Cancer-related fatigue: epidemiology, pathogenesis, diagnosis, and treatment

Physical exercise recommendations for patients with chronic myeloid leukemia based on individual preferences identified in a large international patient survey study of the East German Study Group for Hematology and Oncology (OSHO #97)

Background

Tyrosine kinase inhibitors (TKIs) have significantly lowered mortality of chronic myeloid leukemia (CML) patients adjusting life expectancy to that of the standard population. However, CML and its treatment with TKIs causes a high disease burden. Physical exercise (PE) could be a non-pharmacological approach to reducing these and improving quality of life.

Purpose

The aim of this study was to determine the individual disease burden as well as PE preferences of CML patients and to deduce thereof specific PE recommendations.

Methods

This multicenter survey was conducted in cooperation with the LeukaNET/Leukemia-patient network including CML patients aged ≥18 years (German Registry of Clinical Trials, DRKS00023698). The severity of selected symptoms was assessed using the adapted Myeloproliferative Neoplasms Symptom Assessment Form: 0 (absent), 1-30 (mild), 31-70 (moderate), or 71-100 (severe). Information about patients' PE needs and preferences depending on their motivation was recorded.

Results

A total of 212 questionnaires were analyzed (52% female, median age 54 years). The prevalence of moderate-to-severe symptoms was 49% for fatigue, 40% for musculoskeletal pain, and 37% for concentration problems. Other commonly reported symptoms included skin reactions (42%) and weight gain (24%). The proportion of overweight/obese patients was 52%. Half of all respondents requested more information regarding PE. Patients with CML preferred individual training (82%), located outdoors (71%), at home (47%), or in an indoor swimming pool (31%). Regarding the training frequency, sports-inactive patients preferred a frequency of 1-2 training sessions per week, whereas sports-active patients preferred 3-4 sessions per week (p <0.001). Sports-inactive patients preferred a training time of 15-45 minutes, while sports-active patients preferred 30-60 minutes (p = 0.002). Subsequently, PE recommendations were developed for patients with CML. Combined resistance and endurance training (moderate intensity twice per week for 30 minutes) was recommended for beginners. Obese patients should prioritize joint-relieving sports. To reduce the risk of skin reactions, direct sunlight and possibly water sports should be avoided, and UV protection should be used.

Conclusion

Counseling and motivation of CML patients to be physically active should be part of the standard of care as well as support for implementation.

Characteristics and predictors associated with cancer-related fatigue among solid and liquid tumors

PURPOSE

Cancer-related fatigue (CRF) is a devastating complication with limited recognized clinical risk factors. We examined characteristics among solid and liquid cancers utilizing Machine learning (ML) approaches for predicting CRF.

METHODS

We utilized 2017 National Inpatient Sample database and employed generalized linear models to assess the association between CRF and the outcome of burden of illness among hospitalized solid and non-solid tumors patients. And further applied lasso, ridge and Random Forest (RF) for building our linear and non-linear ML models.

RESULTS

The 2017 database included 196,330 prostate (PCa), 66,385 leukemia (Leuk), 107,245 multiple myeloma (MM), and 41,185 cancers of lip, oral cavity and pharynx (CLOP) patients, and among them, there were 225, 140, 125 and 115 CRF patients, respectively. CRF was associated with a higher burden of illness among Leuk and MM, and higher mortality among PCa. For the PCa patients, both the test and the training data had best areas under the ROC curve [AUC = 0.91 (test) vs. 0.90 (train)] for both lasso and ridge ML. For the CLOP, this was 0.86 and 0.79 for ridge; 0.87 and 0.84 for lasso; 0.82 for both test and train for RF and for the Leuk cohort, 0.81 (test) and 0.76 (train) for both ridge and lasso.

CONCLUSION

This study provided an effective platform to assess potential risks and outcomes of CRF in patients hospitalized for the management of solid and non-solid tumors. Our study showed ML methods performed well in predicting the CRF among solid and liquid tumors.

An eHealth App (CAPABLE) Providing Symptom Monitoring, Well-Being Interventions, and Educational Material for Patients With Melanoma Treated With Immune Checkpoint Inhibitors: Protocol for an Exploratory Intervention Trial

BACKGROUND

Since treatment with immune checkpoint inhibitors (ICIs) is becoming standard therapy for patients with high-risk and advanced melanoma, an increasing number of patients experience treatment-related adverse events such as fatigue. Until now, studies have demonstrated the benefits of using eHealth tools to provide either symptom monitoring or interventions to reduce treatment-related symptoms such as fatigue. However, an eHealth tool that facilitates the combination of both symptom monitoring and symptom management in patients with melanoma treated with ICIs is still needed.

OBJECTIVE

In this pilot study, we will explore the use of the CAPABLE (Cancer Patients Better Life Experience) app in providing symptom monitoring, education, and well-being interventions on health-related quality of life (HRQoL) outcomes such as fatigue and physical functioning, as well as patients' acceptance and usability of using CAPABLE.

METHODS

This prospective, exploratory pilot study will examine changes in fatigue over time in 36 patients with stage III or IV melanoma during treatment with ICI using CAPABLE (a smartphone app and multisensory smartwatch). This cohort will be compared to a prospectively collected cohort of patients with melanoma treated with standard ICI therapy. CAPABLE will be used for a minimum of 3 and a maximum of 6 months. The primary endpoint in this study is the change in fatigue between baseline and 3 and 6 months after the start of treatment. Secondary end points include HRQoL outcomes, usability, and feasibility parameters.

RESULTS

Study inclusion started in April 2023 and is currently ongoing.

CONCLUSIONS

This pilot study will explore the effect, usability, and feasibility of CAPABLE in patients with melanoma during treatment with ICI. Adding the CAPABLE system to active treatment is hypothesized to decrease fatigue in patients with high-risk and advanced melanoma during treatment with ICIs compared to a control group receiving standard care. The Medical Ethics Committee NedMec (Amsterdam, The Netherlands) granted ethical approval for this study (reference number 22-981/NL81970.000.22).

TRIAL REGISTRATION

ClinicalTrials.gov NCT05827289; https://clinicaltrials.gov/study/NCT05827289.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49252.

Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel

Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.

Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care

Objectives

Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients.

Material and methods

A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft.

Results

The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors.

Conclusion

The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

A review of the impact of energy balance on triple-negative breast cancer

Cancer cells cannot proliferate without sufficient energy to generate biomass for rapid cell division, as well as to fuel their functions at baseline. For this reason, many recent observational and interventional studies have focused on increasing energy expenditure and/or reducing energy intake during and after cancer treatment. The impact of variance in diet composition and in exercise on cancer outcomes has been detailed extensively elsewhere and is not the primary focus of this review. Instead, in this translational, narrative review we examine studies of how energy balance impacts anticancer immune activation and outcomes in triple-negative breast cancer (TNBC). We discuss preclinical, clinical observational, and the few clinical interventional studies on energy balance in TNBC. We advocate for the implementation of clinical studies to examine how optimizing energy balance-through changes in diet and/or exercise-may optimize the response to immunotherapy in people with TNBC. It is our conviction that by taking a holistic approach that includes energy balance as a key factor to be considered during and after treatment, cancer care may be optimized, and the detrimental effects of cancer treatment and recovery on overall health may be minimized.

[Exercise tolerance and fatigue in women survivors of non-metastatic breast cancer]

BACKGROUND

Breast cancer is the most common type of cancer worldwide, and the leading cause of disability and death in young women in Latin America. One of the most common symptoms in this population is fatigue, reported by 70 to 100% of survivors.

OBJECTIVE

To describe the relationship between exercise tolerance and fatigue in women survivors of non-metastatic breast cancer.

MATERIALS AND METHODS

Cross-sectional descriptive study in 40 women between 18 and 65 years of age, from a database pertaining to a highly complex healthcare institution in the city of Cali, Colombia. The relationship between fatigue and exercise tolerance was identified using the "Functional Assessment of Cancer Therapy FACT-F" questionnaire and the 6-minute walk test (TC6M).

RESULTS

37.5% of the participants presented fatigue related to breast cancer; 33% of women presented dyspnea at the end of the TC6M, 37.5% reported having lower limb fatigue (modified Borg) and 42.5% did not reach 80% of the predicted distance in the TC6M.

CONCLUSION

A positive correlation (p 0.000) was found between fatigue and exercise tolerance in women survivors of non-metastatic breast cancer.

