Cancer related fatigue syndrome in neoplastic diseases

The prognostic role of fatigue, depression and anxiety on postoperative outcomes after pancreatectomy for pancreatic cancer. A prospective observational study (FAT-PRO study)

OBJECTIVES

This study aims to assess the prevalence of preoperative fatigue, depression and anxiety among patients undergoing pancreatic surgery for pancreatic cancer (PC), and possible relationship with postoperative outcomes.

METHODS

Prospective data from 162 consecutive patients undergoing pancreatectomy for PC at a third-level referral centers for pancreatic surgery were collected. All patients preoperatively completed four questionnaires assessing depression (PHQ-9), anxiety (STAI-Y2), chronic illness fatigue (FACIT-F) and cancer therapy fatigue (FACT-G).

RESULTS

Forty patients (25%) where in the first quartile for chronic illness (FACIT-F ≤34) and/or cancer therapy (FACT-G ≤78) fatigue, 26 patients (16%) met the criteria for major depression (PHQ-9 ≥10) and 34 patients (21%) had anxiety symptoms (STAI-Y2 ≥40). Cancer therapy fatigue was significantly associated with higher rates of morbidity (70% vs 49%), major morbidity (Clavien-Dindo ≥3) (28% vs 11%), post-pancreatectomy hemorrhage (18% vs 4%), pulmonary complications (20% vs 9%) and mortality (8% vs null) (all P ≤ 0.01). Major depression was associated with higher rates of post-pancreatectomy hemorrhage and readmission (23% vs 5%). Multivariable logistic regression analysis of preoperative factors confirmed diabetes (OR 2.71, 95%CI 1.01-7.20; P = 0.04), ASA score ≥3 (OR 4.12, 95%CI 1.52-11.21; P < 0.01) and cancer therapy fatigue (OR 2.95, 95%CI 1.01-8.74; P = 0.04) to be independent predictors of major morbidity.

CONCLUSIONS

Higher levels of fatigue (in particular cancer therapy fatigue) strongly correlates with worse postoperative outcomes.

Commonalities in the Features of Cancer and Chronic Fatigue Syndrome (CFS): Evidence for Stress-Induced Phenotype Instability?

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and Cancer-Related Fatigue (CRF) are syndromes with considerable overlap with respect to symptoms. There have been many studies that have compared the two conditions, and some of this research suggests that the etiologies of the conditions are linked in some cases. In this narrative review, CFS/ME and cancer are introduced, along with their known and putative mechanistic connections to multiple stressors including ionizing radiation. Next, we summarize findings from the literature that suggest the involvement of HPA-axis dysfunction, the serotonergic system, cytokines and inflammation, metabolic insufficiency and mitochondrial dysfunction, and genetic changes in CRF and CFS/ME. We further suspect that the manifestation of fatigue in both diseases and its causes could indicate that CRF and CFS/ME lie on a continuum of potential biological effects which occur in response to stress. The response to this stress likely varies depending on predisposing factors such as genetic background. Finally, future research ideas are suggested with a focus on determining if common biomarkers exist in CFS/ME patients and those afflicted with CRF. Both CFS/ME and CRF are relatively heterogenous syndromes, however, it is our hope that this review assists in future research attempting to elucidate the commonalities between CRF and CFS/ME.

Effect of Exergaming on Muscle Strength, Pain, and Functionality of Shoulders in Cancer Patients

Objective: To compare the strength of the middle deltoid muscle by means of dynamometry and the Shoulder Pain and Disability Index (SPADI) in participants in treatment for cancer after the practice of an exergaming protocol. Materials and Methods: We conducted a randomized controlled clinical trial. Thirty-eight voluntary participants were divided into two groups: cancer group (n = 19; age = 61.46 ± 8.79 years; body mass index [BMI] = 28.36 ± 4.94 kg/m3) and control group (n = 19; age = 57.62 ± 7.57 years; BMI = 28.06 ± 3.74 kg/m3), and they participated in the study. All participants performed an exergame protocol by using Xbox 360 Kinect® (Microsoft, Redmond) with the game Your Shape Fitness Evolved 2012 two to three times per week for 20 sessions. They were evaluated through the isometric dynamometer in the middle deltoid muscle and the SPADI at three moments: preintervention (EV1), after 10 sessions (EV2), and after 20 sessions (EV3). Results: The cancer group scored higher on both the disability index, in all three evaluations, and the pain index, in EV2 and EV3, when compared with the control group. There was a significant reduction in the disability score in EV2 and EV3 when compared with EV1 in the cancer group, whereas pain was lower in EV2 and EV3 when compared with EV1 in the control group. There were no significant interevaluation or intergroup differences in the maximal isometric voluntary contraction of the deltoid muscle of both upper limbs. Conclusion: At the end of the exergaming, protocol reduced the disability of the shoulder joint of the cancer group and decreased the differences between the groups for disability and pain scores, without changing isometric force.

