Aiming for a better understanding and management of cancer-related fatigue

Exploring the nexus between fatigue, body composition, and muscle strength in hemodialysis patients

BACKGROUND

Fatigue is a relatively prevalent condition among hemodialysis patients, resulting in diminished health-related quality of life and decreased survival rates. The purpose of this study was to investigate the relationship between fatigue and body composition in hemodialysis patients.

METHODS

This cross-sectional study included 92 patients in total. Fatigue was measured by Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) (cut-off ≤ 34). Body composition was measured based on quantitative computed tomography (QCT), parameters including skeletal muscle index (SMI), intermuscular adipose tissue (IMAT), and bone mineral density (BMD). Handgrip strength was also collected. To explore the relationship between fatigue and body composition parameters, we conducted correlation analyses and binary logistic regression.

RESULTS

The prevalence of fatigue was 37% (n = 34), abnormal bone density was 43.4% (n = 40). There was a positive correlation between handgrip strength and FACIT-F score (r = 0.448, p < 0.001). Age (r = - 0.411, p < 0.001), IMAT % (r = - 0.424, p < 0.001), negatively associated with FACIT-F score. Multivariate logistic regression analysis shows that older age, lower serum phosphorus, higher IMAT% are associated with a high risk of fatigue.

CONCLUSION

The significantly increased incidence and degree of fatigue in hemodialysis patients is associated with more intermuscular adipose tissue in paraspinal muscle.

Network analysis used to investigate the interplay among somatic and psychological symptoms in patients with cancer and cancer survivors: a scoping review

PURPOSE

Patients with cancer often experience multiple somatic and psychological symptoms. Somatic and psychological symptoms are thought to be connected and may reinforce each other. Network analysis allows examination of the interconnectedness of individual symptoms. The aim of this scoping review was to examine the current state of knowledge about the associations between somatic and psychological symptoms in patients with cancer and cancer survivors, based on network analysis.

METHODS

This scoping review followed the five-stage framework of Arksey and O'Malley. The literature search was conducted in May, 2023 in PubMed, APA PsycINFO, Embase Cochrane central, and CINAHL databases.

RESULTS

Thirty-two studies were included, with eleven using longitudinal data. Seventeen studies reported on the strength of the associations: somatic and psychological symptoms were associated, although associations among somatic as well as among psychological symptoms were stronger. Other findings were the association between somatic and psychological symptoms was stronger in patients experiencing more severe symptoms; associations between symptoms over time remained rather stable; and different symptoms were central in the networks, with fatigue being among the most central in half of the studies.

IMPLICATIONS FOR CANCER SURVIVORS

Although the associations among somatic symptoms and among psychological symptoms were stronger, somatic and psychological symptoms were associated, especially in patients experiencing more severe symptoms. Fatigue was among the most central symptoms, bridging the somatic and psychological domain. These findings as well as future research based on network analysis may help to untangle the complex interplay of somatic and psychological symptoms in patients with cancer.

The Mechanisms Underlying the Beneficial Impact of Aerobic Training on Cancer-Related Fatigue: A Conceptual Review

Cancer-related fatigue (CRF) is a prevalent and persistent issue affecting cancer patients, with a broad impact on their quality of life even years after treatment completion. The precise mechanisms underlying CRF remain elusive, yet its multifaceted nature involves emotional, physical, and cognitive dimensions. The absence of effective medical treatments has prompted researchers to explore integrative models for potential insights. Notably, physical exercise emerges as a promising strategy for managing CRF and related symptoms, as studies showed a reduction in CRF ranging from 19% to 40%. Current recommendations highlight aerobic training at moderate intensity as beneficial, although questions about a dose-response relationship and the importance of exercise intensity persist. Despite the positive impact of exercise on CRF, the underlying mechanisms remain elusive. This review aims to provide a theoretical model explaining how aerobic exercise may alleviate CRF. Focusing on acute exercise effects, this review delves into the potential influence on peripheral and neural inflammation, immune function dysregulation, and neuroendocrine system disruptions. The objective is to enhance our understanding of the intricate relationship between exercise and CRF, ultimately paving the way for tailored interventions and potential pharmacological treatments for individuals unable to engage in physical exercise.

The Effect of Melatonin Supplementation on Cancer-Related Fatigue during Chemotherapy Treatment of Breast Cancer Patients: A Double-Blind, Randomized Controlled Study

Cancer-related fatigue (CRF) is a common distressing complaint of breast cancer (BC) patients treated with chemotherapy. Nutritional quality plays a pivotal role in CRF, while increased interest towards new pharmacological agents has been observed. Melatonin, an endogenous hormone that regulates the human sleep-wake cycle, could alleviate CRF. In the present randomized, placebo-controlled 3-month trial, we investigated the effects of melatonin intake (i.e., 1 mg/day) vs. placebo in BC patients on CRF. In both arms, the Mediterranean diet (MD) was implemented. Medical history, anthropometry and blood withdrawal were performed. CRF was evaluated by the Functional Assessment of Chronic Illness Therapy-Fatigue questionnaire and MD adherence by the MedDietScore. In total, 49 BC women (median age 52 years) were recruited, namely N = 23 in the intervention arm and N = 26 in the placebo arm. At baseline, CRF was positively associated with body mass index (BMI), even when adjusted for age, waist circumference and blood indices related to disease prognosis (beta = -0.882, p = 0.003). At 3 months, both groups showed a BMI decrease (p < 0.05), but only the intervention group improved CRF compared to baseline (p = 0.003). No differences in CRF were observed between the groups. In conclusion, melatonin oral supplementation could ameliorate CRF in BC patients.

Sociodemographic and treatment-related correlates of fatigue in breast cancer survivors at an oncology clinic in Nigeria

Background

Breast cancer survivors (BCS) still experience fatigue that may impair their quality of life even after completion of treatment. There is a need to understand the sociodemographic and treatment-related factors associated with this to develop relevant and effective interventions.

Aim

To assess the relationship between cancer-related fatigue and sociodemographic and treatment-related factors in BCS.

Materials and methods

This is a cross-sectional study involving 80 BCS attending the radiation oncology University College Hospital Ibadan. Their sociodemographic, disease and treatment characteristics were obtained. Fatigue Symptom Inventory was used to assess fatigue. A score of at least 3 on average fatigue severity item was taken as cut-off for clinically meaningful fatigue.

Result

The mean age of patients was 51.5 years. The prevalence of fatigue was 22.5%. On univariate analysis, fatigue was significantly associated with younger age (p = 0.022), employment (p = 0.006), stage of the disease(p = 0.014), anthracycline-based chemotherapy (p = 0.026), last chemotherapy less than 1 year (p = 0.001). Using logistic regression analysis, stage (Odds ratio (OR) 5.115, 95% CI 1.029-25.438, p = 0.046), employment status (OR 52.224, 95% CI 3.611-755.899, p = 0.004) and year of last cycle chemotherapy (OR 6.375, 95% CI 1.108-36.680, p = 0.038) were associated with fatigue in BCS.

Conclusion

About a quarter of BCS reported fatigue. Advance stage disease, employment status and receiving last course of chemotherapy less than a year are correlates of fatigue.

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

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

Cultural adaptation of the Pan-Canadian Oncology Symptom triage and remote support practice guide for cancer-related fatigue in China: Integration of traditional Chinese medicine nursing evidence

Objective

This study aimed at culturally adapting pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) Cancer-related fatigue (CRF) Practice Guide to enable its use in China. This article focuses on presenting the key cultural adaptation step: supplementing traditional Chinese medicine (TCM) nursing recommendations for CRF symptom management according to evidence.

Methods

Guided by A Guideline Adaptation and Implementation Planning Resource (CAN-IMPLEMENT), the process for cultural adaptation of the CRF guide in the COSTaRS project included translation, expert committee review, acceptability and feasibility assessment, and targeted adaptation to include TCM nursing techniques for CRF management via the Delphi method.

