were selected if they had included more than 20 BCS, after finishing their treatment, fatigue was measured with a quantitative scale and biomarkers were analyzed.

RESULTS

The final database was composed of 1896 records. Sixty-four studies finally met the eligibility criteria. Inflammation (61%), hypothalamic-pituitary-adrenal (HPA) axis dysregulation (14%), autonomic nervous system (ANS) dysfunction (11%), and diet (9%) were the biological pathways most frequently studied. Unfortunately, results from studies about inflammation and HPA axis show many inconsistencies.

CONCLUSION

More research about the role of ANS dysfunction and diet on the pathogenesis of CRF would be warranted according to the results of the review. There are some fields such as endocannabinoid systems, mitochondrial dysfunction, gut microbiota, and oxidative stress that have been insufficiently explored.

IMPLICATIONS FOR CANCER SURVIVORS

To widen the scope of future research in the physiopathology of CRF, it is necessary to identify mechanisms that would be potentially involved and have been insufficiently explored. Because of the high prevalence of CRF in BCS and the tremendous impact that fatigue has in their quality of life, it is essential to improve the efficacy of the treatments through a good knowledge of the biological basis of CRF.

Omega-3 polyunsaturated fatty acids (n-3 PUFAs), somatic and fatigue symptoms in cardiovascular diseases comorbid major depressive disorder (MDD): A randomized controlled trial

INTRODUCTION

Cardiovascular diseases (CVDs) and major depressive disorder (MDD) are the two most disabling diseases. Patients with CVDs comorbid depression had somatic and fatigue symptoms and were associated with chronic inflammation and omega-3 polyunsaturated fatty acid (n-3 PUFA) deficits. However, there have been limited studies on the effects of n-3 PUFAs on somatic and fatigue symptoms in patients with CVDs comorbid MDD.

METHOD

Forty patients with CVDs comorbid MDD (58% males, mean age of 60 ± 9 years) were enrolled and randomised to receive either n-3 PUFAs (2 g of eicosapentaenoic acid [EPA] and 1 g of docosahexaenoic acid[DHA] per day) or placebo in a 12-week double-blind clinical trial. We assessed the somatic symptoms with Neurotoxicity Rating Scale (NRS) and fatigue symptoms with Fatigue Scale at baseline, weeks 1, 2, 4, 8 and 12, as well as blood levels of Brain-Derived Neurotrophic Factor (BDNF), inflammatory biomarkers and PUFAs, at the baseline and week 12.

RESULTS

The n-3 PUFAs group had a greater reduction in Fatigue scores than the placebo group at Week 4 (p =.042), while there were no differences in the changes of NRS scores. N-3 PUFAs group also had a greater increase in EPA (p =.001) and a greater decrease in total n-6 PUFAs (p =.030). Moreover, in the subgroup analyses in the younger age group (age < 55), the n-3 PUFAs group had a greater reduction on NRS total scores at Week 12 (p =.012) and NRS Somatic scores at Week 2 (p =.010), Week 8 (p =.027), Week 12 (p =.012) than the placebo group. In addition, the pre- and post-treatment changes of EPA and total n-3 PUFAs levels were negatively associated with the changes of NRS scores at Weeks 2, 4, and 8 (all p <.05), and the changes of BDNF levels were negatively associated with NRS scores at Weeks 8 and 12 (both p <.05) in the younger age group. In the older age group (age ≥ 55), there were a lesser reduction on NRS scores at Weeks 1, 2 and 4 (all p <.05), but a greater reduction on Fatigue score at Week 4 (p =.026), compared to the placebo group. There was no significant correlation between the changes of blood BDNF, inflammation, PUFAs and NRS and Fatigue scores in general and in the older age group.

CONCLUSION

Overall, n-3 PUFAs improved the fatigue symptoms in patients with CVDs comorbid MDD and the general somatic symptoms in specific subpopulation of younger age patients, and perhaps via the interplay between BDNF and EPA. Our findings provide promising rationales for future studies to investigate the treatment effects of omega-3 fatty acids on fatigue and somatic symptoms of chronic mental and medical diseases.

Phytochemicals in the treatment of inflammation-associated diseases: the journey from preclinical trials to clinical practice

Advances in biomedical research have demonstrated that inflammation and its related diseases are the greatest threat to public health. Inflammatory action is the pathological response of the body towards the external stimuli such as infections, environmental factors, and autoimmune conditions to reduce tissue damage and improve patient comfort. However, when detrimental signal-transduction pathways are activated and inflammatory mediators are released over an extended period of time, the inflammatory process continues and a mild but persistent pro-inflammatory state may develop. Numerous degenerative disorders and chronic health issues including arthritis, diabetes, obesity, cancer, and cardiovascular diseases, among others, are associated with the emergence of a low-grade inflammatory state. Though, anti-inflammatory steroidal, as well as non-steroidal drugs, are extensively used against different inflammatory conditions, they show undesirable side effects upon long-term exposure, at times, leading to life-threatening consequences. Thus, drugs targeting chronic inflammation need to be developed to achieve better therapeutic management without or with a fewer side effects. Plants have been well known for their medicinal use for thousands of years due to their pharmacologically active phytochemicals belonging to diverse chemical classes with a number of these demonstrating potent anti-inflammatory activity. Some typical examples include colchicine (alkaloid), escin (triterpenoid saponin), capsaicin (methoxy phenol), bicyclol (lignan), borneol (monoterpene), and quercetin (flavonoid). These phytochemicals often act via regulating molecular mechanisms that synergize the anti-inflammatory pathways such as increased production of anti-inflammatory cytokines or interfere with the inflammatory pathways such as to reduce the production of pro-inflammatory cytokines and other modulators to improve the underlying pathological condition. This review describes the anti-inflammatory properties of a number of biologically active compounds derived from medicinal plants, and their mechanisms of pharmacological intervention to alleviate inflammation-associated diseases. The emphasis is given to information on anti-inflammatory phytochemicals that have been evaluated at the preclinical and clinical levels. Recent trends and gaps in the development of phytochemical-based anti-inflammatory drugs have also been included.

Development and preliminary testing of the cancer-related fatigue comprehensive assessment scale in cancer survivors

BACKGROUND

Tailored management of cancer-related fatigue (CRF) is important for effective coping; however, it has been hindered by the lack of a comprehensive tool that assesses both symptoms and treatable influencing factors.

AIMS AND OBJECTIVES

The aim was to develop a cancer-related fatigue comprehensive assessment scale (CRF-CAS) and assess its psychometric properties.

DESIGN

This was a mixed-method study.

METHODS

The study included two phases which were conducted in Zhejiang Province, China. In phase one, a literature search, brainstorming sessions, Delphi studies, cognitive interviews and a pilot study were conducted to construct and revise CRF-CAS indicators. In phase two, a questionnaire-based survey was conducted among cancer survivors. Item analysis was used to select and optimize indicators. Cronbach's α was calculated for reliability analysis. Validity analysis included concurrent validity and structural validity.

RESULTS

A 93-item tool was initially constructed. Phase one ended with revision and optimization. The preliminary scale included five dimensions (CRF symptoms, physical activity, cognitive-emotional status, sleep status, nutritional status) and 30 items. The mean item-content validity index (I-CVI) and scale-level CVI universal agreement (S-CVI/UA) were .98, and the adjusted mean values of Kappa for indicators ranged from .91-1, as evaluated by the expert group. The Pearson correlation coefficient between the CRF-CAS and criterion scales ranged from .337-.862. Cronbach's α coefficient ranged from .624-.728. Respondents agreed that the scale was acceptable for administration and that it contributed to decision-making in fatigue management. Confirmatory factor analysis (CFA) indicated that the CRF-CAS fit well.

CONCLUSIONS

The construction process of the CRF-CAS, involving panel discussion and expert and participant evaluations, was shown to be scientific and feasible. The CRF-CAS had relatively good validity and reliability in version 5 of its preliminary scale, which requires further improvement in future studies.

How Does Dietary Intake Relate to Dispositional Optimism and Health-Related Quality of Life in Germline BRCA1/2 Mutation Carriers?