[Special Consultation Hour for Patients with Cancer-Related Fatigue: Study Protocol of an Observational Study of a Nationwide Health Care Structure by the Bavarian Cancer Society (BKG) in Bavaria]

Cancer-related fatigue (CRF) is a burdensome condition of persistent tiredness, weakness, and lack of energy on physical, emotional, and cognitive level. CRF occurs in the context of cancer and/or its therapy and correlates with limitations in everyday life functioning, quality of life, and survival time. Up to now, medical care in Germany is inadequate. German wide institutions are lacking, which are specialised in identifying treatable factors influencing CRF as well as in counselling of adequate, evidence-based treatments. Since 2013, the Bavarian Cancer Society (BCS) implemented a nationwide health care structure with ten psychosocial cancer counselling centers in Bavaria. At these locations, the BCS offers for cancer patients with CRF special consultation hours with well-founded diagnostic and guidance. During the conception and further development of the consultation hour, all relevant guidelines have been considered. All consultation hours are directed by physicians with oncological and psycho-oncological experience. All of them took part in an extensive CRF training. The aim of this prospective, multicentre, observational study is the evaluation of the actual state of the TF-consultation including the analyses of offer and need for TF-consultation hours, of patient-reported TF before TF-consultation and ten weeks later, of realization of the recommended interventions to reduce TF as well as the analysis of strengths and potentials for improvement of the current system. The results will help to implement a German wide care structure.

Development and external validation of a machine learning-based prediction model for the cancer-related fatigue diagnostic screening in adult cancer patients: a cross-sectional study in China

PURPOSE

Cancer-related fatigue (CRF) is the most common symptom in cancer patients and may interfere with patients' daily activities and decrease survival rate. However, the etiology of CRF has not been identified. Diagnosing CRF is challenging. Thus, our study aimed to develop a CRF prediction model in cancer patients, using data that healthcare professionals routinely obtained from electronic health records (EHRs) based on the 3P model and externally validate this model in an independent dataset collected from another hospital.

METHODS

Between April 2022 and September 2022, a cross-sectional study was conducted on adult cancer patients at two first-class tertiary hospitals in China. Data that healthcare professionals routinely obtained from electronic health records (EHRs) based on the 3P model were collected. The outcome measure was according to ICD-10 diagnostic criteria for CRF. Data from one hospital (n = 305) were used for model development and internal validation. An independent data set from another hospital (n = 260) was utilized for external validation. logistic regression, random forest (RF), Naive Bayes (NB), and extreme gradient boosting (XGBoost) were constructed and compared. The model performance was evaluated in terms of both discrimination and calibration.

RESULTS

The prevalence of CRF in the two centers was 57.9% and 56.1%, respectively. The Random Forest model achieved the highest AUC of 0.86 among the four types of classifiers in the internal validation. The AUC of RF and NB were above 0.7 in the external validation, suggesting that the models also have an acceptable generalization ability.

CONCLUSIONS

The incidence of CRF remains high and deserves more attention. The fatigue prediction model based on the 3P theory can accurately predict the risk of CRF. Nonlinear algorithms such as Random Forest and Naive Bayes are more suitable for diagnosing and evaluating symptoms.

Association Between Cancer-Related Fatigue and Falls in Patients With Myeloproliferative Neoplasms: Results of a Multicenter Cross-Sectional Survey From the East German Study Group for Hematology and Oncology (OSHO #97)

OBJECTIVE

This study retrospectively examined the association between cancer-related fatigue (CrF) and the number of falls during the last 12 months in patients with myeloproliferative neoplasms (MPNs).

METHODS

A multicenter, 1-time anonymous survey was conducted using analog and digital questionnaires. Sex-stratified multinomial logistic regression analysis was applied to investigate the association between CrF and number of falls. All analyses were adjusted for age, school education, body mass index, MPN subtype, and quality of life.

RESULTS

The final sample comprised 688 patients (mean age 57.4 ± 13.8, 62.4% women). The fall rate was 16.2% in women and 12.2% in men (P = .153). There were no differences between women and men in terms of CrF between individuals with more than 1 fall, whereas women with 1 fall had a higher CrF compared to those without a fall (RRR = 1.019; 95% CI [1.002-1.039]), respectively.

CONCLUSION

CrF increases the risk of falls in women with MPN. Physicians should evaluate and manage CrF symptoms and implement fall prevention strategies for those who are at increased risk. Further research is needed to better understand the effects of CrF on gait performance and associated fall risk.

Gender Differences in Quality of Life of Metastatic Lung Cancer Patients

Background

Gender aspects in lung cancer patients are a topic of growing interest. But little is known about gender aspects affecting the quality of life (QoL) for those with this life-threatening disease. The aim of the following study was to investigate how gender differences affect QoL in metastatic lung cancer patients.

Methods

In a prospective, multicenter study patients filled out the EORTC QLQ-C30 questionnaire and the recently updated lung cancer module QLQ-LC29 at an undefined point in time during first-line therapy. Gender differences were calculated for all QoL scores using ANCOVAs, which controlled for confounders.

Results

A total of 130 patients with metastatic lung cancer (UICC stage IV) (46 female and 84 male, mean age 66 years) were enrolled in this study by completing the questionnaires. The only significant gender difference in QoL was found regarding hair loss (mean women= 42.498, mean men=25.490, p-value= 0.010), although women received fewer chemotherapy treatments than men (women n=34, 74% and men n=68, 84%).

Conclusion

This study provides evidence that the typical cancer related gender difference effect on QoL, suggesting that men suffer less than women, cannot be found in metastatic tumor stages of lung cancer patients.

BDNF and its signaling in cancer

PURPOSE

Brain-derived neurotrophic factor (BDNF) belongs to the family of neurotrophic factors that can potentially increase cancer cell growth, survival, proliferation, anoikis, and migration by tyrosine kinase receptors TrkB and the p75NTR death receptor. The activation of BDNF/TrkB pathways leads to several downstream signaling pathways, including PI3K/Akt, Jak/STAT, PLCγ, Ras-Raf-MEK-ERK, NF-kB, and transactivation of EGFR. The current review aimed to provide an overview of the role of BDNF and its signaling in cancer.

METHODS

We searched a major medical database, PubMed, to identify eligible studies for a narrative synthesis.

RESULTS

Pathological examinations demonstrate BDNF overexpression in human cancer, notably involving the prostate, lung, breast, and underlying tissues, associated with a higher death rate and poor prognosis. Therefore, measurement of BDNF, either for identifying the disease or predicting response to therapy, can be helpful in cancer patients. Expression profiling studies have recognized the role of microRNAs (miR) in modulating BDNF/TrkB pathways, such as miR-101, miR-107, miR-134, miR-147, miR-191, miR-200a/c, miR-204, miR-206, miR-210, miR-214, miR-382, miR-496, miR-497, miR-744, and miR-10a-5p, providing a potential biological mechanism by which targeted therapies may correlate with decreased BDNF expression in cancers. Clinical studies investigating the use of agents targeting BDNF receptors and related signaling pathways and interfering with the related oncogenic effect, including Entrectinib, Larotrectinib, Cabozantinib, Repotrectinib, Lestaurtinib, and Selitrectinib, are in progress.

CONCLUSION

The aberrant signaling of BDNF is implicated in various cancers. Well-designed clinical trials are needed to clarify the BDNF role in cancer progression and target it as a therapeutic method.

The association between cancer-related fatigue and diabetes from pre-chemotherapy to 6 months post-chemotherapy

PURPOSE

To quantify the relationship between diabetes and fatigue from pre-chemotherapy to 6 months post-chemotherapy for women with breast cancer compared to women without a history of cancer (controls).

METHODS

This was a secondary analysis from a nationwide prospective longitudinal study of female patients with breast cancer undergoing chemotherapy and controls. Diabetes diagnosis (yes/no) was obtained at baseline, and cancer-related fatigue was measured using the Multidimensional Fatigue Symptom Inventory (MFSI) pre-, post-, and 6 months post-chemotherapy in patients; controls were assessed at equivalent time points. Repeated measures mixed effects models estimated the association between fatigue and diabetes controlling for cancer (yes/no), body mass index, exercise and smoking habits, baseline anxiety and depressive symptoms, menopausal status, marital status, race, and education.