Results

First, an expert committee of nurses, nurse leaders, and researchers was established. The practice guide was translated and verified by the members of the expert committee. Nurses then rated the practice guide for acceptability and feasibility. Concurrently, 83 stakeholders (nurses and patients) identified five relevant TCM nursing techniques: acupuncture, moxibustion, acupressure therapy, Taijiquan, and auricular acupoint embedding. A systematic review of literature identified three clinical practice guidelines and four systematic reviews. Through two rounds of Delphi expert consultation, five TCM care strategies were added into the culturally adapted COSTaRS practice guide.

Conclusions

Cultural adaptation of the Canadian CRF practice guide involved not only language translation but also the addition of relevant TCM evidence. Combining TCM evidence and the Delphi method was a novel aspect of the cultural adaptation process. Further research is needed to investigate the implementation of the guide in appropriate settings in China.

A review of therapeutic potentials of milk thistle (Silybum marianum L.) and its main constituent, silymarin, on cancer, and their related patents

For more than 2000 years, Silybum marianum L. (milk thistle) has been used for treating different complications such as jaundice, hepatitis, and cancers. It has also been shown that silymarin, a flavonolignan extract of the plant, demonstrates chemopreventive effects against cancers. This patent review presents and discusses recent patents concerning the anticancer effects of S. marianum and silymarin. The data were gathered by searching an extensive literature review conducted in Google Scholar, PubMed, Scopus, Google Patent, Patent Scope, and US Patent. Milk thistle and silymarin have been used in a variety of medical, therapeutic, and pharmaceutical fields, according to a large number of documents and patents. Milk thistle and silymarin have been used as complementary treatments for cancers such as skin, prostate, and colorectal cancers, as well as hepatoprotective agents. Silymarin exerts a chemopreventive effect on reactivating cell death pathways by modulation of the antiapoptotic proteins and synergizing with agonists of death domain receptors. Based on the results of these patents, silymarin could be beneficial to oncology patients, especially for the treatment of the side effects of anticancer chemotherapeutics. Following the human propensity to use phytocompounds rather than medicines based on chemical constituents, special attention must be paid to tie the value of milk thistle and silymarin from basic science to clinical applications.

Transcutaneous electrical acupoint stimulation (TEAS) for cancer-related fatigue: study protocol for a systematic review and meta-analysis

INTRODUCTION

Cancer-related fatigue (CRF) is a prevalent symptom in cancer survivors. Transcutaneous electrical acupoint stimulation (TEAS) has been reported as a promising therapy for CRF. This protocol is proposed for a systematic review that aims to assess the efficacy and safety of TEAS for CRF.

METHODS AND ANALYSIS

Cochrane Central Register of Controlled Trials, PubMed, Medline, Embase, Chinese National Knowledge Infrastructure, VIP, Wanfang database, Chinese Biomedical Literature Database, Chinese Clinical Trial Registry System, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform will be searched from inception to 31 January 2021 without language limitations. The eligible randomised controlled trials will be included. The primary outcomes include changes in the revised Piper fatigue scale, the Brief fatigue inventory, the Multidimensional fatigue inventory and the Functional assessment of chronic illness therapy fatigue. The secondary outcomes are the quality-of-life measurement index, the Hamilton anxiety scale, the Hamilton depression scale and adverse events. The selection of studies, data extraction and assessment of risk of bias will be conducted independently by two reviewers. Data synthesis will be performed using RevMan V.5.4.1. The quality of evidence will be evaluated with the Grading of Recommendations, Assessment, Development and Evaluation system. This study will strictly adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a systematic review and meta-analysis based on previously published studies involving no private information of patients. The results of this study will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020220282.

Cancer-related fatigue: an overview

A diagnosis of cancer is a major life stressor that can affect the physiological, psychological and physical state of the person concerned. 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. The aim of this review is to provide background information on cancer-related fatigue. This review discusses cancer-related fatigue (CRF) in terms of the definition, prevalence, risk factors, aetiology, and the measurement scales used. The differences between definitions of symptoms and relevant theories will be explored and discussed to help explain the variety of instruments used in its measurement. The prevalence of fatigue will be assessed by looking critically at the evidence of fatigue and the factors that affect it. Potential treatment and management strategies for CRF will also be discussed. Finally, there will be an overview of the instruments used to measure fatigue. This review also provides important evidence for measuring and managing CRF that can help nurses to understand fatigue among patients with cancer. Assessing CRF should be routinely undertaken in clinical settings to help identify the proper interventions, treatments and management to reduce fatigue among cancer patients.

Association of Fatigue and Outcomes in Advanced Cancer: An Analysis of Four SWOG Treatment Trials

PURPOSE

Patient-reported outcomes may be associated with cancer outcomes. We evaluated clinically significant fatigue (CSF), overall survival, adverse events (AEs), and quality of life (QOL) during cancer treatment.

METHODS

We compared outcomes in four phase II or III chemotherapy trials, two advanced non-small-cell lung cancer and two advanced hormone-refractory prostate cancer, with or without baseline CSF. CSF was defined as a rating of two or greater on the Functional Assessment of Cancer Therapy fatigue question or a European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 fatigue symptom score of 50% or greater. Survival was compared according to CSF using Kaplan-Meier estimates and Cox regression models. Differences in AE rates by CSF were assessed via chi-squared tests, and QOL changes from baseline to 3 months via linear regression.

RESULTS

Of 1,994 participants, 1,907 (median age 69 years, range: 32-91) had complete baseline QOL survey data, with 52% reporting CSF at baseline. For the two hormone-refractory prostate cancer studies, baseline CSF was associated with higher mortality rates, with adjusted hazard ratios of (95% CI, P value) 1.32 (1.13 to 1.55, P < .001) and 1.31 (1.02 to 1.67, P = .03) and with increased incidence of grade 3-5 constitutional (16.5% v 9.4%, P = .002; 13.9% v 6.3%, P = .002) and neurologic (11.7% v 6.1%, P = .006; 9.0% v 3.9%, P = .01) AEs, respectively. Baseline CSF was associated with a higher mortality rate in one non-small-cell lung cancer study: hazard ratio 1.44 and 1.04 to 2.00, P = .03.

CONCLUSION

Oncology trial participants with baseline CSF had poorer survival and experienced more AEs than participants without CSF. This indicates fatigue as an important baseline prognostic factor in oncology treatment trials.

Systematic review of cancer-related fatigue instruments in breast cancer patients

OBJECTIVE

Fatigue is having high prevalence and increased acknowledgment of negative effect on the patient's well-being which has resulted in fatigue being important research variable in breast cancer patients. The recent development shows greater receptivity of health professionals to assessing cancer-related fatigue (CRF). In this review, an attempt has been made to identify CRF instruments which have been used in breast cancer patients with the detailed description about the instruments and their psychometric properties.

METHOD

A search was conducted from January 2000 to April 2020 from electronic databases such as PubMed, Cochrane, Embase, and Google Scholar. The studies were included if the instrument was used to measure fatigue in breast cancer patients and its description and psychometric properties reported in breast cancer patients. The search was limited to studies in the English language and use of English version of instruments.

RESULTS

Among 34 CRF instruments, 9 instruments were included according to inclusion and exclusion criteria. From nine instruments, six were multidimensional, two were unidimensional, and one instrument was quality-of-life (QOL) subscale. All the scales have showed accepted reliability and validity in breast cancer patients. A minimal clinically important difference was available for Multidimensional Fatigue Symptom Inventory - Short Form, Brief Fatigue Inventory, Piper Fatigue Scale - Revised, FACIT Fatigue scale, and Fatigue symptom inventory instruments.