Background: The Mediterranean diet (MD) is an anti-inflammatory diet linked to improved health-related quality of life (HRQoL). Germline (g)BRCA1/2 mutation carriers have an increased risk of developing breast cancer and are often exposed to severe cancer treatments, thus the improvement of HRQoL is important. Little is known about the associations between dietary intake and HRQoL in this population. Methods: We included 312 gBRCA1/2 mutation carriers from an ongoing prospective randomized controlled lifestyle intervention trial. Baseline data from the EPIC food frequency questionnaire was used to calculate the dietary inflammatory index (DII), and adherence to MD was captured by the 14-item PREDIMED questionnaire. HRQoL was measured by the EORTC QLQ-C30 and LOT-R questionnaires. The presence of metabolic syndrome (MetS) was determined using anthropometric measurements, blood samples and vital parameters. Linear and logistic regression models were performed to assess the possible impact of diet and metabolic syndrome on HRQoL. Results: Women with a prior history of cancer (59.6%) reported lower DIIs than women without it (p = 0.011). A greater adherence to MD was associated with lower DII scores (p < 0.001) and reduced odds for metabolic syndrome (MetS) (p = 0.024). Women with a more optimistic outlook on life reported greater adherence to MD (p < 0.001), whereas a more pessimistic outlook on life increased the odds for MetS (OR = 1.15; p = 0.023). Conclusions: This is the first study in gBRCA1/2 mutation carriers that has linked MD, DII, and MetS to HRQoL. The long-term clinical implications of these findings are yet to be determined.

Feasibility of Investigational Procedures and Efficacy of a Personalized Omega-3 Dietary Intervention in Alleviating Pain and Psychoneurological Symptoms in Breast Cancer Survivors

BACKGROUND

Breast cancer survivors (BCS) are at risk for psychoneurological symptoms (PNS) and inflammation for years following cancer treatment. Fish, particularly salmon, provides a rich source of omega-3 long chain fatty acids (omega-3LC), which has an anti-inflammatory effect. However, the benefit of omega-3LC on PNS is not well-known.

AIMS

This study evaluated the feasibility and the initial efficacy of a personalized meal plan with dietary omega-3LC in reducing PNS.

METHODS

A prospective, randomized controlled trial design (n = 46) was used to evaluate the feasibility of a personalized meal plan using two omega-3LC dose levels (high and low omega-3LC) in reducing PNS including pain, depression, fatigue, sleep, and stress.

RESULTS

The recruitment rate was 4.9% with overall retention rate of 74% and 67.1% adherence to personalized meal plan and dietary procedures. Of participants who completed the investigation, 94% completed fish adherence logs and consumed ≥70% of the assigned quantity of fish. Saliva collection was 97.8% at baseline and 100% at follow-up. BCS in the high omega-3LC group had a significant decrease in pain (p < .01), perceived stress (p < .05), sleep (p < .001), depression (p < .001), and fatigue (p < .01) over the course of intervention. There were trends of PNS improvement in the low omega-3LC group but the differences did not reach statistical significance.

CONCLUSION

Our results support the feasibility of our investigational design, procedures, and intervention. The outcomes provide preliminary support for an expanded research effort using fish as a source of omega-3LC and personalized dietary planning as a vehicle for symptom self-management in BCS.

n-3 PUFA can reduce IL-6 and TNF levels in patients with cancer

Current studies on inhibitory effects of n-3 PUFA on pro-inflammatory cytokines have inconsistent results. Thus, a meta-analysis of randomised controlled trials was conducted to identify the effects of n-3 PUFA administration on circulating IL-6 and TNF in patients with cancer. Studies that examined the effects of n-3 PUFA administration on circulating IL-6 and TNF in patients with cancer were identified by searching PubMed and EMBASE from January 1975 to February 2021. Differences in n-3 PUFA administration and control conditions were determined by calculating standardised mean differences (SMD) with 95 % CI. Twenty studies involving 971 patients met the inclusion criteria. The overall SMD were 0·485 (95 % CI 0·087, 0·883) for IL-6 and 0·712 (95 % CI 0·461, 0·962) for TNF between n-3 PUFA administration and control conditions. Sources of heterogeneity were not found through subgroup and meta-regression analyses. Publication bias was observed in TNF with a slight contribution to the effect size. n-3 PUFA can reduce circulating IL-6 and TNF levels in patients with cancer. Results supported the recommendation of n-3 PUFA as adjuvant therapy for patients with cancer, possibly excluding head and neck cancer, owing to their anti-inflammatory properties.

Management of cancer-related fatigue in Taiwan: an evidence-based consensus for screening, assessment and treatment

BACKGROUND

Cancer-related fatigue is one of the most common and persistent issues experienced by cancer patients. Cancer-related fatigue is a distinct form of fatigue that is subjective, long-lasting and unalleviated by rest or sleep. Studies have shown that almost all cancer patients experience severe fatigue that disrupts the quality of life and physical function, but cancer-related fatigue remains under-addressed in clinical care, and only about half of all patients receive treatment.

METHODS

To increase the awareness of cancer-related fatigue and improve current management, the Taiwan Society of Cancer Palliative Medicine and the Taiwan Oncology Nursing Society convened a consensus committee to develop recommendations for the screening, assessment and treatment of cancer-related fatigue.

RESULTS

Thirteen consensus recommendations were subsequently developed based on the best available evidence and the clinical experience of committee members.

CONCLUSIONS

These recommendations are expected to facilitate the standardization of cancer-related fatigue management across Taiwan and may also serve as a reference for other clinicians.

Inflammatory, Oxidative Stress, and Cardiac Damage Biomarkers and Radiation-Induced Fatigue in Breast Cancer Survivors

PURPOSE

Studies examining biomarkers associated with fatigue in breast cancer survivors treated with radiation are limited. Therefore, we examined the longitudinal association between serum biomarkers and post-breast cancer fatigue in survivors treated with radiation: [oxidative stress] 8-hydroxyguanosine, myeloperoxidase; [inflammation] interleukin-6 (IL-6), c-reactive protein, growth differentiation factor-15 (GDF-15), placental growth factor, transforming growth factor-beta, [cardiac damage] cystatin-C, troponin-I.

METHODS

In a secondary analysis, we included participants from the Women's Health Initiative if they had: a previous breast cancer diagnosis (stages I-III), no prior cardiovascular diseases, pre-and post-breast cancer serum samples drawn approximately 3 years apart, and fatigue measured using the Short-Form 36 vitality subscale at both serum collections. Biomarkers were measured using ELISA or RT-qPCR and modeled as the log2 post-to pre-breast cancer ratio.

RESULTS

Overall, 180 women with a mean (SD) age of 67.0 (5.5) years were included. The mean (SD) vitality scores were 66.2 (17.2) and 59.7 (19.7) pre- and post-breast cancer, respectively. Using multivariable weighted linear regression, higher biomarker ratios of cystatin-C, IL-6, and GDF-15 were associated with a lower vitality score (i.e., higher fatigue). For example, for each 2-fold difference in cystatin-C biomarker ratio, the vitality score was lower by 7.31 points (95% CI: -14.2, -0.45).

CONCLUSION

Inflammatory and cardiac damage biomarkers are associated with fatigue in breast cancer survivors treated with radiation; however, these findings should be replicated in a larger sample. Biomarkers could be measured in clinical practice or assessed in risk prediction models to help identify patients at high risk for fatigue.

Changes in Patient-Reported Health Status in Advanced Cancer Patients from a Symptom Management Clinic: A Longitudinal Study Conducted in China

Objectives. The integration of patient-reported health status has been increasingly emphasised for delivering high-quality care to advanced cancer patients. This research is designed to track health status changes over time in Chinese advanced cancer patients to explore the risk factors affecting their health status. Methods. Advanced cancer patients were recruited from Peking University Cancer Hospital. An electronic patient-reported outcome (ePRO) system with validated measurements was used to collect the data. ANOVA, the chi-square test, the nonparametric Kruskal–Wallis H test, and generalized estimating equation (GEE) analysis were used for the data analysis. Results. One hundred and three patients completed a baseline survey (T = 0) and two follow-up surveys (T1 = 14 days, T2 = 28 days). Chi-square test results indicate a significant decrease in the percentage of patients reporting moderate or severe difficulty experienced by patients in terms of mobility, pain/discomfort, and anxiety/depression. However, there is a significant increase in the percentage of patients reporting moderate or severe difficulty in self-care and usual activities. Scores on the visual analogue scale in the EQ-5D-5L instrument (EQ-VAS) are associated with patients’ income, and the degree of moderate or severe anxiety/depression is found to be associated with employment status. The GEE results show that pain, loss of appetite, poor walking status effected by symptoms, depression, and anxiety has worsened the health status. Conclusions. The health status of Chinese advanced cancer patients under ePRO follow-up in China significantly improves in the physical and psychological dimensions, accompanied by a decrease in usual activities and self-care. Routine screening and rational supportive care are recommended in oncology for cancer care. Based on the rational application of ePRO, longitudinal studies exploring the potential mechanisms of health status changing would provide more beneficial guidance for improving the quality of life in patients with advanced cancer.