RESULTS

Among 439 patients and 235 controls (52.8 ± 10.5 years old), diabetes was twice as prevalent among patients as controls (11.6% vs. 6.8%). At baseline, diabetes was associated with worse fatigue (4.1 ± 1.7 points, p = 0.017). Also, diabetes was associated with clinically meaningful worse fatigue throughout the study period among all participants (5.2 ± 1.9 points, p = 0.008) and patients alone (4.5 ± 2.0, p = 0.023). For the MFSI subdomains among patients, diabetes was associated with worse general (p = 0.005) and mental fatigue (p = 0.026).

CONCLUSIONS

Diabetes was twice as prevalent in women with breast cancer compared to controls, and diabetes was associated with more severe cancer-related fatigue in patients before and after chemotherapy and at 6 months post-chemotherapy. Interventions that address diabetes management may also help address cancer-related fatigue during chemotherapy treatment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01382082, first posted June 27, 2011.

Baduanjin’s impact on quality of life and sleep quality in breast cancer survivors receiving aromatase inhibitor therapy: a randomized controlled trial

Purpose

The aim of the current study is to investigate the impact of Baduanjin, a traditional Chinese exercise, on quality of life and sleep quality in breast cancer survivors receiving aromatase inhibitor (AI) therapy.

Methods

A total of 72 breast cancer survivors who had received AI treatment for more3 than 6 months were enrolled in the current study using non-probability consecutive sampling procedure. Participants were randomly assigned in a 1:1 ratio to a 12-week Baduanjin exercise program or to a wait-list control group. The Baduanjin exercise group performed two 90-min supervised sessions per week. The primary outcomes were changes in quality of life measured by the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 30 (EORTC QLQ-C30) and in sleep quality evaluated using the Pittsburgh Sleep Quality Index (PSQI).

Results

A total of 68 participants completed the trial (Baduanjin exercise group: n = 33; control group: n = 35). Baseline values for quality of life did not differ between groups. Both global quality of life and physical functioning scores increased significantly by 12.39 (P < 0.001) and 8.48 (P < 0.001) in the Baduanjin exercise group compared with those in the control. Overall PSQI score also decreased by 4.85 (P < 0.001) in the Baduanjin exercise group, whereas it increased by 0.34 in the control group.

Conclusion

Baduanjin exercise training led to improvement in the quality of life and sleep quality of breast cancer patients undergoing AI therapy.

Time-restricted Eating to Address Cancer-related Fatigue among Cancer Survivors: A Single-arm Pilot Study

Purpose

Cancer-related fatigue is a prevalent, debilitating condition that can persist for months or years after treatment. In a single-arm clinical trial, the feasibility and safety of a time-restricted eating (TRE) intervention were evaluated among cancer survivors, and initial estimates of within-person change in cancer-related fatigue were obtained.

Methods

Participants were 4-60 months post-cancer treatment, were experiencing fatigue (≥ 3 on a scale 0-10), and were not following TRE. TRE entailed limiting all food and beverages to a self-selected 10-h window for 14 days. Participants reported their eating window in a daily diary and completed the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Brief Fatigue Inventory (BFI), and symptom inventory pre- and post-intervention. This study was pre-registered at clinicaltrials.gov in January 2020 (NCT04243512).

Results

Participants (n=39) were 61.5 ± 12.4 years old and 1.8 ± 1.3 years post-treatment; 89.7% had had breast cancer. The intervention was feasible in that 36/39 (92.3%) of participants completed all questionnaires and daily diaries. It was also safe with no severe adverse events or rapid weight loss (average loss of 1.1 ± 2.3 pounds, p=0.008). Most adhered to TRE; 86.1% ate within a 10-h window at least 80% of the days, and the average eating window was 9.33 ± 1.05 h. Fatigue scores improved 5.3 ± 8.1 points on the FACIT-F fatigue subscale (p<0.001, effect size [ES]=0.55), 30.6 ± 35.9 points for the FACIT-F total score (p<0.001, ES=0.50), and -1.0 ± 1.7 points on the BFI (p<0.001, ES=-0.58).

Conclusion

A 10-h TRE intervention was feasible and safe among survivors, and fatigue improved with a moderate effect size after two weeks.

Limitations

This was a single-arm study, so it is possible that expectation effects were present for fatigue outcomes, independent of effects of TRE per se. However, this feasibility trial supports evaluation of TRE in randomized controlled trials to address persistent cancer-related fatigue.

[Post-COVID syndrome-Focus fatigue]

Die Weltgesundheitsorganisation (WHO) definiert Post-COVID-19(„coronavirus disease 2019“) als Zustand, der bei Personen mit einer anamnestisch wahrscheinlichen oder bestätigten SARS-CoV-2(„severe acute respiratory syndrome coronavirus type 2“)-Infektion 3 Monate nach Beginn der COVID-19-Symptome und mindestens 2 Monate andauernd vorhanden ist und durch eine alternative Diagnose nicht erklärbar ist. Kernsymptome des Post-COVID-Syndroms umfassen Atemnot, Fatigue und kognitive Dysfunktion, welche das alltägliche Funktionsniveau beeinflussen. Neuropsychiatrische Spätfolgen sind bei COVID-19-Patienten mit Inzidenzraten von über 30 % häufig. Neben den genannten Kernsymptomen zeigen Schlafstörungen, Depression und Angsterkrankungen erhöhte Inzidenzen. Nach gegenwärtiger Meinung werden assoziierte neuropsychiatrische Symptome sowohl unter dem Begriff Post-COVID-Syndrom subsumiert, aber auch als Komorbiditäten interpretiert, welche die Manifestation eines Post-COVID-Syndroms begünstigen können. So zeigt das Kernsymptom Fatigue Symptomüberlappung und Komorbidität mit psychischen Erkrankungen. Bildgebungsstudien deuten auf ein organisches Korrelat der Fatigue bei Post-COVID-Patienten hin, darüber hinaus wurden psychosoziale Aspekte und psychiatrische Komorbiditäten wie Depression und Angsterkrankungen als modulierende und damit potenziell behandelbare Faktoren identifiziert. Die Therapie der Fatigue umfasst neben dem pharmakologischen Management mit u. a. Stimulanzien und Antidepressiva auch nichtpharmakologische Strategien, hier vor allem die kognitive Verhaltenstherapie sowie körper- und bewegungsfokussierte Interventionen. Die Evidenz hierfür erwächst aus Metaanalysen bei tumorassoziierter oder postviraler Fatigue.

Serum carotenoids and cancer-related fatigue: An analysis of the 2005-2006 National Health and Nutrition Examination Survey

Cancer-related fatigue is a prevalent, debilitating condition, and preliminary evidence suggests a relationship between higher diet quality and lower fatigue. Serum-based carotenoids, Vitamin A, and Vitamin E are biomarkers of fruit and vegetable intake and therefore diet quality. To further elucidate the link between diet quality and cancer-related fatigue, associations were assessed between these serum-based nutrients and fatigue among American adults with special attention to cancer history. Data were analyzed from the United States 2005-2006 National Health and Nutrition Examination Survey (NHANES) dataset. Ten carotenoids, vitamin A, vitamin E, and γ-tocopherol were measured from fasting blood samples and fatigue was patient-reported. Associations between carotenoid concentration and fatigue were estimated using ordinal logistic regression models. Adjusted models included a diagnosis of cancer (with the exception on non-melanoma skin cancer, yes/no), age, body mass index, race/ethnicity, education, and exercise habits as covariates, and additional models included a cancer×nutrient interaction. Of 4091 participants, 272 (8.0%) reported a history of cancer. Greater fatigue was associated with lower serum trans-lycopene, retinyl palmitate, and retinyl stearate (all p<0.05) in separate models adjusting for potential confounders. For these nutrients, a one-standard deviation increase in nutrient was associated with a 6.8-9.9% lower risk of greater fatigue. Among cancer survivors only (n=272), statistically significant associations were not observed between any of the nutrients and fatigue. In conclusion, greater serum concentrations of carotenoid biomarkers were associated with less fatigue. These results support further exploration into relationships between carotenoid intake, diet quality, and persistent fatigue.

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.

Fatigue and Its Related Factors Among Iranian Cancer Survivors

Introduction: Cancer-related fatigue (CRF) is one of the major problems experienced by cancer patients. Identifying the prevalence and factors associated with CRF may be effective in designing appropriate interventions to reduce this problem. This study aimed to examine the prevalence of CRF and its related factors among Iranian cancer survivors.