SIGNIFICANCE OF RESULTS

This review will help healthcare providers who are dealing with breast cancer patients to acknowledge and better understand what their patients are experiencing. The most appropriate tool will allow healthcare providers to use for holistic assessment of CRF. The instrument will help them to monitor their patient's condition or treatment progress, so it can be incorporated into treatment decisions for better management of fatigue.

Ginseng for the Management of Cancer-Related Fatigue: An Integrative Review

Background

Cancer-related fatigue (CRF) is one of the most prevalent, debilitating symptoms affecting a majority of patients with cancer worldwide. It can lead to poor compliance with anticancer therapy and discontinuation of treatment. Current management strategies for CRF center around activity and exercise; however, these strategies can be challenging for many patients undergoing active treatment. Ginseng has been shown to improve CRF and may provide benefit for patients suffering from CRF.

Methods

A systematic review was completed by searching PubMed and Scopus databases.

Results

115 search results were reduced to a final sample of five articles after applying inclusion and exclusion criteria. Published results suggest that 2,000 mg of American ginseng once daily improves symptoms of CRF. Minimal side effects or drug interactions are observed. Additional research is needed to further evaluate the role of ginseng for CRF.

Conclusion

There are data to support the use of American ginseng to treat CRF. Large-scale randomized controlled trials are needed to validate these findings and determine optimal dosage and duration of therapy.

External application of liver compresses to reduce fatigue in patients with metastatic cancer undergoing radiation therapy, a randomized clinical trial

BACKGROUND

Liver compresses are frequently used in integrative medicine as supportive therapy during cancer treatment in order to reduce fatigue. We performed a pilot study to test whether the external application of yarrow liver compresses impacts fatigue in patients with metastatic cancer undergoing radiation therapy.

METHODS

A randomized prospective pilot trial was performed including patients with brain metastasis or bone metastasis of solid tumors. Patients underwent either palliative radiation therapy (RT) of the metastatic lesions (control group) over two weeks or the same RT with additional external application of yarrow liver compresses once daily during RT. The primary objective was improvement on the general fatigue subscale of the multidimensional fatigue inventory (MFI-20) at the end of treatment, where a mean difference of two points is considered clinically relevant. Secondary objectives included psychological distress, quality of life and qualitative analysis with self-established visual analogue scales (VAS). Mean differences in general fatigue at the end of treatment compared to baseline were analyzed using the ANCOVA test.

RESULTS

From 09/2017 to 08/2019 a total of 39 patients were randomized. Due to drop outs 24 patients (12 per group) were available for analysis. Patients in the intervention group received a mean number of 10.5 (range, 7-14) applications of yarrow liver compresses. The mean improvement at the end of therapy on the general fatigue subscale of the MFI-20 was 2 points in favor of the intervention group (p = 0.13), and all other MFI-20 subscales showed at least a trend towards improvement in favor of the intervention group. Likewise, psychological distress and VAS data was improved, the latter reaching statistical significance for the symptoms fatigue, tension and lack of drive. Major toxicities were not observed.

CONCLUSIONS

External application of liver compresses appears to reduce fatigue within a clinical relevant range in patients with metastatic cancer undergoing radiation therapy.

TRIAL REGISTRATION

ISRCTN, ICTRP DRKS00012999.

Predictors and short-term outcomes of post-stroke fatigue in initial phase of transition from hospital to home: A prospective observational study

AIM

To analyse the interactions of associated factors with post stroke fatigue (PSF) after discharge home and determine the predictors of PSF and their impact on stroke survivors.

DESIGN

A prospective observational study.

METHODS

A total of 94 patients with acute stroke were recruited between May 2019 -July 2020. The main outcomes were fatigue, depression, insomnia, sarcopenia, and health-related quality of life (HRQOL) and were assessed at admission and 1 month after discharge. Fatigue was measured using the Fatigue Assessment Scale. Depression and Insomnia were assessed using the Hospital Anxiety and Depression Scale-Depression and Insomnia Severity Index, respectively. Sarcopenia was measured using the SARC-F questionnaire, and HRQOL was assessed using the Short Form-8.

RESULTS

Acute phase PSF was an independent predictor of PSF after discharge home. Moreover the path analysis revealed that this effect is mediated through both the direct effect of acute-phase PSF on PSF after discharge home and through the indirect effect of interaction with pre-stroke SARC-F, acute phase depression, and acute phase insomnia, which remains a separate predictor of acute-phase PSF. In total, 17% of the survivors had persistent PSF. Persistent PSF was significantly associated with depression, insomnia, sarcopenia, and a lower quality of life scores.

CONCLUSIONS

Post-stroke fatigue may occur in the acute phase and persists after discharge, it will not only affect later depression, insomnia, and quality of life, but also sarcopenia.

IMPACT

Acute phase PSF was found to be an independent predictor of PSF after discharge home. In addition, the interaction with pre-stroke SARC-F, acute phase depression and insomnia had an indirect connection with PSF after discharge home, which remains a separate predictor of acute-phase PSF. Thus, early assessment and management of mental status, sleep problems, and sarcopenia during hospitalization might be an important step in post-stroke rehabilitation and home transition.

Development and Internal Validation of a Nomogram to Predict Post-Stroke Fatigue After Discharge

OBJECTIVES

We aimed to develop and validate a nomogram for the individualized prediction of the risk of post-stroke fatigue (PSF) after discharge.

MATERIALS AND METHODS

Fatigue was measured using the Fatigue Assessment Scale. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the least absolute shrinkage and selection operator regression model. Discrimination, calibration, and clinical usefulness of the predictive model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was conducted using bootstrapping validation. Finally, a web application was developed to facilitate the use of the nomogram.

RESULTS

We developed a nomogram based on 95 stroke patients. The predictors included in the nomogram were sex, pre-stroke sarcopenia, acute phase fatigue, dysphagia, and depression. The model displayed good discrimination, with a C-index of 0.801 (95% confidence interval: 0.700-0.902) and good calibration. A high C-index value of 0.762 could still be reached in the interval validation. Decision curve analysis showed that the risk of PSF after discharge was clinically useful when the intervention was decided at the PSF risk possibility threshold of 10% to 90%.

CONCLUSION

This nomogram could be conveniently used to provide an individual, visual, and precise prediction of the risk probability of PSF after being discharged home. Thus, as an aid in decision-making, physicians and other healthcare professionals can use this predictive method to provide early intervention or a discharge plan for stroke patients during the hospitalization period.

Improved cancer-related fatigue in a randomised clinical trial: methylphenidate no better than placebo

INTRODUCTION

Methylphenidate is a psychostimulant drug used to treat fatigue in patients with advanced cancer, for which there is no gold standard of treatment.

OBJECTIVE

To explore the efficacy of methylphenidate in the relief of fatigue in patients with advanced cancer.

MATERIALS AND METHODS

A randomised double-blind placebo-controlled multicentre clinical trial, stratified according to the intensity of fatigue. The treatment was considered effective if the improvement in mean fatigue intensity between baseline values and day 6 was significantly higher in the methylphenidate group than in the placebo group. The responses were measured using the Edmonton Symptoms Assessment System (ESAS) and the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) scales.

RESULTS

35 patients received placebo and 42 patients received methylphenidate. The populations of both groups were homogeneous. Patients receiving methylphenidate did not exhibit statistically significant improvement of fatigue in comparison to patients receiving placebo (p=0.52). The mean improvement of fatigue (ESAS) on day 6 was -1.9 (±2.5) in the placebo group, and -2.3 (±2.6) in the methylphenidate group (p=0.52). The results obtained with the FACT-F were congruent with those obtained by the ESAS. The responses in patients with severe fatigue were -2.4 (±2.9) in the placebo group and -3.4 (±2.5) in the methylphenidate group; the difference was not statistically significant (p=0.3).

CONCLUSION

Methylphenidate was not more efficient than placebo to treat cancer-related fatigue. Fatigue improved significantly after 3 days of treatment and was stabilised on day 6, both with placebo and methylphenidate. The side effects of methylphenidate were mild and infrequent.