Association of dietary intake of n-3 polyunsaturated fatty acids with breast cancer risk in pre- and postmenopausal Chinese women

OBJECTIVE

This study aimed to evaluate the associations between breast cancer risk and intake of n-3 polyunsaturated fatty acids (PUFAs) and/or n-3 PUFA subclasses in Chinese women, and determine whether these associations varied with menopausal status or clinical characteristics.

METHODS

A hospital-based case-control study including 1,589 cases and 1,621 age-frequency-matched controls was conducted. Dietary data were assessed by a validated food frequency questionnaire. Odds ratios (ORs) and 95% confidence intervals were obtained using multiple unconditional logistic regression models after controlling for potential confounders.

RESULTS

Higher intake of marine n-3 PUFAs and total n-3 PUFAs was associated with lower risk of breast cancer, with adjusted OR quartile 4 v.1 (95% confidence intervals) of 0.68 (0.55-0.84) and 0.56 (0.42-0.75), respectively. Dietary a-linolenic acid, eicosapentaenoic acid, docosapentaenoic acid, docosahexaenoic acid were also inversely associated with breast cancer risk, with adjusted ORs (95% confidence intervals) of 0.51 (0.38-0.70), 0.68 (0.55-0.84), 0.68 (0.55-0.85), and 0.76 (0.61-0.94), respectively. In stratified analyses, these inverse associations between risk and dietary n-3 PUFAs were more evident among premenopausal women and women with ER+, PR+ and ER+PR+ tumors. A decreased risk of breast cancer was significantly associated with increasing n-3 PUFA intake in obese/overweight women, but not in women of normal weight. There was a significant interaction between linoleic acid and marine n-3 PUFAs.

CONCLUSIONS

High intake of n-3 PUFAs and n-3 PUFA subtypes was associated with a lower risk of breast cancer, especially among premenopausal women and women with ER+ and/or PR+ subtype breast cancer.

Breast cancer survivors' typhoid vaccine responses: Chemotherapy, obesity, and fitness make a difference

PURPOSE

To investigate breast cancer survivors' inflammatory responses to typhoid vaccine as a window into their innate immune response to novel pathogens.

METHODS

This double-blind crossover trial randomized 158 breast cancer survivors to either the vaccine/saline placebo or the placebo/vaccine sequence. The relative contributions of age, cardiorespiratory fitness (VO_2peak), type of cancer treatment, central obesity, and depression to interleukin (IL)-6, IL-1 receptor antagonist (IL-1Ra), and WBC vaccine responses were assessed pre-injection and 1.5, 3, 4.5, 6, and 7.5 h post-injection.

RESULTS

The vaccine produced larger IL-6, IL-1Ra, and WBC responses than placebo, ps < 0.0001. Prior chemotherapy, higher central obesity, and lower VO_2peak were associated with smaller vaccine responses after controlling for baseline inflammation. Vaccine response was summarized by the percent increase in area under the curve (IL-6, WBC) or average post-injection mean (IL-1Ra) for vaccine relative to placebo. Women who received chemotherapy had smaller vaccine responses than women who did not for both IL-6 (44% vs 78%, p <.001) and WBC (26% vs 40%, p <.001); IL-1ra response was not significantly moderated by chemotherapy. Women whose central adiposity was one standard deviation above the mean had smaller vaccine responses than women with average adiposity for IL-6 (33% vs 54%, p <.001), WBC (20% vs 30%, p <.001), and IL-1Ra (2.0% vs 3.2%, p <.001). Women with an average level of VO_2peak had smaller vaccine responses than women whose VO_2peak was one standard deviation above the mean for IL-6 (54% vs 73%, p <.001), WBC (30% vs 40%, p <.001), and IL-1Ra (3.2% vs. 4.1%, p = 0.01). Age and depression did not significantly moderate vaccine responses.

CONCLUSIONS

This study provided novel data on chemotherapy's longer-term adverse immune consequences. The data also have an important public health message: even relatively low levels of fitness can benefit the innate immune response to a vaccine.

Depression and anxiety in colorectal cancer patients: TIES TO PAIN, FATIGUE, AND INFLAMMATION

OBJECTIVE

Colorectal cancer poses a significant threat to both psychological and physical health. This study examined relationships between anxiety and depressive symptoms with pain, fatigue, and inflammation among colorectal patients.

METHODS

Colorectal cancer patients (n = 88, stages 0-IV) completed a laboratory-based study visit before undergoing adjuvant cancer treatment. Patients completed questionnaires assessing depressive, anxiety, pain, and fatigue symptoms. A blood sample was also collected to measure c-reactive protein (CRP). Analyses controlled for age, sex, cancer stage, body mass index (BMI), and menopause status.

RESULTS

Multiple linear regression analyses showed colorectal patients with higher depressive and anxiety symptoms had greater pain, fatigue, and CRP (ps < .03). Approximately one-third of patients with clinically significant depressive (CESD > 16) and anxiety symptoms (BAI > 16) also had clinically-elevated levels of CRP ( > 3mg/L) (ps = .02).

CONCLUSION

These results extend findings from other cancer subgroups showing heightened symptom burden among patients with depression and anxiety. They also highlight the detrimental role that elevated anxiety and depressive symptoms may play in the physical and biological side effects associated with colorectal cancer. This article is protected by copyright. All rights reserved.

The Link Between Energy-Related Sensations and Metabolism: Implications for Treating Fatigue

Energy-related sensations include sensation of energy and fatigue as well as subjective energizability and fatigability. First, we introduce interdisciplinary useful definitions of all constructs and review findings regarding the question of whether sensations of fatigue and energy are two separate constructs or two ends of a single dimension. Second, we describe different components of the bodily energy metabolism system (e.g., mitochondria; autonomic nervous system). Third, we review the link between sensation of fatigue and different components of energy metabolism. Finally, we present an overview of different treatments shown to affect both energy-related sensations and metabolism before outlining future research perspectives.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

A Molecular Approach to Understanding the Role of Diet in Cancer-Related Fatigue: Challenges and Future Opportunities

Cancer-related fatigue (CRF) is considered one of the most frequent and distressing symptoms for cancer survivors. Despite its high prevalence, factors that predispose, precipitate, and perpetuate CRF are poorly understood. Emerging research focuses on cancer and treatment-related nutritional complications, changes in body composition, and nutritional deficiencies that can compound CRF. Nutritional metabolomics, the novel study of diet-related metabolites in cells, tissues, and biofluids, offers a promising tool to further address these research gaps. In this position paper, we examine CRF risk factors, summarize metabolomics studies of CRF, outline dietary recommendations for the prevention and management of CRF in cancer survivorship, and identify knowledge gaps and challenges in applying nutritional metabolomics to understand dietary contributions to CRF over the cancer survivorship trajectory.

Diet/Nutrition: Ready to Transition from a Cancer Recurrence/Prevention Strategy to a Chronic Pain Management Modality for Cancer Survivors?

Evidence for the relationship between chronic pain and nutrition is mounting, and chronic pain following cancer is gaining recognition as a significant area for improving health care in the cancer survivorship population. This review explains why nutrition should be considered to be an important component in chronic pain management in cancer survivors by exploring relevant evidence from the literature and how to translate this knowledge into clinical practice. This review was built on relevant evidence from both human and pre-clinical studies identified in PubMed, Web of Science and Embase databases. Given the relationship between chronic pain, inflammation, and metabolism found in the literature, it is advised to look for a strategic dietary intervention in cancer survivors. Dietary interventions may result in weight loss, a healthy body weight, good diet quality, systemic inflammation, and immune system regulations, and a healthy gut microbiota environment, all of which may alter the pain-related pathways and mechanisms. In addition to being a cancer recurrence or prevention strategy, nutrition may become a chronic pain management modality for cancer survivors. Although additional research is needed before implementing nutrition as an evidence-based management modality for chronic pain in cancer survivors, it is already critical to counsel and inform this patient population about the importance of a healthy diet based on the data available so far.