Methods: The samples of this descriptive cross-sectional study included 131 cancer survivors referred to outpatient clinic of Shahid Gazi Hospital affiliated to Tabriz University of Medical Sciences. Brief fatigue inventory (BFI) questionnaire was used for data collection. The data were analyzed using SPSS software version 13, descriptive statistics, and regression analysis.

Results: The mean (SD) fatigue score was 6.41 (1.68) and 89% of survivors reported that they had suffered from CRF. The factors affecting CRF included blood pressure, diabetes mellitus, anemia, serum levels of blood urea nitrogen (BUN), marital status, type of cancer, and physical activity.

Conclusion: High level of CRF in cancer survivors requires special attention and designing effective interventions through considering the identified factors associated with CRF.

Mechanisms, Management and Prevention of Pemetrexed-Related Toxicity

Pemetrexed is a cytostatic antifolate drug and a cornerstone in the treatment of lung cancer. Although generally well tolerated, a substantial part of the patient population experiences dose-limiting or even treatment-limiting toxicities. These include mucositis, skin problems, fatigue, renal toxicity, and neutropenia. Several studies confirmed that pemetrexed pharmacokinetics can serve as a prognostic factor for the development of toxicity, especially for neutropenia. Preventing and managing toxicity of pemetrexed can help to ensure durable treatment. Several evidence-based strategies are already implemented in clinical care. With the introduction of standard vitamin supplementation and dexamethasone, the incidence of hematological toxicity and skin reactions substantially decreased. In the case of high risk for toxicity, granulocyte colony-stimulating factor can be used to prevent severe hematological toxicity. Moreover, high-dose folinic acid can resolve severe pemetrexed-induced toxicity. There are several experimental options to prevent or manage pemetrexed-related toxicity, such as the use of standard folinic acid, hemodialysis, antidotes such as thymidine, hypoxanthine, and glucarpidase, and the use of therapeutic drug monitoring. These strategies still need clinical evaluation before implementation, but could enable treatment with pemetrexed for patients who are at risk for toxicity, such as in renal impairment.

The effect of mobile health educational intervention on body image and fatigue in breast cancer survivors: a randomized controlled trial

BACKGROUND

Cancer-related fatigue, physical changes, and pain are among the most troublesome symptoms caused by breast cancer treatment and influence the patients' quality of life. The aim of the present study was to examine the effect of mobile health educational intervention on body image and fatigue in breast cancer survivors.

METHODS

The present clinical trial study conducted on 38 women with breast cancer referred to Golestan and Shahid Baghaei 2 hospitals, Ahvaz, south west Iran in 2018-2019. Patients were randomly assigned into two intervention group, and control groups on 1:1 basis. Data collection tool included three parts: cancer fatigue scale, body image concern inventory, and demographic information. Text messages sent to intervention group via WhatsApp messenger for 7 weeks on a daily schedule. The control group did not receive any messages. Data were analyzed using SPSS Version 23.0.

RESULTS

The mean age of participants was 46.34 ± 9.96. The mean score of cancer fatigue scale after the intervention in the intervention group was decreased significantly (p = 0.005), but no statistically significant difference was observed in the control group. There was a significant difference in the mean score of body image concern inventory in the intervention group (p = 0.002) after the intervention compared with the control group.

CONCLUSION

Mobile health educational intervention improved cancer-related fatigue and body image among women breast cancer survivors. The integration of education for the management of fatigue and body image disturbance as part of routine care among breast cancer survivors is recommended.

Psychosocial Burden and Quality of Life of Lung Cancer Patients: Results of the EORTC QLQ-C30/QLQ-LC29 Questionnaire and Hornheide Screening Instrument

Background

Overall survival is the ultimate criterion for the therapy of lung cancer, but psychosocial care, which helps the patient to cope with the disease, becomes a more and more important issue in the treatment of this life-threatening disease.

Methods

We report the satellite project within a prospective, international, cross-cultural, multicenter study to validate the EORTC QLQ-LC29, a new designed module to assess the quality of life of lung cancer patients. The participants filled in the EORTC QLQ-C30, the recently updated lung cancer module QLQ-LC29 and the Hornheide questionnaire (HSI).

Results

A total of 81 patients (32 female and 49 male, mean age 65.2 years, SD = 9.7) were enrolled in this study by completing the questionnaires. Fatigue (mean 55.4, SD = 26.3) and dyspnea (mean 46.3, SD = 36.2) were the most prominent symptoms. Thirty-nine patients (48.1%) according to the HSI needed psychosocial support. When using the EORTC questionnaires as screening instrument with 50 as cut-off in contrast only 29.5% of our patients needed psychosocial support. The need for psychosocial support according to the HSI correlated most with the EORTC scales “fatigue” (38.3% overlap between the two questionnaires), “existential fear” (38.3% overlap between the two questionnaires) and worse “global quality of life” (27.2% overlap between the two questionnaires).

Conclusion

If psychosocial distress is at the core, the HSI is a suitable instrument for quick screening. The EORTC measures help to specify impaired quality of life areas and also cover somatic symptoms that are specific for cancer patients. Once psychosocial distress has been ascertained, clinicians should be particularly aware of specific problems regarding “fatigue”, “existential fear” and diminished “global quality of life”.

Trial Registration

clinicaltrials.gov, reference number NCT02745691. Registered 20 April 2016.

Self-reported fatigue in patients with rheumatoid arthritis compared to patients with cancer: results from two large-scale studies

Fatigue is a common symptom in patients with rheumatoid arthritis (RA) and in patients with cancer (CA). The aim was to investigate the degree of fatigue in RA patients as compared to CA patients as well as potential influencing factors on RA-related fatigue. This was a retrospective analyses of two prospective cohort studies that used the EORTC QLQ-FA12 as a common instrument to assess fatigue. The cohort of RA patients was based on a nationwide survey in Germany. The cohort of CA patients was recruited in the context of an international validation field study. Multivariable ANCOVAs compared levels of fatigue between the two cohorts, also including various subgroup analyses. Regression analyses explored influencing factors on RA patients’ fatigue. Data of n = 705 RA patients and of n = 943 CA patients were available for analyses. RA patients reported significantly higher Physical Fatigue (mean difference = 7.0, 95% CI 4.2–9.7, p < 0.001) and Social Sequelae (mean difference = 7.5, 95% CI 4.7–10.2, p < 0.001). CA patients reported higher Cognitive Fatigue (mean difference = 3.5, 95% CI 1.4–5.6, p = 0.001). No differences in Emotional Fatigue (p = 0.678) and Interference with Daily Life (p = 0.098) were found. In RA patients, mental health and pain were associated with fatigue (p values < 0.001). RA patients showed a considerable level of fatigue that is comparable to and in certain cases even higher than that of CA patients. The implementation of standardized diagnostic procedures and interventions to reduce fatigue in RA patients are recommended.

Bridging the research to practice gap: a systematic scoping review of implementation of interventions for cancer-related fatigue management

BACKGROUND

Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in people with cancer. Although efficacy of interventions for CRF have been extensively investigated, less has been done to ensure successful translation into routine clinical practice. The aim of this systematic scoping review was to synthesise knowledge surrounding the implementation of CRF interventions, summarise the processes and outcomes of implementation strategies used, and identify opportunities for further research.

METHODS

PubMed, Cochrane CENTRAL, EMBASE and CINAHL databases were searched (up to December 2020). The Cochrane Effective Practice and Organisation of Care (EPOC) Group taxonomy and the RE-AIM Framework were used to guide the evaluation of implementation strategies and outcomes, respectively.

RESULTS

Six studies were included. Three used an implementation framework (PARIHS, KTA, Cullens & Adams' Implementation Guide) to guide implementation. Overall, the implementation strategies used across all studies were reported to have directly resulted in immediate changes at the clinician level (e.g., increased clinician behaviours, self-efficacy, attitudes, knowledge of CRF management). No clear relationship was found between the use of implementation models and the number or type of implementation strategies used. For outcomes, Effectiveness and Implementation were the most highly reported RE-AIM measures followed by Reach then Maintenance. Adoption was the least reported.

CONCLUSIONS

Despite the high prevalence of CRF and evidence-based interventions for managing CRF, there is limited evidence informing the sustainable implementation of these interventions. This systematic scoping review emphasises the lack of quality CRF implementation studies presently available in the literature leading to a disconnect between effective CRF interventions, routine clinical care, and cancer survivors at present. This review highlights the need for robust study designs guided by established frameworks to methodically design and evaluate the implementation of CRF management interventions in the future.

