The impact and management of cancer-related fatigue on patients and families

Treatment burden in individuals living with and beyond cancer: A systematic review of qualitative literature

BACKGROUND

Individuals with cancer are being given increasing responsibility for the self-management of their health and illness. In other chronic diseases, individuals who experience treatment burden are at risk of poorer health outcomes. Less is known about treatment burden and its impact on individuals with cancer. This systematic review investigated perceptions of treatment burden in individuals living with and beyond cancer.

METHODS AND FINDINGS

Medline, CINAHL and EMBASE databases were searched for qualitative studies that explored treatment burden in individuals with a diagnosis of breast, prostate, colorectal, or lung cancer at any stage of their diagnostic/treatment trajectory. Descriptive and thematic analyses were conducted. Study quality was assessed using a modified CASP checklist. The review protocol was registered on PROSPERO (CRD42021145601). Forty-eight studies were included. Health management after cancer involved cognitive, practical, and relational work for patients. Individuals were motivated to perform health management work to improve life-expectancy, manage symptoms, and regain a sense of normality. Performing health care work could be empowering and gave individuals a sense of control. Treatment burden occurred when there was a mismatch between the resources needed for health management and their availability. Individuals with chronic and severe symptoms, financial challenges, language barriers, and limited social support are particularly at risk of treatment burden. For those with advanced cancer, consumption of time and energy by health care work is a significant burden.

CONCLUSION

Treatment burden could be an important mediator of inequities in cancer outcomes. Many of the factors leading to treatment burden in individuals with cancer are potentially modifiable. Clinicians should consider carefully what they are asking or expecting patients to do, and the resources required, including how much patient time will be consumed.

The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis

CONTEXT

Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions.

OBJECTIVES

The aim of this review was to synthesize data on the nature of fatigue across long-term conditions.

METHODS

The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized.

RESULTS

The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized.

CONCLUSION

Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

A Qualitative Description of a Family Intervention for Breast Cancer Survivors Experiencing Fatigue

Breast cancer survivors commonly experience fatigue, but family-focused interventions as a means to reduce fatigue are understudied. This qualitative study explored the experience of adding a family component to a multimodal group intervention for fatigue. Data were collected from group observations, in-depth interviews, and debriefing sessions with the program social worker. Fourteen survivors completed the family intervention (mean age 57 years) with a family member or close friend. Four themes associated with the family intervention were identified: (a) importance of family inclusion, (b) education of family members about fatigue,

Physician perspective on incorporation of oncology patient quality-of-life, fatigue, and pain assessment into clinical practice

PURPOSE

Patient-reported outcomes (PROs) such as pain, fatigue, and quality of life (QOL) are important for morbidity and mortality in patients with cancer. Systematic approaches to collect and incorporate PROs into clinical practice are still evolving. We set out to determine the impact of PRO assessment on routine clinical practice.

METHODS

Beginning in July 2010, the symptom assessment questionnaire (SAQ) was administered to every patient in a solid tumor oncology practice at an academic center. The SAQ measures pain, fatigue, and QOL, each on a scale of 0 to 10 points. Results were available to providers before each visit in the electronic medical record. Eighteen months after the SAQ was implemented, an online survey was sent to 83 oncology care providers regarding the use of the SAQ and how it affected their clinical practice, including discussion with patients, duration of visits, and work burden.

RESULTS

A total of 53% of care providers completed the online survey, producing 44 evaluable surveys. Of these, 86% of care providers reported using information from the SAQ; > 90% of care providers indicated the SAQ did not change the length of clinic visits or contribute to increased work burden. A majority of care providers felt that the SAQ had helped or enhanced their practice. Providers endorsed the SAQ for facilitating communication with their patients.

CONCLUSION

This study indicates that simple single-item measures of pain, fatigue, and QOL can be incorporated into oncology clinical practice with positive implications for both patients and physicians without increasing duration of visits or work burden.

High prevalence of fatigue in inflammatory bowel disease: A case control study

BACKGROUND AND AIMS

Many outpatients with Inflammatory Bowel Disease (IBD) complain about fatigue, even in a quiescent disease. The aim of this study is to examine prevalence of fatigue in IBD outpatients and define possible determinants of fatigue.

METHODS

A case-control study was conducted in consecutive IBD outpatients, with Lynchsyndrome gene carriers (Lynch) as a control group. Demographics, laboratory results and Harvey Bradshaw Index (HBI) were obtained from medical records. Subjective fatigue was measured by the revised Piper Fatigue Scale (PFS). Mean PFS scores were compared between groups. Secondly, possible determinants of fatigue were assessed.

RESULTS

Three hundred patients were enrolled. 74% returned the questionnaires (117 CD; 55 UC; and 50 Lynch). Demographics were not different between groups. Mean overall PFS is 4.03. PFS score in IBD patients was significantly higher compared to Lynch. Mean (SD) PFS score was 4.8 (2.09) for CD, 4.2 (2.3) for UC versus 1.9 (2.03) for Lynch (P<0.01). Fatigue was present in 40% of the IBD patients in remission. HBI was positively, but not significantly, correlated with PFS scores (r=0.37).

CONCLUSION

We found a high prevalence of fatigue in IBD patients, compared to a control group, even in a quiescent disease. None of the studied determinants was significantly associated with fatigue.

Use of latent growth curve models for assessing the effects of darbepoetin alfa on hemoglobin and fatigue

BACKGROUND

The relationship between darbepoetin alfa and fatigue in chemotherapy-induced anemia (CIA) patients is complex because of patients receiving transfusions and the mediating effect of hemoglobin. Latent growth models (LGMs) were used to examine simultaneously relationships among drug exposure, fatigue outcomes, covariates, and mediating factors.