Metabolic and Immune Markers for Precise Monitoring of COVID-19 Severity and Treatment

Deep understanding of the SARS-CoV-2 effects on host molecular pathways is paramount for the discovery of early biomarkers of outcome of coronavirus disease 2019 (COVID-19) and the identification of novel therapeutic targets. In that light, we generated metabolomic data from COVID-19 patient blood using high-throughput targeted nuclear magnetic resonance (NMR) spectroscopy and high-dimensional flow cytometry. We find considerable changes in serum metabolome composition of COVID-19 patients associated with disease severity, and response to tocilizumab treatment. We built a clinically annotated, biologically-interpretable space for precise time-resolved disease monitoring and characterize the temporal dynamics of metabolomic change along the clinical course of COVID-19 patients and in response to therapy. Finally, we leverage joint immuno-metabolic measurements to provide a novel approach for patient stratification and early prediction of severe disease. Our results show that high-dimensional metabolomic and joint immune-metabolic readouts provide rich information content for elucidation of the host's response to infection and empower discovery of novel metabolic-driven therapies, as well as precise and efficient clinical action.

Nutritional Status Predicts Fatty Acid Uptake from Fish and Soybean Oil Supplements for Treatment of Cancer-Related Fatigue: Results from a Phase II Nationwide Study

Cancer-related fatigue is a prevalent and debilitating condition that persists for years into survivorship. Studies evaluating both fish oil supplementation on fatigue and associations between fish oil consumption and fatigue have shown mixed effects; it is unknown what factors contribute to these differential effects. Herein, we investigate whether the nutritional status of cancer survivors was associated with serum omega-3 concentration or change in serum omega-3s throughout a fish oil supplementation study, and then if any of these factors were associated with fatigue. Breast cancer survivors 4-36 months post-treatment with moderate-severe fatigue were randomized to take 6 g fish oil, 6 g soybean oil, or 3 g of each daily for 6 weeks. Baseline nutritional status was calculated using the Controlling Nutritional Status tool (serum albumin, lymphocytes, cholesterol). At baseline and post-intervention, serum fatty acids were quantified and fatigue was assessed using the Multidimensional Fatigue Symptom Inventory. Participants (n = 85) were 61.2 ± 9.7 years old with a body mass index of 31.9 ± 6.7 kg/m²; 69% had a good nutritional score and 31% had light-moderate malnutrition. Those with good nutritional status had greater total serum omega-3s at baseline (p = 0.013) and a greater increase in serum omega-3s with supplementation (p = 0.003). Among those who were supplemented with fish oil, greater increases in serum omega-3s were associated with greater improvements in fatigue. In conclusion, good nutritional status may increase uptake of fatty acid supplements, increasing their ability to improve fatigue.

Omega-3 polyunsaturated fatty acids supplementation improve clinical symptoms in patients with Covid-19: A randomised clinical trial

AIMS

We hypothesised that omega-3 fatty acids would be an appropriate adjunct therapy for alleviating the inflammatory response and clinical manifestation in hospitalised patients with Covid-19 disease.

METHODS

This was a single-blind randomised controlled trial in Amir-Alam hospital in Tehran. Thirty adult men and women diagnosed with Covid-19 were allocated to either control group (receiving Hydroxychloroquine) or intervention group (receiving Hydroxychloroquine plus 2 grams of Docosahexaenoic acid [DHA] + Eicosapentaenoic acid [EPA]) for 2 weeks. Primary outcome of the intervention including C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) as well as clinical symptoms including body pain, fatigue, appetite and olfactory and secondary outcomes including liver enzymes were determined at the baseline and after omega-3 supplementation. Clinical signs were measured using self-reported questionnaires. There were commercial kits for determination of CRP and liver enzymes concentrations in the serum of patients. For determination of ESR automated haematology analyser was applied. The study of "Comparison of the effectiveness of omega-3 and Hydroxychloroquine on Inflammatory factors, liver enzymes and clinical symptoms in diabetic Covid-19 patients" was registered in Iranian Registry of Clinical Trials (IRCT) with ID number: IRCT20200511047399N1.

RESULTS

In comparison to control group, patients receiving omega-3 indicated favourable changes in all clinical symptoms except for olfactory (P < .001 for body pain and fatigue, P = .03 for appetite and P = .21 for olfactory). Reducing effects of omega-3 supplementation compared with control group were also observed in the levels of ESR and CRP after treatment (P < .001 for CRP and P = .02 for ESR). However, no between group differences in the liver enzymes serum concentrations were observed after supplementation (P > .05).

CONCLUSION

Current observations are very promising and indicate that supplementation with moderate dosages of omega-3 fatty acids may be beneficial in the management of inflammation-mediated clinical symptoms in Covid-19 patients.

Risk factors for late persistent fatigue after chemoradiotherapy in locally advanced cervical cancer: an analysis from the EMBRACE-I study

Objective To evaluate patient- and treatment-related risk factors for late persistent fatigue within the prospective, multi-center XXX study. Methods Fatigue was prospectively assessed (CTCAE v.3) at baseline and during regular follow-up in 993 locally advanced cervical cancer patients, after treatment with chemoradiotherapy and MRI-guided brachytherapy. Risk factors for baseline and late persistent fatigue were evaluated with multivariable logistic regression. Late persistent fatigue was defined, when either G≥1 or G≥2 was scored in at least half of follow-ups. Results Median follow-up was 57 months. Baseline fatigue G≥1/G≥2 (35.8%/6.3%, respectively) was associated with pre-existing co-morbidities, WHO Performance Status, underweight, severe pain and tumor volume. Late persistent G≥1/G≥2 fatigue (36.3%/5.8%, respectively) was associated with patient-related factors (baseline fatigue, younger age, obesity), alongside the size of irradiated volumes and the level of radiation doses from external beam radiotherapy (EBRT) and brachytherapy (EBRT: V43Gy, V57Gy; EBRT+brachytherapy: V60Gy EQD2). Large volume lymph node (LN) boost compared to no LN boost, increased the risk for late persistent fatigue G≥2 by 18% and 5% (in patients with and without baseline fatigue, respectively). The risk for late persistent fatigue G≥1 increased by 7% and 4% with V43Gy <2000cm³ versus >3000cm³ (in patients with and without baseline fatigue, respectively). Late persistent G≥1 fatigue occurred in 13% of patients without late persistent organ-related symptoms (gastro-intestinal, genito-urinary and vaginal), versus 34-43%, 50-58% and 73% in patients suffering from persistent symptoms involving 1,2 or 3 organs, respectively. Conclusion Late persistent fatigue occurs in a considerable number of patients after chemoradiotherapy. It is associated with patient-related factors, the size of volumes irradiated to intermediate and high EBRT and brachytherapy doses, and other persistent organ-related morbidity. These findings support the importance of ongoing efforts to better tailor the target dose and reduce irradiation of healthy tissue without compromising target coverage, using highly conformal EBRT and brachytherapy techniques.

Polyunsaturated Fatty Acids, Exercise, and Cancer-Related Fatigue in Breast Cancer Survivors

Cancer-related fatigue (CRF) is one of the most frequently reported and disabling symptoms in cancer survivors. With its negative impact on the activities of daily living, work, social activities, and mood, CRF causes severe impairment of quality of life. A previous study showed that omega-6 polyunsaturated fatty acid (PUFA) supplementation unexpectedly reduced CRF compared with omega-3 PUFA supplementation and that omega-6 PUFA supplementation reduced pro-inflammatory serum markers in fatigued American breast cancer survivors. Meanwhile, a recent meta-analysis of individual patient data revealed significant benefits of exercise interventions on CRF. Recently, we completed our randomized controlled trial among early-stage Japanese breast cancer survivors, in which we examined the effect of baseline blood PUFA characteristics on change in CRF during the 12-week trial by exercise group and confirmed that increased Cancer Fatigue Scale (CFS) was associated with both docosahexaenoic acid (DHA) (p = 0.06) and omega-3 index (p = 0.08) at baseline in all participants (n = 46, omega-6/omega-3 ratio = 6.79, SD = 1.90). On the contrary, DHA at baseline was positively correlated with change in CRF (r = 0.40, p = 0.06) in the control group (n = 24, omega-6/omega-3 ratio = 7.0). Moreover, eicosapentaenoic acid (EPA) at baseline was positively correlated with leg strength (r = 0.39, p = 0.10) in the exercise group. In conclusion, blood PUFA balance might be associated with the effect of exercise on CRF. In addition, higher EPA in individuals who conducted exercise likely has a beneficial effect on muscle strength. Further investigation is needed to clarify the interaction between PUFAs and exercise for alleviating CRF.