Gynecologists' attitudes toward and use of complementary and integrative medicine approaches: results of a national survey in Germany

PURPOSE

Despite patients' widespread use and acceptance of complementary and integrative medicine (IM), few data are available regarding health-care professionals' current implementation of it in clinical routine. A national survey was conducted to assess gynecologists' attitudes to and implementation of complementary and integrative treatment approaches.

METHODS

The Working Group on Integrative Medicine of the German Society of Gynecological Oncology conducted an online survey in collaboration with the German Society of Gynecology and Obstetrics (DGGG) in July 2019. A 29-item survey was sent to all DGGG members by email.

RESULTS

Questionnaires from 180 gynecologists were analyzed, of whom 61 were working office-based in private practice and 95 were employed in hospitals. Seventy percent stated that IM concepts are implemented in their routine clinical work. Most physicians reported using IM methods in gynecological oncology. The main indications for IM therapies were fatigue (n = 98), nausea and vomiting (n = 89), climacteric symptoms (n = 87), and sleep disturbances (n = 86). The most commonly recommended methods were exercise therapy (n = 86), mistletoe therapy (n = 78), and phytotherapy (n = 74). Gynecologists offering IM were more often female (P = 0.001), more often had qualifications in anthroposophic medicine (P = 0.005) or naturopathy (P = 0.019), and were more often based in large cities (P = 0.016).

CONCLUSIONS

There is strong interest in IM among gynecologists. The availability of evidence-based training in IM is increasing. Integrative therapy approaches are being implemented in clinical routine more and more, and integrative counseling services are present all over Germany. Efforts should focus on extending evidence-based knowledge of IM in both gynecology and gynecological oncology.

High-Dose Vitamin C in Advanced-Stage Cancer Patients

High-dose intravenously administered vitamin C (IVC) is widely used in cancer patients by complementary and alternative medicine practitioners. The most frequent indications for IVC therapy result from the belief in its effectiveness as a potent anti-cancer agent which additionally enhances chemosensitivity of cancer cells and reduces chemotherapy-related toxicities and fatigue intensity. In this narrative review, we decided to deal with this issue, trying to answer the question whether there is any scientific evidence supporting the rationale for application of high-dose IVC therapy in advanced-stage cancer patients. Although results obtained from preclinical studies demonstrated that millimolar ascorbate plasma concentrations achievable only after IVC administration were cytotoxic to fast-growing malignant cells and inhibited tumor growth as well as prolonged the survival of laboratory animals, such positive effects were not found in human studies with advanced-stage cancer patients. We also have not found the rationale for the use of IVC to increase the effectiveness of chemotherapy and to reduce the chemotherapy-induced toxicity in the above mentioned group. Nevertheless, in palliative care, high-dose IVC might be considered as a therapy improving the quality of life and reducing cancer-related symptoms, such as fatigue and bone pain. However, because of the absence of placebo-controlled randomized trials on IVC efficacy in advanced-stage cancer patients, the placebo effect cannot be excluded.

Effect of Tai Chi and Resistance Training on Cancer-Related Fatigue and Quality of Life in Middle-Aged and Elderly Cancer Patients

OBJECTIVE

To study the effect of Tai Chi (TC) and resistance training (RT) with different intensity on the cancer-related fatigue (CRF) and quality of life (QoL) of middle-aged and elderly cancer patients.

METHODS

Totally 120 cancer patients were enrolled and randomly assigned to 4 groups by a random number table, including TC group, high-intensity 60% one repetition maximum (1-RM) RT group (HIRT), low-intensity (30% 1-RM) RT group (LIRT) and control group, 30 patients in each group. Participants in the TC group received 24-form simplified Yang-style TC training at a frequency of 40 min per day, 3 days per week for 12 weeks. Patients in the two RT groups received 10 sessions, 6 designated movements per day, 3 days per week for 12 weeks. The 1-RM of 6 muscle groups, fat mass (FM), lean body mass (LBM), along with the scores of Brief Fatigue Inventory (BFI), QoL questionnaire for Chinese cancer patients receiving chemobiotherapy (QLQ-CCC), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9) and Pittsburgh Sleep Quality Index (PSQI) were measured before and after training. The adverse effect was also observed.

RESULTS

After 12-week intervention, patients in both TC and RT groups showed significant improvements in CRF and QLQ-CCC compared to pre-treatment (P<0.05). Compared with the LIRT and TC groups, patients in the HIRT group improved more significantly in increasing muscle strength and LBM, and reducing in FM (P<0.05). Patients in the TC group significantly increased in lower limb muscle strength compared with the LIRT group (P<0.05). In addition, patients in the TC group showed more significant improvements in scores of GAD-7, PHQ-9 and PSQI than 2 RT groups (P<0.05).

CONCLUSIONS

TC and RT, both low- and high-intensity training, can significantly increase muscle strength, reduce CRF and improve QoL in the middle-aged and elderly cancer patients. TC has a better effect than RT in terms of sleep quality and mental health. The long-term application is needed to substantiate the effect of TC as an alternative exercise in cancer patients.

Gender effects on quality of life and symptom burden in patients with lung cancer: results from a prospective, cross-cultural, multi-center study

Background

Lung cancer causes impairment of health-related quality of life (QoL), but little is known about gender aspects in QoL and symptom burden of lung cancer patients. The aim of this study was to investigate gender differences in QoL as assessed by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the updated lung cancer module.

Methods

In a prospective, international, cross-cultural, multicenter study that was undertaken to update the lung cancer-specific module EORTC QLQ-LC13, patients filled in the core questionnaire EORTC QLQ-C30 and the updated lung cancer module. Gender differences were calculated for all QoL scores using ANCOVAs that controlled for known and suspected confounders. Comparisons with historic data were drawn.

Results

A total of 200 patients (82 female and 118 male, median age 65 years) were recruited. With the exception of coughing (estimated marginal means: women 33.86 and men 43.52, P=0.022) and diarrhea (estimated marginal means: women 26.01 and men 17.93, P=0.038) there were no significant QoL gender differences. Fatigue was the most pronounced symptom in both, men and women, outpacing typical respiratory symptoms. Quite generally, our sample of lung cancer patients showed considerably worse QoL in all scores when compared to EORTC reference data (lung cancer and combined cancer diagnoses, mean differences up to 13.70 and 21.54 score points, respectively) and to a German norm reference sample (up to 35.37 score points).

Conclusions

This study adds to the literature in showing that the typical QoL gender difference effect (women doing worse than men) may not be generalizable across all patient samples.

Experiences and views of different key stakeholders on the feasibility of treating cancer-related fatigue

Background

Although cancer-related fatigue (CRF) has gained increased attention in the past decade, therapy remains a challenge. Treatment programs are more likely to be effective if the needs and interests of the persons involved are well represented. This can be achieved by stakeholder engagement.

In this paper, different key stakeholders’ experiences and views on the feasibility of treating CRF in the context of supportive care in hospital environments are analyzed.

Method

In a qualitative study with the aim of developing an integrative treatment program for CRF, a total of 22 stakeholders (6 medical oncologists, 5 nurses, 9 patients, 1 patient family member, 1 representative of the Swiss Cancer League) were interviewed either in a face-to-face (n = 12) or focus group setting (n = 2). For data analyses, the method of qualitative content analysis was used.

Results

The stakeholders referred to different contextual factors when talking about the feasibility of treating CRF in the context of supportive care in hospital environments. These included: assessment, reporting and information; treatability; attitude; infrastructure, time-management, costs and affordability; and integrative approach.

Conclusions

Key factors of a feasible treatment approach to CRF are a coherent, cost effective integrative treatment program facilitated by an interdisciplinary team of health care providers. Furthermore, the treatment approach should be patient orientated, adopting an individualized approach. The major challenges of making the integrative treatment program feasible for CRF are resources and interprofessional collaboration.

Exercise for fatigue in breast cancer patients: An umbrella review of systematic reviews

OBJECTIVE

To evaluate evidence from published systematic reviews about the effectiveness of exercise interventions on fatigue management in breast cancer patients.