TRIAL REGISTRATION NUMBER

EudraCT Registry (2008-002171-27).

Eurythmy therapy versus slow movement fitness in the treatment of fatigue in metastatic breast cancer patients: study protocol for a randomized controlled trial

BACKGROUND

Cancer-related fatigue (CRF) is the most taxing symptom for many breast cancer patients during and after therapy. In patients with metastatic disease, the prevalence of CRF exceeds 75%. Currently, there is no gold standard for the treatment of CRF. Physical activity can reduce CRF and is recommended during and after cancer treatment, but may be too burdensome for patients with metastatic breast cancer. The aim of this study is to assess the effect on fatigue of eurythmy therapy (ERYT) compared to slow movement fitness (CoordiFit) in metastatic breast cancer patients.

METHODS

The ERYT/CoordiFit study is a randomized controlled, open-label, two-arm, multi-center Swiss clinical trial. A sample of 196 patients presenting with CRF will be recruited by oncologists from the departments of clinical oncology at each local study site. All participants will be randomly allocated to the intervention or control group in a 1:1 ratio. The control group is an active control intervention (CoordiFit) in order to control for potential non-intended effects such as therapist-patient interaction and participation in a program. Both ERYT and CoordiFit exercises are easy to learn, and the training sessions will follow the same frequency and duration schedule, i.e., 13 standardized therapy sessions of 45 min (once a week for 6 weeks and then once every second week) during the total intervention period of 20 weeks. The primary endpoint of the study is the change from baseline over the whole intervention period (i.e., including measurements at baseline, weeks 8, 14, and 20) in the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) subscale score.

DISCUSSION

This study is the first-known randomized clinical trial assessing eurythmy therapy in the treatment of fatigue in metastatic breast cancer patients. Given the distress that fatigue causes patients, it is important to validate treatment options. If eurythmy therapy proves beneficial in CRF as part of this randomized controlled clinical trial, the study may be very impactful with implications not only for metastatic breast cancer patients but also for other cancer patients, health care personnel, scientists, and funding and regulatory bodies.

TRIAL REGISTRATION

The ERYT/CoordiFit trial was registered at the US National Institutes of Health (ClinicalTrials.gov) on July 18, 2019, #NCT04024267 , and in the portal for human research in Switzerland on December 3, 2019, #SNCTP000003525 .

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.

Effects of muscle energy technique for quadratus lumborum on respiratory muscle strength in patients with breast cancer

Introduction: Breast cancer is a major cause of morbidity and mortality, leading to functional deficiencies in ventilation, muscle performance, balance and posture.Objective: To describe the effects of the muscle energy technique (MET) for quadratus lumborum on maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in patients with stage I and II breast cancer.Materials and methods: Quasi-experimental study with a pretest-posttest design conducted in 10 patients treated at a highly specialized healthcare center in Bogotá. Physical therapy assessment and three physiotherapy sessions with the MET to measure MIP and MEP were carried out before and after the intervention using a respiratory pressure meter.Results: The average MIP was 41% of the reference value at the beginning of the intervention, which increased to 69% at the end of the sessions. On the other hand, the initial average MEP was 33%, while the post-intervention average MEP was 51%. The average change rate for MIP was 68% and 57% for MEP. The Wilcoxon signed-rank test was performed, achieving a statistically significant difference (z=-2.807, p=0.005).Conclusion: Applying the MET on the quadratus lumborum muscle improves its performance and increases respiratory muscle strength.

Longitudinal Associations Between Fatigue and Perceived Work Ability in Cancer Survivors

Purpose To examine the associations between changes of fatigue and changes of perceived work ability in cancer survivors. Furthermore, to examine the effects of physical job demands on these associations. Methods Data from a feasibility study on a multidisciplinary intervention to enhance return to work in patients with cancer receiving chemotherapy was used. Fatigue (Multidimensional Fatigue Inventory) and perceived work ability (first item of the Work Ability Index) were assessed at baseline, and after 6, 12, and 18 months. Change scores (S1, S2, S3) from each assessment to the next were calculated, thus encompassing three separate time periods of 6 months. Regression analyses were used to quantify associations between change of perceived work ability and (model 1) change of general fatigue, and (model 2) change of mental and physical fatigue for each 6-month period separately. For model 2, interaction effects of perceived physical job demands were studied. Results A total of 89 participants were included for analysis, among which 84% with a diagnosis of breast cancer. On average, in model 1, a reduction of five points on general fatigue was associated with an improvement of one point in perceived work ability in all three 6-month periods. Model 2 showed, similarly, that change of physical fatigue (S1 and S2: B = - 0.225; p < .001 and B = - 0.162; p = .012) and change of mental fatigue (S3: B = - 0.177; p = .027) were significantly inversely associated with change of perceived work ability. Interaction effects were not significant. Conclusion The inverse, longitudinal association between fatigue and perceived work ability supports previous findings from cross-sectional studies and shows potential occupational impact of targeting fatigue in cancer rehabilitation.

Effect of the Chinese Medicine YangZheng XiaoJi on Reducing Fatigue in Mice with Orthotopic Transplantation of Colon Cancer

Background

Fatigue is a common, distressing, and persistent symptom for patients with malignant tumor including colorectal cancer (CRC). Although studies of cancer-related fatigue (CRF) have sprung out in recent years, the pathophysiological mechanisms that induce CRF remain unclear, and effective therapeutic interventions have yet to be established.

Methods

To investigate the effect of the traditional Chinese medicine YangZheng XiaoJi (YZXJ) on CRF, we constructed orthotopic colon cancer mice, randomly divided into YZXJ group and control (NS) group. Physical or mental fatigue was respectively assessed by swimming exhaustion time or suspension tail resting time. At the end of the experiment, serum was collected to measure the expression level of inflammatory factors by ELISA and feces to microbiota changes by 16s rDNA, and hepatic glycogen content was detected via the anthrone method.

Result

The nutritional status of the YZXJ group was better than that of the control group, and there was no statistical difference in tumor weight. The swimming exhaustion times of YZXJ group and control group were (162.80 ± 14.67) s and (117.60 ± 13.42, P < 0.05) s, respectively; the suspension tail resting time of YZXJ group was shorter than that of the control group (49.85 ± 4.56) s and (68.83 ± 7.26) s, P < 0.05)). Serum levels of IL-1β and IL-6 in YZXJ group were significantly lower than the control group (P < 0.05). Liver glycogen in YZXJ group was (5.18 ± 3.11) mg/g liver tissue, which was significantly higher than that in control group (2.95 ± 2.06) mg/g liver tissue (P < 0.05). At phylum level, increased abundance of Bacteroidetes, Verrucomicrobia, Actinobacteria, and Cyanobacteria and decreased Proteobacteria in YZXJ group emerged as the top differences between the two groups, and the Firmicutes/Bacteroidetes ratio was decreased in YZXJ group compared to the control group. At genus level, the abundance of Parabacteroides, unidentified Saprospiraceae, and Elizabethkingia which all belong to phylum Bacteroidetes were increased, while Arcobacter, Marinobacter, Alkanindiges, Sulfuricurvum, Haliangium, and Thiobacillus in phylum Proteobacteria were decreased after YZXJ intervention. YZXJ can also increase Pirellula, Microbacterium, and Alpinimonas and decrease Rubrobacter and Iamia.

Conclusion

YZXJ may reduce the physical and mental fatigue caused by colorectal cancer by inhibiting inflammatory reaction, promoting hepatic glycogen synthesis, and changing the composition of intestinal microbiota.