Effect of the Rehabilitation Program, ReStOre, on Serum Biomarkers in a Randomized Control Trial of Esophagogastric Cancer Survivors

Background

The Rehabilitation Strategies Following Esophagogastric cancer (ReStOre) randomized control trial demonstrated a significant improvement in cardiorespiratory fitness of esophagogastric cancer survivors. This follow-up, exploratory study analyzed the biological effect of exercise intervention on levels of 55 serum proteins, encompassing mediators of angiogenesis, inflammation, and vascular injury, from participants on the ReStOre trial.

Methods

Patients >6 months disease free from esophagogastric cancer were randomized to usual care or the 12-week ReStOre program (exercise training, dietary counselling, and multidisciplinary education). Serum was collected at baseline (T0), post-intervention (T1), and at 3-month follow up (T2). Serum biomarkers were quantified by enzyme-linked immunosorbent assay (ELISA).

Results

Thirty-seven patients participated in this study; 17 in the control arm and 20 in the intervention arm. Exercise intervention resulted in significant alterations in the level of expression of serum IP-10 (mean difference (MD): 38.02 (95% CI: 0.69 to 75.35)), IL-27 (MD: 249.48 (95% CI: 22.43 to 476.53)), and the vascular injury biomarkers, ICAM-1 (MD: 1.05 (95% CI: 1.07 to 1.66)), and VCAM-1 (MD: 1.51 (95% CI: 1.04 to 2.14)) at T1. A significant increase in eotaxin-3 (MD: 2.59 (95% CI: 0.23 to 4.96)), IL-15 (MD: 0.27 (95% CI: 0 to 0.54)) and decrease in bFGF (MD: 1.62 (95% CI: -2.99 to 0.26)) expression was observed between control and intervention cohorts at T2 (p<0.05).

Conclusions

Exercise intervention significantly altered the expression of a number of serum biomarkers in disease-free patients who had prior treatment for esophagogastric cancer.

Impact

Exercise rehabilitation causes a significant biological effect on serum biomarkers in esophagogastric cancer survivors.

Clinical Trial Registration

ClinicalTrials.gov (NCT03314311).

The effect of flaxseed on physical and mental fatigue in children and adolescents with overweight/obesity: a randomised controlled trial

Anti-inflammatory agents such as long-chain n-3 fatty acids have been recognised to improve disease-related fatigue. We hypothesised that α-linolenic acid may also benefit in reduction of fatigue in low-grade inflammation such as overweight/obesity. Seventy-two healthy children and adolescents with BMI > 25 kg/m2 were randomised to flaxseed (n 38) and puffed wheat (n 34) groups. Participants consumed isoenergetic amounts of either 20 g/d flaxseed or 25 g/d puffed wheat for 4 weeks. Fatigue, mood feelings (depression, anxiety and stress), appetite, energy intake, weight, height and waist circumference were measured. Analysis was performed based on per-protocol and intention-to-treat (ITT) approaches. Consumption of flaxseed decreased mental fatigue and caused a significant between-group difference (P < 0·001). Although no significant change in physical and total score of fatigue was observed in either group, a significant between-group difference occurred due to a more remarkable change in these parameters in the flaxseed group. General fatigue, motivation, activity and mood feelings did not change significantly between groups. Flaxseed showed less benefit than puffed wheat on anthropometric measures as it caused a smaller increase in height (0·53 (sd 0·89) v. 1·09 (sd 0·87) cm, P = 0·03) and reduction in BMI (-0·25 (sd 0·63) v. -0·67 (sd 0·56) kg/m2, P = 0·01) than puffed wheat. Appetite and waist circumference decreased in both groups, but no significant difference was observed between groups. In ITT analysis, only alteration in mental fatigue was significant. In conclusion, consumption of flaxseed may improve mental fatigue in children with overweight/obesity. However, because of smaller increase in height, it is better to hinder administration of flaxseed during periods of growth.

Omega-3 Polyunsaturated Fatty Acids Can Reduce C-Reactive Protein in Patients with Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ABSTRACTSOmega-3 polyunsaturated fatty acids (PUFAs) possess anti-inflammatory properties. There is a lack of consensus regarding the effects of omega-3 PUFAs on C-reactive protein (CRP), a marker of systemic inflammation, in cancer patients. Herein, a meta-analysis of randomized controlled trials was conducted to evaluate the effects of omega-3 PUFAs on CRP levels in patients with cancer. PubMed and EMBASE were searched until May 2020 to identify randomized controlled trials that examined the effects of omega-3 PUFA administration on CRP levels in cancer patients. Standardized mean differences (SMDs) with their 95% confidence intervals (CIs) were calculated to determine the differences in omega-3 PUFA administration and control conditions. Seventeen eligible studies involving 916 cancer patients were included in this meta-analysis. Significant heterogeneity was present among individual studies (P_{heterogeneity} = 0.000; I² = 74.5%). The overall SMDs of CRP levels between omega-3 PUFA administration and control conditions were 0.628 (95% CI: 0.342-0.914) and 0.456 (95% CI: 0.322-0.590) by the random-effect and fixed-effect models, respectively. Sources of heterogeneity were not found through subgroup and meta-regression analyses. Existing publication bias contributed slightly to the effect size. Omega-3 PUFAs can reduce systemic inflammation, as indicated by CRP levels in cancer patients. The use of omega-3 PUFAs is recommended for cancer patients due to their anti-inflammatory properties.

Gut Microbiota Dysbiosis Associated with Persistent Fatigue in Hematopoietic Cell Transplantation Survivors

Fatigue is one of the most prevalent and distressing complications among hematopoietic stem cell transplantation (HCT) survivors, negatively affecting physical, social, and emotional domains of quality of life. Chronic systemic inflammation has been linked to alterations in nervous system activity and initiation of distressing symptoms, such as fatigue. Damage to gut mucosa due to alteration in gut microbiota (GM) composition and microbial translocation has been shown to increase systemic proinflammatory cytokines. The aim of this study was to evaluate the relationship between fatigue and GM by measuring the differences in GM composition in HCT survivors with and without persistent fatigue. This cross-sectional study included 30 adults who underwent HCT for a hematologic disease and were at least 1 year post-HCT. Patients with chronic graft-versus-host disease were excluded. Fatigue severity was assessed by the Brief Fatigue Inventory (BFI). Based on the BFI score, patients were grouped into 2 categories: 0 to 3 (without fatigue) and ≥4 (with fatigue). The V1 to V3 region of the 16S rRNA gene from fecal specimens was sequenced using the Illumina MiSeq. Sequencing reads were processed, denoised, and replicated, chimeras were filtered, amplicon sequence variants (ASVs) were generated, and taxonomy was assigned using DADA2. Beta diversity analysis through principal coordinate analysis was generated using the Bray-Curtis dissimilarity matrix, and the difference was tested using linear model with generalized least squares in R. An alpha diversity analysis was performed using Chao1. Linear discriminant analysis effect size (LEfSe) was used to find markers that differ between the 2 groups. Based on the BFI results, patients were categorized into 2 cohorts: with fatigue (n = 14) and without fatigue (n = 16). The 2 cohorts were similar in terms of demographics, disease, and transplant characteristics. Based on the GM analysis, there was a significant difference in GM composition (beta diversity) between the 2 cohorts (P = .001). Alpha diversity (richness) was also significantly lower in survivors with fatigue (P =.002). LEfSe analysis identified 46 discriminative features (P < .05; linear discriminant analysis score >2) whose relative abundance varied significantly among individuals with fatigue and those without fatigue. Ten ASVs were associated with the patients with fatigue, and 36 ASVs were associated with those without fatigue. Several ASVs enriched in survivors with fatigue included organisms such as Klebsiella and Enterococcus, which have been implicated in inflammatory bowel diseases. The ASVs enriched in the cohort without fatigue were members of the Ruminococcaceae family (Oscillospira spp) and the Lachnospiraceae family (Fusicatenibacter and Coprococcus spp), which are known to have the ability to ferment complex plant carbohydrates. These findings show an association between GM composition and fatigue and suggest a microbial contribution to clinically significant fatigue post-HCT, which may guide the development of new approaches to treating fatigue based on manipulation of the GM.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cooking for Vitality: Pilot Study of an Innovative Culinary Nutrition Intervention for Cancer-Related Fatigue in Cancer Survivors