METHODS

PubMed, Web of Science, the Cochrane Library, the Cumulative Index of Nursing and Allied Health (CINAHL), Embase databases, the China National Knowledge Infrastructure (CNKI), the Wanfang database, the China Biomedical Literature Database (CBM), and the VIP database were searched to identify relevant systematic reviews. The reviews which assessed exercise interventions on cancer-related fatigue (CRF) in breast cancer patients were included. Quality of evidence was evaluated by the Grade of Recommendation, Assessment, Development, and Evaluation (GRADE) tool. The Assessment of Multiple Systematic Reviews (AMSTAR) appraisal tool was used to evaluate the methodological quality of included systematic reviews.

RESULTS

Twenty-four systematic reviews met all the inclusion criteria. The overall mean score for AMSATR is 7.38 and ranged from 4 to 10 points. In addition, 21 reviews arrived at positive conclusions, which exercises could reduce CRF, and 3 obtained that exercise does not affect fatigue. As for GRADE, 8 of the reviews were graded as 'moderate', 2 of the studies were 'very low', and the others were 'low'.

CONCLUSIONS

Aerobic and resistance exercise can be regarded as beneficial to CRF in breast cancer patients, and limited evidence exists that yoga had an effect on reducing fatigue. The quality of the current systematic review is still far from satisfactory.

The Experiences of Cancer-Related Fatigue among Adult Cancer Patients: A Systematic Review

Introduction: Cancer-related fatigue (CRF) is one of the symptoms commonly experienced and it is a subjective feeling felt by cancer patients. The aim of this systematic review was to summarize how fatigue has been described from the perspective of adult cancer patients, the impact of fatigue on their quality of life, what the patient reported as contributing factors and potential coping strategies to reduce fatigue.Methods: A systematic review is in line with PRISMA guidelines. Five databases were systematically searched (Scopus, PubMed, Springerlink, ProQuest and Science Direct) from January 2009 to February 2019 for qualitative studies describing the experience of adult cancer patients using a predefined search strategy and any relevant keywords.Results: In total, 13 out of 4692 studies were included. The ages of the included patient cancer ranged from 26 to 84 years. The majority of studies used in-depth interviews and semi-structured interviews to elicit the participant’s experiences of fatigue. Four themes were identified: the perception of cancer-related fatigue, the etiology of cancer fatigue, impact and coping strategies.Conclusion: Fatigue is impactful on quality of life from the perspective of cancer patients. Future research should focus on the prospective exploration of the impact of fatigue on woman's and men's health and identifying approaches to reduce fatigue. 

American Ginseng (Panax quinquefolium L.) as a Source of Bioactive Phytochemicals with Pro-Health Properties

Panax quinquefolium L. (American Ginseng, AG) is an herb characteristic for regions of North America and Asia. Due to its beneficial properties it has been extensively investigated for decades. Nowadays, it is one of the most commonly applied medical herbs worldwide. Active compounds of AG are ginsenosides, saponins of the glycosides group that are abundant in roots, leaves, stem, and fruits of the plant. Ginsenosides are suggested to be primarily responsible for health-beneficial effects of AG. AG acts on the nervous system; it was reported to improve the cognitive function in a mouse model of Alzheimer's disease, display anxiolytic activity, and neuroprotective effects against neuronal damage resulting from ischemic stroke in animals, demonstrate anxiolytic activity, and induce neuroprotective effects against neuronal damage in ischemic stroke in animals. Administration of AG leads to inhibition of hypertrophy in heart failure by regulation of reactive oxygen species (ROS) in mice as well as depletion of cardiac contractile function in rats. It also has an anti-diabetic and anti-obesity potential as it increases insulin sensitivity and inhibits formation of adipose tissue. AG displays anti-cancer effect by induction of apoptosis of cancer cells and reducing local inflammation. It exerts antimicrobial effects against several pathogenic strains of bacteria. Therefore, AG presents a high potential to induce beneficial health effects in humans and should be further explored to formulate precise nutritional recommendations, as well as to assess its value in prevention and therapy of some disorders, including cancer.

Influence of a Multimodal and Multimodal-Aerobic Therapy Concept on Health-Related Quality of Life in Breast Cancer Survivors

CONTEXT

Cancer-related fatigue (CRF) is one of the most burdensome symptoms in breast cancer survivors (BCSs), accompanied by reduced health-related quality of life (HRQOL).

OBJECTIVES

This study investigated the influence of a multimodal therapy (MT; psychoeducation, eurythmy therapy, painting therapy, and sleep education/restriction), or a combination therapy (CT; MT plus aerobic training [AT]) on HRQOL in BCS with chronic CRF in comparison with AT alone.

METHODS

One hundred and twenty-six BCSs with CRF were included in a pragmatic comprehensive cohort study and allocated either per randomization or by preference to MT, CT, or AT. The EORTC QLQ-C30 core questionnaire was used to measure HRQOL. All analyses on HRQOL parameters were done in an explorative intention.

RESULTS

Patients were assigned to MT (n = 44), CT (n = 54), or AT (n = 28). CT was significantly superior to AT after 10 weeks of intervention (T1) in improving physical function. MT was found to have significant superiority over AT at T1 and T2 for physical functioning, emotional functioning, insomnia, and financial problems as well as role functioning, cognitive, social functioning, and fatigue 6 months later (T2).

CONCLUSION

A multimodal approach appears to be a suitable concept for BCS with chronic CRF. A confirmatory study with larger samples should demonstrate the superiority of MT and adapted CT in HRQOL compared with the current treatment AT found in these explorative analyses.

Health status among long-term breast cancer survivors suffering from higher levels of fatigue: a cross-sectional study

PURPOSE

The aims of this study were to evaluate the health status of long-term breast cancer survivors (LTBCS) suffering from higher levels of fatigue, to highlight their needs, and to establish the key points of intervention support programs.

METHODS

A cross-sectional observational study was conducted at the Sport and Health Joint University Institute (iMUDS) between September 2016 and July 2017 with 80 LTBCS that were classified into non-fatigued (≤ 3.9) or fatigued (≥ 4) according to the Piper Fatigue Scale (PFS) total score. The instruments used were the European Organization for Research and Treatment of Cancer Core 30 and its breast cancer (BC) module, the Visual Analog Scale (VAS), the Brief Pain Inventory (BPI), the Scale for Mood Assessment (EVEA), the International Fitness Scale (IFIS), and the Charlson Comorbidity Index.

RESULTS

The analysis revealed that 41.2% of LTBCS were considered moderately fatigued and showed significantly higher levels for the categories of "nausea and vomiting" (P = .005), "pain," "dyspnea" and "insomnia" (P < .001), "appetite loss" (P = .002), "financial difficulties" (P = .010), "systemic therapy side effects" (P < .001), "breast symptoms" and "arm symptoms" (P = .002), and "upset by hair loss" (P = .016). In addition, LTBCS presented significantly higher levels of pain in the affected and non-affected arm, "sadness-depression." "anxiety," "anger/hostility" (All: P < .001), and lower general physical fitness (P < .001). The rest of the variables did not show significant differences.

CONCLUSION

LTBCS suffering from higher levels of fatigue had lower QoL, higher level of pain, worse mood state, and lower physical fitness.

Self-reported fatigue following intensive care of chronically critically ill patients: a prospective cohort study

Background

Protracted treatment on intensive care unit (ICU) sets the patients at increased risk for the development of chronic critical illness (CCI). Muscular and cardio-respiratory deconditioning are common long-term sequelae, going along with a state of chronic fatigue. At present, findings regarding the frequency, long-term course, and associated factors of self-reported fatigue following ICU treatment of CCI patients are lacking.

Methods

CCI patients with the diagnosis of critical illness polyneuropathy/myopathy (CIP/CIM) were assessed at three time points. Four weeks following the discharge from ICU at acute care hospital (t1), eligibility for study participation was asserted. Self-reported fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20) via telephone contact at 3 (t2, n = 113) and 6 months (t3, n = 91) following discharge from ICU at acute care hospital.

Results

At both 3 and 6 months, nearly every second CCI patient showed clinically relevant fatigue symptoms (t2/t3: n = 53/n = 51, point prevalence rates: 46.9%/45.1%). While total fatigue scores remained stable in the whole sample, female patients showed a decrease from 3 to 6 months. The presence of a coronary heart disease, the perceived fear of dying at acute care ICU, a diagnosis of major depression, and the perceived social support were confirmed as significant correlates of fatigue at 3 months. At 6 months, male gender, the number of medical comorbidities, a diagnosis of major depression, and a prior history of anxiety disorder could be identified. A negative impact of fatigue on the perceived health-related quality of life could be ascertained.