The pathophysiology of cancer-related fatigue: current controversies

Fatigue is one of the most common and debilitating cancer symptoms, and is associated with impaired quality of life. The exact pathophysiology of cancer-related fatigue (CRF) is poorly understood, but in any individual, it is likely multifactorial and involves inter-related cytokine, muscular, neurotransmitter, and neuroendocrine changes. Underlying CRF mechanisms proposed include central and peripheral hypotheses. Central mechanisms include hypotheses about cytokine dysregulation, hypothalamic-pituitary-adrenal-axis disruption, circadian rhythm disruption, serotonin, and vagal afferent nerve function while peripheral mechanisms include hypotheses about adenosine triphosphate and muscle contractile properties. Currently, these hypotheses are largely based on evidence from other conditions in which fatigue is characteristic. The purpose of this article is to provide a narrative review of the literature and present the current controversies in the pathophysiology of CRF, particularly in relation to central and peripheral hypotheses for CRF. An understanding of pathophysiology may facilitate direct and simple therapeutic interventions for those with cancer.

The use of methylphenidate to relieve fatigue

PURPOSE OF REVIEW

To review recent evidence on the efficacy and safety of methylphenidate as a symptomatic treatment of patients with cancer-related fatigue (CRF).

RECENT FINDINGS

Five clinical trials published since 2011 were identified. Two of these concluded that methylphenidate is more efficacious than placebo in providing relief from CRF, but the remaining three showed no difference in favour of methylphenidate. The studies were heterogeneous as per the dosage, scales used for evaluating fatigue and the target group studied. None of the studies detected serious reactions, and only mild and infrequent side-effects of methylphenidate were reported. Three new metanalyses show the slightly superior effect of methylphenidate compared to placebo in CRF.

SUMMARY

Overall, literature supports the existence of moderate benefit of methylphenidate in CRF, backed up by weak evidence. Future studies should aim at better identifying the profile of patients who would benefit most from this pharmacological intervention.

Soluble interleukin-6 receptor mediated fatigue highlights immunological heterogeneity of patients with early breast cancer who undergo radiation therapy

Purpose

This study aimed to explore the associations between dose-volume parameters of localized breast irradiation, longitudinal interleukin-6 soluble receptor (sIL-6R), and leukocyte counts as markers of an immune-mediated response and fatigue as a centrally-driven behavior.

Methods and Materials

This prospective cohort study recruited 100 women who were diagnosed with stage 0-IIIa breast cancer, prescribed 40 Gy in 15 fractions over 3 weeks adjuvant radiation therapy, and had no prior or concurrent chemotherapy. Dose-volume parameters were derived from treatment plans and related to serum sIL-6R concentrations, leukocyte counts, and a validated measure of self-reported fatigue at baseline, after 10 and 15 fractions, and 4 weeks after radiation therapy.

Results

sIL-6R concertation was significantly higher in patients with a total volume of tissue irradiated within the 50% isodose >2040 cm³ (P = .003). When controlling for body mass index, this result only remained significant after treatment. The volume of liver irradiated within the 10% isodose correlated with the sIL-6R concentration during and after radiation therapy (ρ = .3-.4; P = .03-.007). The 38% of the cohort that was classified as fatigued had a higher mean sIL-6sR concentration at all observation points, but the differences were only statistically significant during radiation therapy: Mean (standard deviation [SD]) after 15 fractions for fatigued patients was 47.6 ng/dL (11.2 SD) versus 41.6 ng/dL (11.4 SD) for nonfatigued patients (P = .01). Cohort leukocyte counts and leukocyte subsets decreased consistently from baseline and the values for the fatigued group were 4% lower at baseline and between 7% and 9% lower during and after treatment compared with those of the nonfatigued group but the differences were not statistically significant.

Conclusions

This is the first study to show that localized irradiation induces increased systemic sIL-6R during treatment in participants who reported elevated levels of fatigue before, during, and after treatment. This behavioral response appears to reflect a variation in innate host immunity, which then mediates the cellular and/or psychological stress of radiation therapy.

Untire: an all-embracing self-management eHealth program to cope with cancer-related fatigue

Cancer-related fatigue (CRF) is a frequent and invalidating problem in (former) cancer patients. If there are no medical causes, relief of fatigue can be attained by means of non-pharmacological interventions. Guidelines prescribe a multimodal approach with a focus on mental processes, physical activity and sleep. Online interventions have been shown to be effective in reducing CRF. These results inspired the creation of an all-embracing app on the various behavioural and physical activity modification themes that are recommended in oncological guidelines. This basis for the 'Untire' app is the Daily Program, consisting of 4 components. In 2018, the 'Untire' app will be launched in several languages throughout the European Union and some other countries outside Europe, such as the USA. Its effectiveness will be studied by means of a randomized controlled trial.

Effects of Tai Chi Exercise on Cancer-Related Fatigue in Patients With Nasopharyngeal Carcinoma Undergoing Chemoradiotherapy: A Randomized Controlled Trial

CONTEXT

Tai Chi exercise has been shown to improve cancer-related fatigue (CRF) and autonomic nervous system (ANS) balance in some cancer patients or survivors; however, such effects are yet to be verified in nasopharyngeal carcinoma (NPC) patients undergoing chemoradiotherapy.

OBJECTIVES

To explore the effects of Tai Chi exercise on CRF in NPC patients undergoing chemoradiotherapy and then to evaluate ANS information indicated by heart rate variability parameters and their association with CRF.

METHODS

A randomized controlled trial of Tai Chi exercise was conducted from January 2014 to August 2015. Participants in the Tai Chi group practiced Tai Chi a one-hour session, five sessions/week during chemoradiotherapy. Participants in the control group received usual care. The primary end points were scores of the multidimensional fatigue symptom inventory-short form (MFSI-SF). Secondary end points were heart rate variability parameters, including normalized low-frequency (nLF) power, normalized high-frequency (nHF) power, and the nLF/nHF ratio, and their association with CRF.

RESULTS

One hundred fourteen patients were recruited in this study, and 83 patients completed the trial. The Tai Chi group and the control group had comparable baseline characteristics. After chemoradiotherapy, the Tai Chi group exhibited lower MFSI-SF total score and three negative subscale (general, physical, and emotional fatigue) scores and higher vigor score compared with the control group (P < 0.01 for all). The nLF/nHF ratio was significantly lower in the Tai Chi group compared to the control group after chemoradiotherapy. The MFSI-SF total score was markedly correlated with the nLF/nHF ratio.

CONCLUSION

Tai Chi exercise is conducive to alleviate CRF in NPC patients undergoing chemoradiotherapy. The improvement in ANS balance might fit into the process of Tai Chi for CRF management in this population.

The impact of physical activity on fatigue and quality of life during and after adjuvant treatment for breast cancer

BACKGROUND

Although physical activity (PA) can alleviate fatigue and improve quality of life (QoL) in patients with breast cancer (BC), not all domains of PA may have equal impact. The objective of the current study was to examine the longitudinal impact of PA components on the evolution of fatigue and QoL during and after adjuvant treatment for BC.

METHODS

The women included in the study were participants in the 2-year longitudinal FATSEIN ("Fatigue dans le cancer du Sein") study. Fatigue and QoL were measured using the Multidimensional Fatigue Inventory and the European Organization for Research and Treatment of Cancer 30-item QoL questionnaire, respectively. Group-based trajectory analysis was used to determine patterns of PA evolution (frequency, duration, and intensity). Cross-sectional and longitudinal associations between PA patterns and fatigue and QoL were analyzed by using multivariable linear regression and a mixed model.

RESULTS

Among the 424 women who were included (mean ± standard deviation age, 57.1 ± 10.4 years), 2 trajectories were identified for each of the 3 PA components: low and insufficient frequency (51.2%) or regular and moderate frequency (48.8%), low and insufficient duration (47.6%) or regular and moderate duration (52.4%), and low intensity (47.2%) or low to moderate intensity (52.8%). Overall, during treatment, fatigue was increased and QoL was decreased, and the reverse was observed after treatment. During treatment, increased fatigue and decreased QoL were limited by regular PA frequency (β = -8.71 for total fatigue; β = 14.59 for emotional function), but the results were less significant after treatment.