(1) Background: Cancer-related fatigue (CRF) is one of the most prevalent and distressing side effects experienced by patients with cancer during and after treatment, and this negatively impacts all aspects of quality of life. An increasing body of evidence supports the role of poor nutritional status in the etiology of CRF and of specific diets in mitigating CRF. We designed a group-based two session culinary nutrition intervention for CRF, Cooking for Vitality (C4V), aimed at increasing understanding of how food choices can impact energy levels and establishing basic food preparation and cooking skills as well as the application of culinary techniques that minimize the effort/energy required to prepare meals. The purpose of this pilot mixed-method study was to evaluate: Feasibility of the experimental methods and intervention; acceptability and perceived helpfulness of intervention; and to obtain a preliminary estimate of the effectiveness of the intervention on fatigue (primary outcome), energy, overall disability, and confidence to manage fatigue (secondary outcomes). (2) Methods: Prospective, single arm, embedded mixed-methods feasibility study of cancer survivors with cancer-related fatigue was conducted. Participants completed measures at baseline (T0), immediately following the intervention (T1), and three months after the last session (T2). Qualitative interviews were conducted at T2. (3) Results: Recruitment (70%) and retention (72%) rates along with qualitative findings support the feasibility of the C4V intervention for cancer survivors living with CRF (program length and frequency, ease of implementation, and program flexibility). Acceptability was also high and participants provided useful feedback for program improvements. Fatigue (FACT-F) scores significantly improved from T0–T1 and T0–T2 (p < 0.001). There was also a significant decrease in disability scores (WHO-DAS 2.0) from T0–T2 (p = 0.006) and an increase in POMS-Vigor (Profile of Mood States) from T0–T1 (p = 0.018) and T0–T2 (p = 0.013). Confidence in managing fatigue improved significantly from T0–T1 and T0–T2 (p < 0.001). (4) Conclusions: The results suggest that the C4V program was acceptable and helpful to patients and may be effective in improving fatigue levels and self-management skills. A randomized controlled trial is required to confirm these findings.

Postdiagnosis Physical Activity: Association With Long-Term Fatigue and Sleep Disturbance in Older Adult Breast Cancer Survivors

BACKGROUND

Physical activity is frequently proposed as an intervention to reduce fatigue and sleep disturbance in cancer survivors; however, the long-term effects of physical activity are often not reported, and older adults are typically excluded from these intervention studies.

OBJECTIVES

This article aimed to examine if postdiagnosis physical activity is associated with lower long-term fatigue and sleep disturbance in older adult breast cancer survivors.

METHODS

Data were analyzed of a prospective cohort of 440 breast cancer survivors aged 65 years or older from the Women's Health Initiative study. Multiple linear and logistic regression models were used to examine associations of physical activity with fatigue and sleep disturbance.

FINDINGS

Higher postdiagnosis physical activity was associated with lower long-term fatigue but was not associated with lower sleep disturbance after adjusting for demographics, cancer characteristics, and baseline measures.

Cancer-related Fatigue in Breast Cancer Survivors: A Review

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

Mediterranean-style dietary pattern improves cancer-related fatigue and quality of life in men with prostate cancer treated with androgen deprivation therapy: A pilot randomised control trial

BACKGROUND & AIMS

Cancer-related fatigue (CRF) is a prevalent and persistent symptom from androgen deprivation therapy (ADT) in prostate cancer. The Mediterranean-style dietary pattern (MED-diet) offers a plausible mechanism to mitigate CRF through reducing inflammation and improving body composition. This study aimed to evaluate the effects of a 12-week MED-diet, compared to usual care, on CRF and quality of life in men with prostate cancer treated with ADT.

METHODS

Twenty-three men (65.9 ± 7.8 years; body mass index: 29.6 ± 2.7 kg/m²; ADT duration: 33.8 ± 35.6 months) receiving ADT for ≥3 months were randomly assigned (1:1) to 12-weeks of usual care or the MED-diet involving six individualised nutrition consults. Primary outcomes included CRF [Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale (FACIT-F) and quality of life [FACIT-General (FACIT-G)], secondary outcomes included body mass/composition and interleukin (IL)-6 and IL-8 concentrations measured at baseline, 8-weeks and 12 weeks. Intervention feasibility was measured by intervention safety, study completion rate, consult attendance, and adherence to the MED-diet through the Mediterranean-diet adherence screener (MEDAS). Intention to treat linear mixed models were used to determine changes in outcomes between the MED-diet and usual care at baseline, 8-weeks and 12-weeks.

RESULTS

The MED-diet improved CRF (FACIT-F) at 8-weeks [+4.8 (0.0, 9.8); P = 0.05] and 12-weeks [+7.2 (2.2, 12.0); P = 0.005], quality of life (FACIT-G) at 12-weeks [+9.2 (2.7, 15.8); P = 0.006], reduced total body mass at 8-weeks [-2.51 kg (-4.25, -0.78); P = 0.005] and 12-weeks [-2.97 kg (-4.71, -1.25); P = 0.001], lean mass at 8-weeks [-1.50 kg (-2.91, -0.10); P = 0.036], and IL-8 at 8-weeks [-0.18 ng/ml (-0.34, -0.02); P = 0.029] compared to usual care. The MED-diet demonstrated zero adverse events, 91% study completion, 100% attendance, and 81% adherence to the MEDAS.

CONCLUSION

The MED-diet is safe and feasible, and has the potential to improve CRF and quality of life in overweight men treated with ADT compared to usual care. Further exploration of the MED-diet is warranted in a larger powered sample size to consolidate these findings.

Dietary N-3 PUFA deficiency affects sleep-wake activity in basal condition and in response to an inflammatory challenge in mice

Essential polyunsaturated fatty acids (PUFA) from the n-3 and n-6 series constitute the building blocks of brain cell membranes where they regulate most aspects of cell physiology. They are either biosynthesized from their dietary precursors or can be directly sourced from the diet. An overall increase in the dietary n-6/n-3 PUFA ratio, as observed in the Western diet, leads to reduced n-3 PUFAs in tissues that include the brain. Some clinical studies have shown a positive correlation between dietary n-3 PUFA intake and sleep quantity, yet evidence is still sparse. We here used a preclinical model of dietary n-3 PUFA deficiency to assess the precise relationship between dietary PUFA intake and sleep/wake activity. Using electroencephalography (EEG)/electromyography (EMG) recordings on n-3 PUFA deficient or sufficient mice, we showed that dietary PUFA deficiency affects the architecture of sleep-wake activity and the oscillatory activity of cortical neurons during sleep. In a second part of the study, and since PUFAs are a potent modulator of inflammation, we assessed the effect of dietary n-3 PUFA deficiency on the sleep response to an inflammatory stimulus known to modulate sleep/wake activity. We injected mice with the endotoxin lipopolysaccharide (LPS) and quantified the sleep response across the following 12 h. Our results revealed that n-3 PUFA deficiency affects the sleep response in basal condition and after a peripheral immune challenge. More studies are now required aimed at deciphering the molecular mechanisms underlying the intimate relationship between n-3 PUFAs and sleep/wake activity.

n-3 Polyunsaturated Fatty Acids and Their Derivates Reduce Neuroinflammation during Aging

: Aging is associated to cognitive decline, which can lead to loss of life quality, personal suffering, and ultimately neurodegenerative diseases. Neuroinflammation is one of the mechanisms explaining the loss of cognitive functions. Indeed, aging is associated to the activation of inflammatory signaling pathways, which can be targeted by specific nutrients with anti-inflammatory effects. Dietary n-3 polyunsaturated fatty acids (PUFAs) are particularly attractive as they are present in the brain, possess immunomodulatory properties, and are precursors of lipid derivates named specialized pro-resolving mediators (SPM). SPMs are crucially involved in the resolution of inflammation that is modified during aging, resulting in chronic inflammation. In this review, we first examine the effect of aging on neuroinflammation and then evaluate the potential beneficial effect of n-3 PUFA as precursors of bioactive derivates, particularly during aging, on the resolution of inflammation. Lastly, we highlight evidence supporting a role of n-3 PUFA during aging.