MyD88 signalling is critical in the development of pancreatic cancer cachexia

BACKGROUND

Up to 80% of pancreatic cancer patients suffer from cachexia, a devastating condition that exacerbates underlying disease, reduces quality of life, and increases treatment complications and mortality. Tumour-induced inflammation is linked to this multifactorial wasting syndrome, but mechanisms and effective treatments remain elusive. Myeloid differentiation factor (MyD88), a key component of the innate immune system, plays a pivotal role in directing the inflammatory response to various insults. In this study, we tested whether MyD88 signalling is essential in the development of pancreatic cancer cachexia using a robust mouse tumour model.

METHODS

Sex, age, and body weight-matched wide type (WT) and MyD88 knockout (MyD88 KO) mice were orthotopically or intraperitoneally implanted with a pancreatic tumour cell line from a syngeneic C57BL/6 KRAS^G12D/+ P53^R172H/+ Pdx-Cre (KPC) mouse. We observed the effects of MyD88 signalling during pancreatic ductal adenocarcinoma progression and the cachexia development through behavioural, histological, molecular, and survival aspects.

RESULTS

Blocking MyD88 signalling greatly ameliorated pancreatic ductal adenocarcinoma-associated anorexia and fatigue, attenuated lean mass loss, reduced muscle catabolism and atrophy, diminished systemic and central nervous system inflammation, and ultimately improved survival. Our data demonstrate that MyD88 signalling plays a critical role in mediating pancreatic cancer-induced inflammation that triggers cachexia development and therefore represents a promising therapeutic target.

CONCLUSIONS

MyD88-dependent inflammation is crucial in the pathophysiology of pancreatic cancer progression and contributes to high mortality. Our findings implicate the importance of innate immune signalling pathways in pancreatic cancer cachexia and a novel therapeutic target.

Effects of Exergaming in Cancer Related Fatigue in the Quality of Life and Electromyography of the Middle Deltoid of People with Cancer in Treatment: A Controlled Trial

Objective:

In the present study, we aimed to evaluate the effects an exergaming protocol for cancer patients who undergo or have already undergone cancer treatment. We sought to evaluate changes in cancer-related fatigue, function, and ability to perform daily activities, in addition to changes in the electromyographic pattern of the middle deltoid muscle.

Methods:

We conducted a controlled trial. Nineteen volunteers in the cancer group (aged 61 ± 9 years; body mass index28 ± 5) and 19 in the control group (aged 58 ± 8 years); body mass index 28 ± 4) participated in the study. They were evaluated by means of a sociodemographic and clinical questionnaire, the Functional Assessment of Chronic Therapy-Fatigue (FACIT-F) questionnaire, and surface electromyography in the deltoid muscle at three moments: before the beginning of the exergaming protocol, after 10 training sessions, and after 20 sessions. The protocol consisted of practicing exergaming using Xbox 360^® (Microsoft, Redmond, USA) with Kinect^®. The game “Your Shape Fitness Evolved” (Ubisoft, Rennes, France) was used.

Results:

Total FACIT-F scores, fatigue subscale scores, and median frequency values observed in the cancer group were lower than those in the control group. These values improved in relation to the initial evaluation in the cancer group after the practice of the exergaming protocol.

Conclusion:

The exergaming protocol used in this study was effective for reducing reported symptoms of fatigue, increasing perceived quality of life, and improving the pattern of deltoid muscle contraction in cancer patients.