CONCLUSIONS

PA, especially its frequency, is an important determinant of fatigue and QoL during adjuvant treatment for BC. The promotion of regular PA among women who are receiving treatment for BC may be an effective way to reduce fatigue and improve QoL. Cancer 2018;124:797-806. © 2017 American Cancer Society.

Acute Leukemia Patients' Needs: Qualitative Findings and Opportunities for Early Palliative Care

CONTEXT

Patients with acute leukemias likely have needs that palliative care can respond to, yet little is known about specific challenges they face, particularly during active treatment. We examined acute myeloid leukemia (AML) patients' expressed challenges and supports after intensive induction chemotherapy.

OBJECTIVES

We aimed to understand opportunities for palliative care interventions in this population.

METHODS

We conducted a qualitative study of AML patients with high-risk disease at Duke University Hospital, Durham, NC. Patients were interviewed about care experiences approximately 3 months after treatment initiation. Multiple coders used descriptive content analysis to identify common and recurrent themes.

RESULTS

We analyzed 22 patient transcripts. Sample demographics included 10 (45.5%) females, 12 (54.5%) males, mean age 62 (SD 10.9), 19 (86.4%) non-Hispanic white, and three (13.6%) nonwhite/non-Hispanic. All had high-risk disease, by age, relapse status, or molecular markers. We identified four themes in our analysis: physical symptoms, psychological issues, uncertainty regarding prognosis, and patients' sources of support. Specific challenges noted by patients included feelings of helplessness/hopelessness, activity restriction, fatigue, fevers, caregiver stress, and lack of clarity regarding treatment decision making.

CONCLUSION

AML patients face substantial challenges regarding physical symptoms, psychological distress, and uncertainty regarding prognosis. These challenges signal needs for which palliative care in high-risk AML patients may help. Our findings highlight opportunities to develop targeted palliative care interventions addressing unmet needs in AML patients.

Anamorelin (ONO-7643) for the treatment of patients with non-small cell lung cancer and cachexia: Results from a randomized, double-blind, placebo-controlled, multicenter study of Japanese patients (ONO-7643-04)

BACKGROUND

Cachexia, described as weight loss (mainly in lean body mass [LBM]) and anorexia, is common in patients with advanced cancer. This study examined the efficacy and safety of anamorelin (ONO-7643), a novel selective ghrelin receptor agonist, in Japanese cancer patients with cachexia.

METHODS

This double-blind clinical trial (ONO-7643-04) enrolled 174 patients with unresectable stage III/IV non-small cell lung cancer (NSCLC) and cachexia in Japan. Patients were randomized to daily oral anamorelin (100 mg) or a placebo for 12 weeks. The primary endpoint was the change from the baseline LBM (measured with dual-energy x-ray absorptiometry) over 12 weeks. The secondary endpoints were changes in appetite, body weight, quality of life, handgrip strength (HGS), and 6-minute walk test (6MWT) results.

RESULTS

The least squares mean change (plus or minus the standard error) in LBM from the baseline over 12 weeks was 1.38 ± 0.18 and -0.17 ± 0.17 kg in the anamorelin and placebo groups, respectively (P < .0001). Changes from the baseline in LBM, body weight, and anorexia symptoms showed significant differences between the 2 treatment groups at all time points. Anamorelin increased prealbumin at weeks 3 and 9. No changes in HGS or 6MWT were detected between the groups. Twelve weeks' treatment with anamorelin was safe and well tolerated in NSCLC patients.

CONCLUSIONS

Anamorelin significantly increased LBM and improved anorexia symptoms and the nutritional state, but not motor function, in Japanese patients with advanced NSCLC. Because no effective treatment for cancer cachexia is currently available, anamorelin can be a beneficial treatment option. Cancer 2018;124:606-16. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

The Effect of Nutrition Therapy and Exercise on Cancer-Related Fatigue and Quality of Life in Men with Prostate Cancer: A Systematic Review

Background: Improvements in diet and/or exercise are often advocated during prostate cancer treatment, yet the efficacy of, and optimal nutrition and exercise prescription for managing cancer-related fatigue and quality of life remains elusive. The aim of this study is to systematically review the effects of nutrition and/or exercise on cancer-related fatigue and/or quality of life. Methods: A literature search was conducted in six electronic databases. The Delphi quality assessment list was used to evaluate the methodological quality of the literature. The study characteristics and results were summarized in accordance with the review’s Population, Intervention, Control, Outcome (PICO) criteria. Results: A total of 20 articles (one diet only, two combined diet and exercise, and seventeen exercise only studies) were included in the review. Soy supplementation improved quality of life, but resulted in several adverse effects. Prescribing healthy eating guidelines with combined resistance training and aerobic exercise improved cancer-related fatigue, yet its effect on quality of life was inconclusive. Combined resistance training with aerobic exercise showed improvements in cancer-related fatigue and quality of life. In isolation, resistance training appears to be more effective in improving cancer-related fatigue and quality of life than aerobic exercise. Studies that utilised an exercise professional to supervise the exercise sessions were more likely to report improvements in both cancer-related fatigue and quality of life than those prescribing unsupervised or partially supervised sessions. Neither exercise frequency nor duration appeared to influence cancer-related fatigue or quality of life, with further research required to explore the potential dose-response effect of exercise intensity. Conclusion: Supervised moderate-hard resistance training with or without moderate-vigorous aerobic exercise appears to improve cancer-related fatigue and quality of life. Targeted physiological pathways suggest dietary intervention may alleviate cancer-related fatigue and improve quality of life, however the efficacy of nutrition management with or without exercise prescription requires further exploration.

Muscle mass as a target to reduce fatigue in patients with advanced cancer

BACKGROUND

Cancer-related fatigue (CRF) reduces quality of life and the activity level of patients with cancer. Cancer related fatigue can be reduced by exercise interventions that may concurrently increase muscle mass. We hypothesized that low muscle mass is directly related to higher CRF.

METHODS

A total of 233 patients with advanced cancer starting palliative chemotherapy for lung, colorectal, breast, or prostate cancer were studied. The skeletal muscle index (SMI) was calculated as the patient's muscle mass on level L3 or T4 of a computed tomography scan, adjusted for height. Fatigue was assessed with the Functional Assessment of Chronic Illness Therapy-fatigue questionnaire (cut-off for fatigue <34). Multiple linear regression analyses were conducted to study the association between SMI and CRF adjusting for relevant confounders.

RESULTS

In this group of patients with advanced cancer, the median fatigue score was 36 (interquartile range 26-44). A higher SMI on level L3 was significantly associated with less CRF for men (B 0.447, P 0.004) but not for women (B - 0.401, P 0.090). No association between SMI on level T4 and the Functional Assessment of Chronic Illness Therapy-fatigue score was found (n = 82).

CONCLUSIONS

The association between SMI and CRF may lead to the suggestion that male patients may be able to reduce fatigue by exercise interventions aiming at an increased muscle mass. In women with advanced cancer, CRF is more influenced by other causes, because it is not significantly related to muscle mass. To further reduce CRF in both men and women with cancer, multifactorial assessments need to be performed in order to develop effective treatment strategies.