Biomarkers panels can predict fatigue, depression and pain in persons living with HIV: A pilot study

BACKGROUND

Persons living with HIV experience high symptom burden that can negatively impact medication adherence, work productivity, and quality of life. Symptoms are highly subjective, which can lead to under- or improper treatment. The purpose of this exploratory study was to examine relationships between circulating biomarkers representative of inflammatory, coagulation, and vascular function pathways and prevalent HIV symptoms.

SETTING AND SAMPLE

Adults >18 years who were diagnosed with HIV and spoke English for this cross-sectional study were recruited from community clinics and organizations.

METHODS

Symptom burden was measured with the HIV Symptom Index; depression with the Patient Health Questionnaire. Human multiplex kits were used to determine serum concentrations of select biomarkers representing inflammatory, coagulation, and vascular function pathways. The biomarkers were included as features in machine learning models to determine which biomarkers predicted the most prevalent HIV symptoms (fatigue and muscle/joint pain) and the symptom of depression.

RESULTS

Participants (N = 32) were representative of the local population of people with HIV, being mostly Black (54.4%) and male (60.6%). Depression was predicted by age, gender, glucose, hemoglobin A1c, and inflammation. Muscle/joint pain was predicted by adiponectin, C-reactive protein, and serum amyloid A (SAA). Fatigue was predicted by adiponectin, SAA, and soluble interleukin-1 receptor type II (sIL-1RII).

CONCLUSION

Biomarker clusters can be a tool to monitor symptoms. Adding an objective measure to subjective patient experiences could improve management and monitoring of symptoms. Defining a biomarker cluster for the objective assessment of HIV symptoms warrants further investigation; however, the presence of comorbid conditions needs to be controlled.

Identification and quantitation of bioactive components from honeycomb (Nidus Vespae)

Honeycomb (Nidus Vespae) as an agri-food waste in bee product industry is in soaring demand for high-value utilization. This study is dedicated to investigate the physicochemical properties, chemical composition, and nutritional value of honeycomb by determination of physicochemical parameters, total phenolic and total flavonoid contents, antioxidant capacity in vitro, and bioactive components. By using ultra high-performance liquid chromatography-high resolution mass spectrometry (UHPLC-HRMS) method, a total of 76 bioactive components from hydro-ethanolic extracts of honeycomb (EHB) were tentatively identified, where the principal ones are polyphenols and fatty acids, which were further quantified by LC-MS and GC-MS, respectively. Moreover, antimicrobial activities test has been conducted, verifying that EHB can inhibit both Gram-negative (G^-) bacteria and Gram-positive (G+) bacteria, which is beneficial for the high-value utilization of honeycomb.

Inhibition of lung cancer growth and metastasis by DHA and its metabolite, RvD1, through miR-138-5p/FOXC1 pathway

BACKGROUND

Non small cell lung cancer (NSCLC) is one of the most common cancers in the world. DHA is known to be capable of suppressing NSCLC cell proliferation and metastasis. However, the mechanisms by which DHA exhibits its antitumor effects are unknown. Here we aimed to identify the effects and mechanisms of DHA and its metabolites on lung cancer cell growth and invasion.

METHODS

As measures of cell proliferation and invasion ability, the cell viability and transwell assays were used in vitro. Transgenic mfat-1 mice, which convert ω-6 PUFAs to ω-3 PUFAs, were used to detect the effect of endogenous DHA on tumor transplantation. An LC - MS/MS analysis identified the elevation of several eicosanoid metabolites of DHA. By using qPCR miRNA microarray, online prediction software, luciferase reporter assays and Western blot analysis, we further elucidated the mechanisms.

RESULTS

Addition of exogenous DHA inhibited the growth and invasion in NSCLC cells in vitro. Endogenously produced DHA attenuated LLC-derived tumor growth and metastasis in the transgenic mfat-1 mice. Among the elevation of DHA metabolites, resolvin D1 (RvD1) significantly contributed to the inhibition in cell growth and invasion. MiRNA microarray revealed that the level of miR-138-5p was significantly increased after RvD1 treatment. MiR-138-5p mimics decreased cell viability and invasion; while miR-138-5p inhibitor abolished RvD1-mediated suppression of cell viability and invasion. The expression of FOXC1 was significantly reduced upon overexpression of miR-138-5p while luciferase reporter assay showed that FOXC1 was a direct target of miR-138-5p. In vivo, endogenous DHA by the mfat-1 transgene enhanced miR-138-5p expression and decreased FOXC1 expression. Furthermore, overexpression of FOXC1 reversed the inhibition in cell viability and invasion induced by RvD1 treatment.

CONCLUSIONS

These data identified the RvD1/miR-138-5p/FOXC1 pathway as a novel mechanism by DHA and its metabolite, RvD1, and the potential of targeting such pathway as a therapeutic strategy in treating NSCLC.

The effect of Delphinium denudatum (Jadwar) on fatigue: A randomized double blind placebo-controlled clinical trial

OBJECTIVES

Fatigue is a common problem in modern-day life. The aim of this study was to evaluate the effect of Delphinium denudatum (Jadwar) on fatigue.

METHODS

This study was a randomized double-blind placebo-controlled clinical trial between healthy normal university students. In each group, participants were given one capsule of either WEACURE® (containing 500 mg of Jadwar root powder) or placebo for 15 consecutive days. Multidimensional Fatigue Inventory (MFI) questionnaire was used before and after the intervention to evaluate different aspects of fatigue.

RESULTS

A total number of 64 participants completed the study. Data analysis showed decrease in the scores of all five domains of fatigue in Jadwar group (13.31 ± 3.05-7.75 ± 2.66, 12.31 ± 3.55-7.63 ± 2.62, 12.22 ± 4.26-6.97 ± 2.06, 11.56 ± 4.21 to 7.28 ± 2.37, 12.91 ± 3.09-7.34 ± 2.13 in general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue domains, respectively) which was statistically significant (P value<0.0001). This situation was significantly superior to the placebo group. Prescribed dosage of WEACURE® capsule was well tolerated.

CONCLUSION

As a complementary tonic agent, Jadwar have a potential to reduce fatigue in normal population. However, objective evaluation of its anti-fatigue effect should be further evaluated.

Anti-Inflammatory Diets and Fatigue

Accumulating data indicates a link between a pro-inflammatory status and occurrence of chronic disease-related fatigue. The questions are whether the observed inflammatory profile can be (a) improved by anti-inflammatory diets, and (b) if this improvement can in turn be translated into a significant fatigue reduction. The aim of this narrative review was to investigate the effect of anti-inflammatory nutrients, foods, and diets on inflammatory markers and fatigue in various patient populations. Next to observational and epidemiological studies, a total of 21 human trials have been evaluated in this work. Current available research is indicative, rather than evident, regarding the effectiveness of individuals’ use of single nutrients with anti-inflammatory and fatigue-reducing effects. In contrast, clinical studies demonstrate that a balanced diet with whole grains high in fibers, polyphenol-rich vegetables, and omega-3 fatty acid-rich foods might be able to improve disease-related fatigue symptoms. Nonetheless, further research is needed to clarify conflicting results in the literature and substantiate the promising results from human trials on fatigue.

The Effects of Doxorubicin-based Chemotherapy and Omega-3 Supplementation on Mouse Brain Lipids

Chemotherapy-induced cognitive impairment affects ~30% of breast cancer survivors, but the effects on how chemotherapy impacts brain lipids, and how omega-3 polyunsaturated fatty acid supplementation may confer protection, is unknown. Ovariectomized mice were randomized to two rounds of injections of doxorubicin + cyclophosphamide or vehicle after consuming a diet supplemented with 2% or 0% EPA+DHA, and sacrificed 4, 7, and 14 days after the last injection (study 1, n = 120) or sacrificed 10 days after the last injection (study 2, n = 40). Study 1 whole brain samples were extracted and analyzed by UHPLC-MS/MS to quantify specialized pro-resolving mediators (SPMs). Lipidomics analyses were performed on hippocampal extracts from study 2 to determine changes in the brain lipidome. Study 1 results: only resolvin D1 was present in all samples, but no differences in concentration were observed (P > 0.05). Study 2 results: chemotherapy was positively correlated with omega-9 fatty acids, and EPA+DHA supplementation helped to maintain levels of plasmalogens. No statistically significant chemotherapy*diet effect was observed. Results demonstrate a limited role of SPMs in the brain post-chemotherapy, but a significant alteration of hippocampal lipids previously associated with other models of cognitive impairment (i.e., Alzheimer's and Parkinson's disease).