Docetaxel does not impair skeletal muscle force production in a murine model of cancer chemotherapy

Chemotherapy drugs such as docetaxel are commonly used to treat cancer. Cancer patients treated with chemotherapy experience decreased physical fitness, muscle weakness and fatigue. To date, it is unclear whether these symptoms result only from cancer‐derived factors or from the combination of cancer disease and cancer treatments, such as chemotherapy. In this study, we aimed at determining the impact of chemotherapy per se on force production of hind limb muscles from healthy mice treated with docetaxel. We hypothesized that docetaxel will decrease maximal force, exacerbate the force decline during repeated contractions and impair recovery after fatiguing stimulations. We examined the function of soleus and extensor digitorum longus (EDL) muscles 24 h and 72 h after a single injection of docetaxel (acute treatment), and 7 days after the third weekly injection of docetaxel (repeated treatment). Docetaxel was administrated by intravenous injection (20 mg/kg) in female FVB/NRj mice and control mice were injected with saline solution. Our results show that neither acute nor repeated docetaxel treatment significantly alters force production during maximal contractions, repeated contractions or recovery. Only a tendency to decreased peak specific force was observed in soleus muscles 24 h after a single injection of docetaxel (−17%, P = 0.13). In conclusion, docetaxel administered intravenously does not impair force production in hind limb muscles from healthy mice. It remains to be clarified whether docetaxel, or other chemotherapy drugs, affect muscle function in subjects with cancer and whether the side effects associated with chemotherapy (neurotoxicity, central fatigue, decreased physical activity, etc.) are responsible for the experienced muscle weakness and fatigue.

Evaluation of fatigue in patients with pancreatic cancer receiving chemotherapy treatment: a cross-sectional observational study

BACKGROUND AND AIM OF THE WORK

Cancer-related fatigue (CRF) is one of the most common symptoms experienced by cancer patients (CPs) and negatively affects quality of life. Although CRF is frequently experienced, it is often underreported, underdiagnosed and undertreated. The objectives of this study were to evaluate the level of fatigue in patients with pancreatic cancer undergoing chemotherapy and to analyse its correlation with patients' demographic and clinical variables.

METHODS

A cross-sectional observational study was implemented in the Oncology Day Hospital of a Northern Italian hospital. A sample of 48 patients receiving chemotherapy were evaluated through the Brief Fatigue Inventory Italian version (BFI-I) between 1 May and 12 October 2016. Data were statistically analysed.

RESULTS

Most of our patients (94%) experienced fatigue. Women as well as patients with an age ≥65 years reported more fatigue. Anemia, pain and a weight loss of over 16 kg in the last 6 months were significantly related to the perception of fatigue. Regarding life habits, smoking was related to high global score of BFI-I.

CONCLUSIONS

In accordance with literature, our study suggests that fatigue is a frequent symptom influenced by many constitutional, clinical and environmental factors. Our results highlight the need for an early and regular evaluation of fatigue among cancer patients, in order to implement all those pharmacological and non-pharmacological interventions with proven efficacy in attenuating this symptom.

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.

Fatigue among patients with brain tumors

Fatigue is a ubiquitous and an extremely distressing symptom among patients with brain tumors (BT), particularly those with high-grade gliomas. The pathophysiology of cancer-related fatigue (CRF) in the context of patients with BT is multifactorial and complex, involving biological, behavioral, medical and social factors. The etiology of CRF in the general oncology population is pointing to the role of inflammatory cytokines as a key factor in the genesis of CRF, but this research is currently limited in the setting of BT. CRF should be screened, assessed and managed according to clinical practice guidelines. Fatigue has recently emerged as a strong, independent prognostic factor for survival that provides incremental prognostic value to the traditional markers of prognosis in recurrent high-grade gliomas. Therefore, strategies to treat fatigue warrant investigation, not only to improve the QOL of a group of patients with often limited life expectancy, but also possibly to optimize survival.

Fatigue and interleukin-6 - a multi-faceted relationship

Many connective tissue diseases are characterized by fatigue, which is described in the literature as prostration, weakness, lassitude or asthenia. In many other diseases (autoimmune, neurologic or metabolic) fatigue impinges on daily activities and thus influences the quality of life. Different molecular backgrounds are involved in the development of fatigue. Not only does the immunosuppressive treatment of autoimmune diseases reduce fatigue, but also selective nutritional components may have an effect on secretion of cytokines which are responsible for development of the sensation of tiredness (e.g. secretion of interleukin-6). The beneficial influence of selected food components (such as polyunsaturated omega-3 fatty acids, nutritional antioxidants or adequate fat intake with the diet) on proinflammatory cytokine secretion has been demonstrated in many studies. In this review, the biochemical, neurological and nutritional aspects of fatigue in autoimmune diseases are underlined.