The problem of fatigue in patients suffering from neoplastic disease

Modern therapeutic management of patients with cancer is associated with many adverse side effects, including fatigue defined as weariness, burnout, lassitude, malaise, apathy, impatience, and/or inability to perform daily activities. It occurs frequently before the diagnosis of cancer and may persist for a long time after the end of cancer therapy. It is a common problem that occurs regardless of the type of cancer and applied therapeutic procedure. The appearance of this symptom significantly affects the quality of life of patients and often reduces the effectiveness of implemented treatment. The symptom of fatigue occurs among approximately 80% of patients treated with chemotherapy and/or radiotherapy, as well as among more than 75% of patients with metastatic disease. Causes of fatigue include metabolic and immune system disorders as well as increased level of tumour necrosis factor α (TNF-α). Recent studies also indicate a significant contribution of other cytokines, especially pro-inflammatory ones, i.e. interleukin-1 (IL-1), interleukin-6 (IL-6), soluble tumour necrosis factor receptor type II (sTNF type II) and C-reactive protein (CRP). A patient reporting fatigue should be properly diagnosed and thoroughly interviewed by doctors. Patients are mostly treated non-pharmacologically (by means of physical exercise and psychotherapy) and pharmacologically (by applying methylphenidate and methylprednisolone). What is also extremely important is proper education of the patient and their closest family/friends on the symptoms, which significantly reduces anxiety and stress. On the other hand therapeutic management hinders the subjectivity of feeling and lack of standardised scales to rate symptoms.

A Single Center Survey of Health-Related Quality of Life among Acute Myeloid Leukemia Survivors in First Complete Remission

BACKGROUND

Acute myeloid leukemia (AML) is one of the most common types of leukemia in adults, but there is limited information on survivors' quality of life (QOL) after remission.

OBJECTIVE

We piloted a survey exploring patient-reported outcomes for people with AML in first complete remission (CR1) to determine whether patients felt the survey is relevant to their well-being and to summarize patient characteristics.

DESIGN/MEASUREMENTS

Cross-sectional survey of a convenience sample of AML patients in CR1 assessing QOL and functioning (European Organization for Research and Treatment of Cancer [EORTC] QLQ-C30 v 3.0), well-being (QOL-cancer survivor [QOL-CS]), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-Fatigue]), and anxiety and depression (hospital anxiety and depression scale [HADS]). The survey contained five open-ended questions.

RESULTS

Eighteen patients completed the survey. Most felt it was completely or mostly relevant (88.8%) in describing their QOL. Participants scored well on the EORTC QLQ-C30, fatigue being the most common symptom (83%).The FACIT-Fatigue mean score was 28.7 and median score was 33.5 (normal ≥30). Two scored in the abnormal range for anxiety and one for depression on the HADS. On the QOL-CS, participants scored more than 6 out of 10 in most domains, except the subscales of distress and fear.

CONCLUSIONS

The survey content and length were appropriate. Patients reported ongoing fatigue, fears of future test results, getting a second cancer, and recurrence of cancer. Survivors experience ongoing symptoms, highlighting the importance of providers performing ongoing symptom and needs assessments.

Fatigue: a distressing symptom for patients with irritable bowel syndrome

BACKGROUND

Fatigue is a frequent symptom in patients with irritable bowel syndrome (IBS), and is associated with poor quality of life. However, few studies have evaluated its impact on daily life or the perceived distress it can cause. Using a multi-methods approach, this study describes the impact and manifestations of fatigue in patients with IBS and investigates the relationship between fatigue severity and illness-related and health-promoting factors.

METHODS

A total of 160 patients with IBS completed self-reported questionnaires assessing fatigue, gastrointestinal symptoms, psychological distress, and sense of coherence. Fatigue was assessed with the Fatigue Impact Scale, which also includes structured and open-ended questions which were analyzed with a deductive qualitative analysis. Patients were classified as having severe, moderate, or mild fatigue based on frequency, distress and impact on daily life.

KEY RESULTS

The open-ended questions revealed a multidimensional impact on life. Fatigue mainly interfered with the ability to perform physical activities, work, and domestic work, and the ability to interact socially. Decreased stamina was evident, along with strategies to limit the bodily consequences of tiredness. Severe fatigue was accompanied by more severe IBS symptoms, anxiety and depression and lower sense of coherence.

CONCLUSIONS & INFERENCES

Fatigue is a distressing symptom which occurs in a sizeable proportion of patients with IBS. It affects life in a multidimensional way, with poor bodily stamina being the most prominent feature. Fatigue, along with sense of coherence, depression and anxiety, needs to be assessed, confirmed and targeted for interventions.

Cancer and Cancer-Related Fatigue and the Interrelationships With Depression, Stress, and Inflammation

Cancer-related fatigue (CRF) is a common symptom experienced in cancer patients. Depression, anxiety, and stress are associated with cancer. Depression and anxiety are also associated with CRF. At the cellular level, much is known about the impact of stress on the body generally, and its potential role in cancer. Stress, anxiety, and depression have been found to depress the immune system. Depression and stress have also been found to create inflammatory changes in the body and there is emerging evidence that inflammation is involved in cancer pathogenesis and in CRF. This article examines the relationships between stress, anxiety, depression, and cancer; relationships between anxiety and depression and CRF; and what happens at the cellular level, including impact on the immune system and emerging evidence of the role of inflammation in CRF. It also reports on research in relation to some Chinese herbal medicines that may be used to treat CRF.

Unemployment Risk and Decreased Income Two and Four Years After Thyroid Cancer Diagnosis: A Population-Based Study

BACKGROUND

Thyroid cancer (TC) often occurs in relatively young patients and has a high cure rate. However, decreased psychological and physical well-being may reduce the work capability of patients with TC. This study aimed to compare the risk for unemployment and decreased income in TC survivors with a matched non-cancer group at two and four years after diagnosis. The study also aimed to predict unemployment and income changes at two and four years after diagnosis.

METHODS

A historical prospective study design was used, with cohort inception and baseline measurements drawn from the Israeli Central Bureau of Statistics 1995 National Census, with follow-up until 2011. Cancer incidence was obtained from the Israel Cancer Registry, and employment status from the Tax Authority. A matched group was sampled from the census population. Binary logistic regression analyses were used to assess odds ratios (OR) for the study outcomes, controlled for age, sex, ethnicity, education years, socioeconomic position, and employment status at two years before diagnosis.

RESULTS

In total, 417 cases of TC and 1277 non-cancer matched subjects were included in the study. People who died during the study period were excluded. The mean age at the time of cancer diagnosis was 43.5 years in the TC group and 43.8 years in the control group (p = 0.6). After adjusting for potential confounders, a positive association was found between TC and risk of unemployment two years after diagnosis (OR = 1.46 [confidence interval (CI) 1.09-1.95]), and decreased income two years after diagnosis (OR = 1.61 [CI 1.23-2.01]) and four years after diagnosis (OR = 1.63 [CI 1.25-2.13]). The association between TC and unemployment at four years after diagnosis weakened and lost significance (OR = 1.30 [CI 0.98-1.72]).

CONCLUSIONS

TC survivorship was associated with unemployment at two years and decreased income at two and four years after diagnosis. Decreased income may be a marker for a shift to part-time work rather than a return to full-time work. The findings suggest that interventions to enhance the return to full-time work are needed in this population.

A Practical Approach to Fatigue Management in Colorectal Cancer

Cancer-related fatigue is serious and complex, as well as one of the most common symptoms experienced by patients with colorectal cancer, with the potential to compromise quality of life, activities of daily living, and ultimately survival. There is a lack of consensus about the definition of cancer-related fatigue; however, definitions have been put forward by the European Association for Palliative Care (EAPC) and the National Comprehensive Cancer Network (NCCN). Numerous cancer- and treatment-related factors can contribute to fatigue, including disease progression, comorbidities, medical complications such as anemia, side effects of other medications, and a number of physical and psychologic factors. This underlines the importance of tackling factors that may contribute to fatigue before reducing the dose of treatment. NCCN guidelines and the EAPC have proposed approaches to managing fatigue in cancer patients; however, relatively few therapeutic agents have been demonstrated to reduce fatigue in randomized controlled trials. It is recognized that physical activity produces many beneficial physiologic modifications to markers of physical performance that can help to counteract various causes of fatigue. In appropriately managed and monitored patients with colorectal cancer, emerging evidence indicates that exercise programs may have a favorable influence on cancer-related fatigue, quality of life, and clinical outcomes, and therefore may help patients tolerate chemotherapy. This review assesses fatigue in patients with colorectal cancer and proposes updates to a treatment algorithm that may help clinicians manage this common problem.