Conclusions

Nearly every second CCI patient showed fatigue symptoms up to 6 months post-ICU. Patients at risk should be informed about fatigue, and appropriate treatment options should be offered to them.

Trial registration

The present study was registered retrospectively at the German Clinical Trials Register (date of registration: 13th of December 2011; registration number: DRKS00003386). Date of enrolment of the first participant to the present trial: 09th of November 2011.

The Relationship between Perception of Social Support and Fatigue in Patients with Cancer

Background:

Fatigue is one of the most common issues related to cancer. Social support has direct effects on health status and coping with illness. This study investigated the relationship between the perception of social support and fatigue in patients with cancer.

Materials and Methods:

This descriptive/correlational study was conducted in Omid Hospital in Isfahan, Iran in 2014. One hundred and twenty-five cancer patients receiving chemotherapy were included in the study. Study participants were selected using consecutive sampling. Data were collected using the Cancer Fatigue Scale (CFS), Perceived Social Support Scale, and a demographic characteristics questionnaire. The collected data were analyzed using descriptive and analytical statistical tests in SPSS software.

Results:

Mean (SD) of patients’ fatigue and perceived social support scores were 40.63 (11.59) out of 100 and 49.33 (7.85) out of 100, respectively. The Pearson correlation coefficient showed an inverse relationship between fatigue and social support, however, this relationship was not significant. Multiple regression test was used to detect which dimension of perceived social support was a better predictor of the reduction in fatigue score. This test showed that the best predictor was informational support (B = −0.35, p = 0.004).

Conclusions:

Results showed a negative relationship between fatigue and perceived social support in cancer patients undergoing chemotherapy. Therefore, social support interventions can help reduce fatigue.

Physical condition, nutritional status, fatigue, and quality of life in oncological out-patients

Objective:

Early detection of limited physical activity and nutritional deficiencies in cancer survivors could contribute to early treatment and preservation of quality of life. The aim of this study is to describe the association of physical condition and nutritional status with fatigue and quality of life in oncological out-patients.

Methods:

Data in this descriptive study was collected on bioelectrical impedance analysis, postural stability (stability index), body mass index, Karnofsky Index, quality of life (Short-Form 36-Item Health Survey) and fatigue (multidimensional fatigue inventory-20) in a consecutive sample of 203 oncological out-patients. Phase angle was calculated from bioelectrical impedance analysis. Values were intercorrelated and compared to appropriate standard values.

Results:

Phase angle and stability index outcomes were far below the values of a healthy population of similar age (p < 0.001). Quality of life was significantly lower than in the normal population (p < 0.001), and the level of fatigue was significantly higher (p < 0.001). Phase angle correlated with Karnofsky Index (p = 0.002) and Short-Form 36-Item Health Survey Summary physical function (p < 0.001). Furthermore, multidimensional fatigue inventory-20 scales ‘physical fatigue’ and ‘reduced activity’ were significantly associated with phase angle (p = 0.04, p = 0.005). Stability indices correlated with Short-Form 36-Item Health Survey physical function.

Conclusion:

The physical condition and the nutritional status are key components determining the individual quality of life of oncological out-patients. These variables also showed an association with the manifestation of fatigue. Results highlight the need for interdisciplinary cooperation to detect physical, nutritional and psychological deficiencies in oncological out-patients.

Developing an Integrative Treatment Program for Cancer-Related Fatigue Using Stakeholder Engagement - A Qualitative Study

Background: Although cancer-related fatigue (CRF) has gained increased attention in the past decade, it remains difficult to treat. An integrative approach combining conventional and complementary medicine interventions seems highly promising. Treatment programs are more likely to be effective if the needs and interests of the people involved are well represented. This can be achieved through stakeholder engagement. Objectives: The aim of the study was to develop an integrative CRF treatment program using stakeholder engagement and to compare it to an expert version. Method: In a qualitative study, a total of 22 stakeholders (4 oncologists, 1 radiation-oncologist, 1 psycho-oncologist, 5 nurses/nurse experts, 9 patients, 1 patient family member, 1 representative of a local Swiss Cancer League) were interviewed either face-to-face or in a focus group setting. For data analysis, qualitative content analysis was used. Results: With stakeholder engagement, the integrative CRF treatment program was adapted to usual care using a prioritizing approach and allowing more patient choice. Unlike the expert version, in which all intervention options were on the same level, the stakeholder engagement process resulted in a program with 3 different levels. The first level includes mandatory nonpharmacological interventions, the second includes nonpharmacological choice-based interventions, and the third includes pharmacological interventions for severe CRF. The resulting stakeholder based integrative CRF treatment program was implemented as clinical practice guideline at our clinic (Institute for Complementary and Integrative Medicine, University Hospital Zurich). Conclusion: Through the stakeholder engagement approach, we integrated the needs and preferences of people who are directly affected by CRF. This resulted in an integrative CRF treatment program with graded recommendations for interventions and therefore potentially greater sustainability in a usual care setting.

FORECAST - A cloud-based personalized intelligent virtual coaching platform for the well-being of cancer patients

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The challenges of cancer patients and the benefits of coaching are presented.

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Evidence of impact of coaching on the well being of cancer patients is presented.

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A cloud-based personalized intelligent virtual coaching platform for the well-being of cancer patients is proposed.

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Technology acceptance of the platform is presented, based on validation trials.

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Future work is discussed.

Well-being of cancer patients and survivors is a challenge worldwide, considering the often chronic nature of the disease. Today, a large number of initiatives, products and services are available that aim to provide strategies to face the challenge of well-being in cancer patients; nevertheless the proposed solutions are often non-sustainable, costly, unavailable to those in need, and less well-received by patients. These challenges were considered in designing FORECAST, a cloud-based personalized intelligent virtual coaching platform for improving the well-being of cancer patients. Personalized coaching for cancer patients focuses on physical, mental, and emotional concerns, which FORECAST is able to identify. Cancer patients can benefit from coaching that addresses their emotional problems, helps them focus on their goals, and supports them in coping with their disease-related stressors. Personalized coaching in FORECAST offers support, encouragement, motivation, confidence, and hope and is a valuable tool for the wellbeing of a patient.

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

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

Cancer-Related Fatigue in Post-Treatment Cancer Survivors: Theory-Based Development of a Web-Based Intervention

BACKGROUND

Cancer-related fatigue (CrF) is the most common and disruptive symptom experienced by cancer survivors. We aimed to develop a theory-based, interactive Web-based intervention designed to facilitate self-management and enhance coping with CrF following cancer treatment.

OBJECTIVE

The aim of our study was to outline the rationale, decision-making processes, methods, and findings which led to the development of a Web-based intervention to be tested in a feasibility trial. This paper outlines the process and method of development of the intervention.

METHODS

An extensive review of the literature and qualitative research was conducted to establish a therapeutic approach for this intervention, based on theory. The psychological principles used in the development process are outlined, and we also clarify hypothesized causal mechanisms. We describe decision-making processes involved in the development of the content of the intervention, input from the target patient group and stakeholders, the design of the website features, and the initial user testing of the website.

RESULTS

The cocreation of the intervention with the experts and service users allowed the design team to ensure that an acceptable intervention was developed. This evidence-based Web-based program is the first intervention of its kind based on self-regulation model theory, with the primary aim of targeting the representations of fatigue and enhancing self-management of CrF, specifically.

CONCLUSIONS

This research sought to integrate psychological theory, existing evidence of effective interventions, empirically derived principles of Web design, and the views of potential users into the systematic planning and design of the intervention of an easy-to-use website for cancer survivors.

Impact of a combined multimodal-aerobic and multimodal intervention compared to standard aerobic treatment in breast cancer survivors with chronic cancer-related fatigue - results of a three-armed pragmatic trial in a comprehensive cohort design

BACKGROUND

Cancer-related fatigue (CRF) and insomnia are major complaints in breast cancer survivors (BC). Aerobic training (AT), the standard therapy for CRF in BC, shows only minor to moderate treatment effects. Other evidence-based treatments include cognitive behavioral therapy, e.g., sleep education/restriction (SE) and mindfulness-based therapies. We investigated the effectiveness of a 10-week multimodal program (MT) consisting of SE, psycho-education, eurythmy- and painting-therapy, administered separately or in combination with AT (CT) and compared both arms to AT alone.