Cardiorespiratory fitness, visceral fat, and body fat, but not dietary inflammatory index, are related to C-reactive protein in cancer survivors

BACKGROUND

The control of chronic inflammation has emerged as a target for improving the health of cancer survivors (CS).

AIM

To examine differences in fitness and dietary characteristics of CS when grouped by low vs. moderate to high serum C-reactive protein (CRP).

METHODS

CS (N = 26, mean age = 68 ± 12 years) were evaluated for body mass index (BMI), body composition, cardiorespiratory fitness, dietary intake, dietary inflammatory index (DII), and serum CRP. Participants were assigned to one of two groups based on serum CRP concentrations: low CRP (≤1 mg/L) (LWC; n = 13) or moderate to high (CRP > 1 mg/L) (MHC; n = 13) and t-tests compared them. Data are presented as mean ± SD.

RESULTS

LWC had higher VO₂peak values (mL/kg/min) (p = 0.0003), and lower visceral fat area (cm²) (p = 0.02) and body fat mass (kg) (p = 0.04). Secondary analysis using Pearson's correlation coefficients, including all current study participant data, found significant negative relationships between CRP and total dietary fat intake (p = 0.02), saturated fat (p = 0.03), and polyunsaturated fat (p = 0.03).

CONCLUSION

CS with moderate to high serum CRP concentrations had higher fat mass, visceral fat mass, and lower cardiorespiratory fitness. There was a significant negative relationship between dietary, fat, polyunsaturated and saturated fat, and CRP. However, these dietary fat related findings warrant further investigation. To summarize, improving cardiorespiratory fitness, maintaining lower body fat, may be helpful in altering chronic inflammation in CS.

Can krill oil be of use for counteracting neuroinflammatory processes induced by high fat diet and aging?

Most neurodegenerative diseases, such as Alzheimer's and Parkinson's disease, demonstrate preceding or on-going inflammatory processes. Therefore, discovering effective means of counteracting detrimental inflammatory mediators in the brain could help alter aging-related disease onset and progression. Fish oil and marine-derived omega-3, long-chain polyunsaturated fatty acids (LC n-3) have shown promising anti-inflammatory effects both systemically and centrally. More specifically, krill oil (KO), extracted from small Antarctic crustaceans, is an alternative type of LC n-3 with reported health benefits including improvement of spatial memory and learning, memory loss, systemic inflammation and depression symptoms. Similar to the more widely studied fish oil, KO contains the long chain fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) which are essential for basic brain functions. Moreover, the phospholipid bound nature of fatty acids found in KO improves bioavailability and efficiency of absorption, thus supporting the belief that KO may offer a superior method of dietary n-3 delivery. Finally, KO contains astaxanthin, an antioxidant capable of reducing potentially excessive oxidative stress and inflammation within the brain. This review will discuss the potential benefits of KO over other marine-based LC n-3 on brain inflammation and cognitive function in the context of high fat diets and aging.

The combined effect of vitamin C and omega-3 polyunsaturated fatty acids on fatigue following coronary artery bypass graft surgery: a triple-blind clinical trial

Background Fatigue is a common compliant among patients who undergo coronary artery bypass graft (CABG) surgery. This may affect patients' function in all aspects. A few studies have already assessed the influence of complementary therapies on minimizing fatigue. This study aimed to investigate the combined effect of vitamin C and omega-3 polyunsaturated fatty acids (n-3 PUFA) on fatigue following CABG surgery. Methods In this randomized, triple-blind placebo-controlled trial, 160 patients who already underwent CABG surgery were randomly assigned into an experimental or a control groups. Each group consisted of 80 patients. The experimental group was given both n-3 PUFA and vitamin C the day before surgery. They also received the same supplements in the first 5 days of operation. The control group received only placebo. Subjects in both groups responded to Multidimensional Fatigue Inventory (MFI-20) scale in the beginning, and at the end of the intervention as well as on the fifth day of the operation. Chi-square test and independent t-test were used for data analysis. Results The mean fatigue score in experimental and control groups came up to 62.01 ± 4.06 and 67.92 ± 4.95 (p<0.0001), respectively, which was greater than that of the values we had before intervention. The mean difference of fatigue score was 3.97 ± 3.49 and 9.56 ± 6.41 (p<0.0001) prior and following the intervention, correspondingly. Conclusion Combination of vitamin C and n-3 PUFA effectively reduces post-operative fatigue among patients who undergo CABG surgery.

Fatigue and physical activity in cancer survivors: A cross-sectional population-based study

Purpose

A substantial proportion of cancer survivors experience fatigue after diagnosis. Physical activity (PA) can impact fatigue after cancer. In this study, we evaluated the prevalence and association of fatigue and the practice of PA in a population with early cancer.

Methods

Using the national population‐based French cross‐sectional study Vie après le cancer 2, we included 1984 patients with early breast (61.1%), prostate (21.5%), and colorectal (17.4%) cancer. Severe fatigue at 2 years postdiagnosis was defined by a score ≥40 in the European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ C30) fatigue subscale. PA was defined as (a) self‐reported PA before diagnosis (active/inactive) and (b) change in PA since diagnosis (increased/maintained exposure vs decreased exposure/remaining inactive). Multivariate regression examined associations of severe fatigue with PA, adjusting for baseline clinical and treatment variables.

Results

Median age was 52 years. 51.5% of patients experienced severe fatigue 2 years post‐diagnosis. 87.7% reported to be physically active before cancer diagnosis; 53.3% of patients either decreased PA or remained inactive at 2 years postdiagnosis. At 2 years postdiagnosis, severe fatigue was associated with a change in PA since diagnosis: patients with decreasing PA/remaining inactive from pre‐ to postdiagnosis had a higher risk of severe fatigue vs those with increasing/maintaining PA (adjusted odds ratio [95% confidence interval] 2.32 [1.85‐2.90]).

Conclusion

Fatigue continues to be a substantial problem for cancer survivors 2 years after cancer diagnosis and is associated with PA decreasing/remaining inactive since diagnosis. Interventions to maintain or increase PA for cancer survivors should be tested to mitigate long‐term fatigue after cancer.

Nutrition therapy for the management of cancer-related fatigue and quality of life: a systematic review and meta-analysis

Cancer-related fatigue (CRF) is one of the most commonly reported disease- and treatment-related side effects that impede quality of life. This systematic review and meta-analysis describes the effects of nutrition therapy on CRF and quality of life in people with cancer and cancer survivors. Studies were identified from four electronic databases until September 2017. Eligibility criteria included randomised trials in cancer patients and survivors; any structured dietary intervention describing quantities, proportions, varieties and frequencies of food groups or energy and macronutrient consumption targets; and measures of CRF and quality of life. Standardised mean differences (SMD) were pooled using random-effects models. The American Dietetic Association's Evidence Analysis Library Quality Checklist for Primary Research was used to evaluate the methodological quality and risk of bias. A total of sixteen papers, of fifteen interventions, were included, comprising 1290 participants. Nutrition therapy offered no definitive effect on CRF (SMD 0·18 (95 % CI -0·02, 0·39)) or quality of life (SMD 0·07 (95 % CI -0·10, 0·24)). Preliminary evidence indicates plant-based dietary pattern nutrition therapy may benefit CRF (SMD 0·62 (95 % CI 0·10, 1·15)). Interventions using the patient-generated subjective global assessment tool and prescribing hypermetabolic energy and protein requirements may improve quality of life. However, the heterogeneity seen in study design, nutrition therapies, quality-of-life measures and cancer types impede definitive dietary recommendations to improve quality of life for cancer patients. There is insufficient evidence to determine the optimal nutrition care plan to improve CRF and/or quality of life in cancer patients and survivors.