Depression, Fatigue, and QoL in Colorectal Cancer Patients During and After Treatment

In this study, we sought to explore the prevalence of depression and fatigue in colorectal cancer patients during and after treatment to examine how these variables affect quality of life (QoL). In total, 170 patients with colorectal cancer participated in this study. The study population was divided into two groups: one receiving treatment and another that had finished treatment. The results showed that depression and fatigue measurements were higher in patients receiving treatment. Depression was a strong and significant predictor of QoL in both groups, whereas fatigue was not, with the exception of the symptom score. These findings underscore the importance of early detection and management of depression and fatigue during the treatment and survival stages of patients with colorectal cancer. Our findings indicate that health care professionals should provide appropriate nursing intervention to decrease depression and fatigue and enhance patient QoL.

Cancer-related fatigue shows a stable association with diurnal cortisol dysregulation in breast cancer patients

Fatigue is a major burden for breast cancer patients undergoing adjuvant therapy. Yet, its pathophysiology is still not well understood. Hypothesized mechanisms include dysregulations in the hypothalamic-pituitary-adrenal (HPA) axis, which may be reflected in alterations in the diurnal cortisol patterns. However, studies on the association between cortisol and fatigue during adjuvant cancer therapy are rare. We therefore assessed salivary cortisol at awakening, 0.5h post-awakening, noon, 5 pm and 10 pm/bedtime in 265 breast cancer patients undergoing adjuvant therapy at three timepoints. Cancer-related fatigue was assessed with the Fatigue Assessment Questionnaire (FAQ) covering the physical, affective, and cognitive fatigue dimensions. Multiple linear regression analyses were performed cross-sectionally at the three timepoints as well as longitudinally considering changes in cortisol and fatigue over time. The results showed that the physical dimension of cancer-related fatigue was significantly associated with increased evening cortisol levels and higher overall cortisol secretion. These associations were independent of depressive symptoms. Morning cortisol levels, the cortisol awakening response and the diurnal slope were not consistently associated with physical fatigue. Affective and cognitive fatigue showed no clear association with any of the cortisol parameters. In conclusion, the physical but not the affective or cognitive dimension of fatigue seems associated with cortisol dysregulations in breast cancer patients undergoing adjuvant therapy, characterized by an unaffected cortisol level in the morning but blunted decline to the evening level. Research focusing on disturbances of the cortisol rhythm and HPA dysregulations during and after cancer treatment may open new strategies to reduce cancer-related fatigue.

Vitamin D deficiency and its association with fatigue and quality of life in advanced cancer patients under palliative care: A cross-sectional study

BACKGROUND

A normal vitamin D status is required for bones and muscles to maintain their function and structure, but it also contributes to the functional integrity of other multiple physiologic systems in the body.

AIM

To assess the relationship of Vitamin D deficiency with health-related quality-of-life issues, fatigue, and physical functioning in advanced cancer patients.

DESIGN

This is a cross-sectional study.

PATIENTS/SETTINGS

Adults under palliative care, having a locally advanced or metastatic or inoperable solid cancer.

RESULTS

Among 30 patients in palliative care with advanced solid cancer, 90% were vitamin D deficient. Serum Vitamin D concentration was positively correlated with patient-reported absence of fatigue (s = 0.49), and physical and functional well-being (s = 0.44 and s = 0.41, respectively, p < 0.01). Fatigue was the symptom with the highest median impact on their lives and was the only one associated with serum vitamin D (p = 0.031), with lower fatigue in patients with vitamin D concentrations in the third tertile. There was no evidence of a direct association between health-related quality of life and vitamin D status.

CONCLUSION

The 90% frequency of advanced cancer patients with vitamin D deficiency, together with the positive correlation of vitamin D status with the absence of fatigue and improved physical and functional well-being, points to vitamin D supplementation as a potential therapy to enhance the patient's quality of life.

Randomized controlled trial of Qigong/Tai Chi Easy on cancer-related fatigue in breast cancer survivors

BACKGROUND

Many breast cancer survivors experience fatigue, mood, and sleep disturbances.

PURPOSE

This study aims to compare a meditative movement practice, Qigong/Tai Chi Easy (QG/TCE) with sham Qigong (SQG), testing effects of meditation/breath aspects of QG/TCE on breast cancer survivors' persistent fatigue and other symptoms.

METHODS

This double-blind, randomized controlled trial tested 12 weeks of QG/TCE versus SQG on fatigue, depression, and sleep among 87 postmenopausal, fatigued breast cancer survivors, stages 0-III, age 40-75.

RESULTS

Fatigue decreased significantly in the QG/TCE group compared to control at post-intervention (p = 0.005) and 3 months follow-up (p = 0.024), but not depression and sleep quality. Improvement occurred over time for both interventions in depression and sleep quality (all p < 0.05).

CONCLUSIONS

QG/TCE showed significant improvement over time compared to SQG for fatigue, but not depression or sleep. Both QG/TCE and SQG showed improvement for two prevalent symptoms among breast cancer survivors, depression and sleep dysfunction.

Psychotropic drugs for the management of cancer-related fatigue: a systematic review and meta-analysis

Cancer-related fatigue (CRF) is a common symptom affecting 60-90% of cancer survivors, and effective management for CRF is not yet available. Recently, an increasing number of trials examining the use of psychotropic drugs for the treatment of CRF have been performed, but these trials have yielded inconsistent results. Therefore, we conducted a meta-analysis aimed at assessing the effect and safety of psychotropic drugs for the management of CRF. Ten eligible trials of the psychotropic drugs methylphenidate and modafinil in a total of 1582 participants treated for CRF were subjected to statistical analyses. A meta-analysis of seven of these studies indicated that methylphenidate was superior to placebo for the treatment of CRF. Another meta-analysis of three studies evaluating modafinil found that this drug was no better than placebo. Adverse events were similar between both methylphenidate and modafinil and the placebo groups. Our meta-analysis indicated that the treatment of CRF with methylphenidate appears to be effective, whereas modafinil provides no benefit. These results of this analysis warrant further trials to confirm the efficacy and safety of psychotropic drugs for the treatment of CRF.

Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment

Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.

Correlation of post-stroke fatigue with glucose, homocysteine and functional disability

BACKGROUND

Our aim was to clarify the correlation between fatigue during the acute stage of stroke with serum glucose and homocysteine (Hcy) levels and functional disability.

MATERIALS AND METHODS

A case group of 214 patients and a control group of 214 subjects were recruited during the same period. The serum glucose, Hcy, blood lipid and fibrinogen (FIB) levels of patients were determined. Fatigue was assessed using the Fatigue Severity Scale (FSS). Patients with an FSS score ≥4 points were defined as having fatigue. Stroke severity and the level of functional disability were assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Barthel-20 Index (BI-20), respectively.

RESULTS

The incidence of fatigue in the case group was higher than that in the control group (P < 0.001). Within the case group, the fatigue group showed higher serum levels of glucose and Hcy, and a lower BI-20 score compared to the non-fatigue group (P < 0.001). Age, gender, chronic disease history, the NIHSS score and the serum blood lipid and FIB levels were not significantly different between the two groups. In the fatigue group, the serum glucose and Hcy levels showed a positive effect and the BI-20 score showed a negative effect on the FSS score (P < 0.01). Age, gender, chronic disease history, the NIHSS score and the serum blood lipid and FIB levels did not significantly affect the FSS score.

CONCLUSIONS

The serum glucose and Hcy levels and functional disability are closely related to fatigue during the acute stage of ischaemic stroke.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR CANCER SURVIVORS

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