METHODS

In a pragmatic comprehensive cohort study BC with chronic CRF were allocated randomly or by patient preference to (a) MT, (b) CT (MT + AT) or (c) AT alone. Primary endpoint was a composite score of the Pittsburgh Sleep Quality Index and the Cancer Fatigue Scale after 10 weeks of intervention (T1); a second endpoint was a follow-up assessment 6 months later (T2). The primary hypothesis stated superiority of CT and non-inferiority of MT vs. AT at T1. A closed testing procedure preserved the global α-level. The intention-to-treat analysis included propensity scores for the mode of allocation and for the preferred treatment, respectively.

RESULTS

Altogether 126 BC were recruited: 65 were randomized and 61 allocated by preference; 105 started the intervention. Socio-demographic parameters were generally balanced at baseline. Non-inferiority of MT to AT at T1 was confirmed (p < 0.05), yet the confirmative analysis stopped as it was not possible to confirm superiority of CT vs. AT (p = 0.119). In consecutive exploratory analyses MT and CT were superior to AT at T1 and T2 (MT) or T2 alone (CT), respectively.

CONCLUSIONS

The multimodal CRF-therapy was found to be confirmatively non-inferior to standard therapy and even yielded exploratively sustained superiority. A randomized controlled trial including a larger sample size and a longer follow-up to evaluate multimodal CRF-therapy is highly warranted.

TRIAL REGISTER

DRKS-ID: DRKS00003736 . Recruitment period June 2011 to March 2013. Date of registering 19 June 2012.

Fatigue and its associated factors in liver transplant recipients in Beijing: a cross-sectional study

OBJECTIVES

Fatigue is a highly prevalent symptom experienced by patients who underwent the liver transplantation. However, the influencing factors of fatigue are poorly understood by healthcare professionals. The aim of this study was to examine the intensity, interference, duration and prevalence of fatigue in liver transplantation recipients and to explore the influencing factors of post-transplantation fatigue.

DESIGN

A cross-sectional design was used in this study.

METHODS

A convenience sample of liver transplant recipients was recruited at an outpatient transplant clinic of a general hospital in Beijing, China. Self-report survey data were provided by liver transplant recipients using the Fatigue Symptom Inventory (FSI), the Hospital Anxiety and Depression Scale (HADS), the Perceived Social Support Scale (PSSS) and the Athens Insomnia Scale (AIS). Demographic, clinical and psychosocial parameters were evaluated as fatigue influencing factors.

RESULTS

Participants (n=285) included 69 women and 216 men. Fatigue was found in 87.0% of liver transplant recipients. Mean scores of fatigue intensity items were 4.47±2.85, 1.93±1.97, 3.15±2.13 and 2.73±2.42 (most fatigue, least fatigue, average fatigue in the week prior to assessment and fatigue at the point of assessment). The mean score of fatigue interference was 2.27±2.09.The number of days fatigued in the week prior to assessment was 2.26±2.02 and the amount of time fatigued each day was 2.75±2.44. Spearman's correlation analysis showed that fatigue intensity was positively associated with anxiety, depression and insomnia (p<0.001 for all), while fatigue interference was positively associated with gender, anxiety, depression and insomnia (p<0.05 for all). In the multiple linear regression analysis, anxiety and insomnia were positively associated with fatigue intensity (p<0.001), and insomnia, depression and anxiety were positively associated with fatigue interference (p<0.001).

CONCLUSIONS

Fatigue is common in liver transplant recipients, and it is strongly associated with insomnia, anxiety and depression.

Lower brain-derived neurotrophic factor levels associated with worsening fatigue in prostate cancer patients during repeated stress from radiation therapy

OBJECTIVES

Fatigue during cancer treatment is associated with depression. Neurotrophic factors play a major role in depression and stress and might provide insight into mechanisms of fatigue. This study investigated the association between plasma concentrations of three neurotrophic factors (BDNF, brain-derived neurotrophic factor; GDNF, glial-derived neurotrophic factor; and SNAPIN, soluble N-ethylmaleimide sensitive fusion attachment receptor-associated protein) and initial fatigue intensification during external beam radiation therapy (EBRT) in euthymic non-metastatic prostate cancer men.

METHODS

Fatigue, as measured by the 13-item Functional Assessment of Cancer Therapy-Fatigue (FACT-F), and plasma neurotrophic factors were collected at baseline (prior to EBRT) and mid-EBRT. Subjects were categorized into fatigue and no fatigue groups using a > 3-point change in FACT-F scores between the two time points. Multiple linear regressions analysed the associations between fatigue and neurotrophic factors.

RESULTS

FACT-F scores of 47 subjects decreased from baseline (43.95 ± 1.3) to mid-EBRT (38.36 ± 1.5, P < 0.001), indicating worsening fatigue. SNAPIN levels were associated with fatigue scores (r_s = 0.43, P = 0.005) at baseline. A significant decrease of BDNF concentration (P = 0.008) was found in fatigued subjects during EBRT (n = 39).

CONCLUSIONS

Baseline SNAPIN and decreasing BDNF levels may influence worsening fatigue during EBRT. Further investigations are warranted to confirm their role in the pathophysiology and therapeutics of fatigue.

Different Phenotyping Approaches Lead to Dissimilar Biologic Profiles in Men With Chronic Fatigue After Radiation Therapy

CONTEXT

Cancer-related fatigue (CRF) persists months after treatment completion. Although a CRF biomarker has not yet been identified, validated self-report questionnaires are used to define and phenotype CRF in the discovery of potential biomarkers.

OBJECTIVES

The purposes of this study are to identify CRF subjects using three well-known CRF phenotyping approaches using validated self-report questionnaires and to compare the biologic profiles that are associated with each CRF phenotype.

METHODS

Fatigue in men with nonmetastatic prostate cancer receiving external beam radiation therapy was measured at baseline (T1), midpoint (T2), end point (T3), and one-year post-external beam radiation therapy (T4) using the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) and Patient Reported Outcomes Measurement Information System-Fatigue. Chronic fatigue (CF) and nonfatigue subjects were grouped based on three commonly used phenotyping approaches: 1) T4 FACT-F <43; 2) T1-T4 decline in FACT-F score ≥3 points; 3) T4 Patient Reported Outcomes Measurement Information System-Fatigue T-score >50. Differential gene expressions using whole-genome microarray analysis were compared in each of the phenotyping criterion.

RESULTS

The study enrolled 43 men, where 34%-38% had CF based on the three phenotyping approaches. Distinct gene expression patterns were observed between CF and nonfatigue subjects in each of the three CRF phenotyping approaches: 1) Approach 1 had the largest number of differentially expressed genes and 2) Approaches 2 and 3 had 40 and 21 differentially expressed genes between the fatigue groups, respectively.

CONCLUSION

The variation in genetic profiles for CRF suggests that phenotypic profiling for CRF should be carefully considered because it directly influences biomarker discovery investigations.

Effects of aerobic exercise on cancer-related fatigue: a meta-analysis of randomized controlled trials

BACKGROUND

Cancer-related fatigue (CRF) is the most commonly reported and most distressing symptom in cancer patients. Currently, there are no effective strategies for managing this condition.

OBJECTIVE

The purpose of this study is to compare the effects of aerobic exercise on CRF with the standard of care.

METHODS

A systematic search for randomized controlled trials (RCTs) was performed using the Cochrane Library, JBI Library, Embase, MEDLINE, Web of Science, China Biology Medicine (CBM), and China National Knowledge Infrastructure (CNKI). The risk of bias was critically evaluated, and data were independently extracted by two reviewers. All of the analyses were performed using Review Manager 5.

RESULTS

A total of 26 qualified studies that included 2830 participants (aerobic exercise, 1426; control, 1404) were included in the meta-analysis. Cancer patients who completed adjuvant therapy in the aerobic exercise group reported reduced CRF levels relative to patients undergoing the standard of care. Aerobic exercise had a moderate effect on CRF for patients not currently undergoing anticancer treatment. Supervised aerobic exercise, exercise for 20–30 min/session, or exercise three times/week had a small effect on CRF. Exercise for 50 min/session or exercise two sessions/week had a significant effect on patient CRF, whereas 8 weeks of exercise had a moderate effect.

CONCLUSIONS

Aerobic exercise is effective for the management of CRF, especially for patients who have completed adjuvant therapy.

IMPLICATIONS FOR PRACTICE

Cancer patients can make more informed choices regarding their cancer-related fatigue management based on the best available evidence.