METHODS

Data from four CIA studies (AMG 20010145: small cell lung cancer, n=547; AMG 980297: lung cancer, n=288; AMG 20000161: lymphoproliferative malignancies, n=339; AMG 20030232: non-myeloid malignancies, n=320) were analyzed separately. Patients reported fatigue using the FACT-Fatigue. The effect of darbepoetin alfa on FACT-F changes mediated through hemoglobin changes was examined with LGMs controlling for transfusions, age, sex, baseline ECOG performance status, and health status (EQ-5D VAS). Model fit was assessed using multiple indices including the comparative fit index (CFI).

RESULTS

Darbepoetin alfa increased hemoglobin levels which were associated with decreases in fatigue. Increases in hemoglobin were statistically significantly (p<0.05) related to decreases in fatigue in the studies (AMG 20030145: beta=0.28; AMG 980297: beta=0.46; AMG 20000161: beta=0.59; and AMG 20030232: beta=0.39). Darbepoetin alfa statistically significantly increased hemoglobin (AMG 20010145:beta=0.50, AMG 980297:beta=0.53, AMG 20000161:beta=0.47, and AMG 20030232:beta=0.30) while controlling for covariates. Model fit was acceptable (CFI> or =0.89) in all studies.

CONCLUSIONS

Results indicate LGMs may be a valuable statistical method for modeling complex relationships among clinical and patient reported outcomes. A statistically significant effect of darbepoetin alfa on fatigue change through hemoglobin change occurred across four studies, after modeling the effects of transfusions, age, sex, EQ-5D VAS and ECOG.

An open-label study of the effects of bupropion SR on fatigue, depression and quality of life of mixed-site cancer patients and their partners

This preliminary study investigated whether bupropion sustained release (SR) improved symptomatic fatigue, depression and quality of life in cancer patients and caregiver quality of life. The sample consisted of a prospective open case series of 21 cancer patients, with fatigue and with or without depression at moderate to severe levels, referred for psychiatric assessment from a tertiary care cancer centre. Both patient symptom ratings and caregiver ratings were measured before and after 4 weeks of treatment with the maximally tolerated dose of bupropion in the range of 100-300 mg per day. At trial completion, significant improvement was found for symptoms of fatigue and depression. Subjects were divided into two groups: depressed and non-depressed (based on a cut-off score of 17 on the Hamilton Depression Rating Scale). Both groups reported improvement for fatigue and depressive symptoms. Depressed subjects and their caregivers did not experience any change in quality of life, while the non-depressed subjects and their caregivers reported improvements. Results from this small group of patients suggest that bupropion may have potential as an effective pharmaceutical agent for treating cancer-related fatigue. A randomized, placebo-controlled trial with this medication is indicated.

The relationship of sick leave benefits, employment patterns, and individual characteristics to radiation therapy-related fatigue

PURPOSE/OBJECTIVES

To examine the relationship among sick leave benefits, employment patterns, individual characteristics, and fatigue in patients receiving radiation therapy.

DESIGN

Prospective, longitudinal design.

SETTING

A community hospital radiation oncology department.

SAMPLE

77 patients receiving radiation therapy to the breast, chest, head and neck, pelvis, or prostate. All were employed at the time of diagnosis.

METHODS

The Piper Integrated Fatigue Model guided the study. The Revised Piper Fatigue Scale (PFS), Brief Fatigue Inventory, and a single-item scale were used to measure five dimensions of subjective fatigue. Sick leave, employment, individual characteristics, and fatigue were measured at baseline, weekly during treatment, and at one month post-treatment.

MAIN RESEARCH VARIABLES

Employment patterns, availability of sick leave benefits, and fatigue.

FINDINGS

Mean total fatigue scores on the PFS ranged from 0-4.77 at baseline (mean = 0.46, SD = 0.93), 0-8.77 at the completion of treatment (mean = 2.84, SD = 2.40), and 0-4.82 at one month post-treatment (mean = 0.77, SD = 1.20). Side effects, education, living situation, age, treatment site, and work were associated with fatigue along the trajectory of radiation therapy. Study participants who were working at the end of radiation had lower fatigue scores than those who were not. Availability of sick leave benefits was associated with employment patterns during treatment.

CONCLUSIONS

Work may have benefits during radiation therapy but may be affected by radiation therapy-related fatigue.

IMPLICATIONS FOR NURSING

Management of treatment side effects, including fatigue, may help patients remain in the workforce during radiation.

Management of cancer-related fatigue

Fatigue is among the most commonly reported symptoms of patients with cancer, with prevalence exceeding 60% in many studies. It is among the most distressing symptoms associated with cancer and cancer treatments because it substantially disturbs patients' quality of life and ability to function optimally on a daily basis. Although the development of this condition has been associated with a number of factors, its etiology remains poorly understood. Important elements to include in any definition of cancer-related fatigue include its pervasiveness, persistence, detrimental effect on quality of life, and its inability to be relieved by rest or sleep. Several validated questionnaires can be used to measure fatigue in patients with cancer, and research efforts are currently focused on ways to distinguish it from depression with which it shares many symptoms. All patients with cancer should be evaluated for fatigue, and treatment options should be considered for those who are experiencing excessive levels of fatigue. Treatment should be individualized according to the underlying pathology when a specific cause has been identified (e.g., anemia, sleep disorder, depression, or metabolic disorder). Nonspecific therapies may be useful in short- and long-term cancer-related fatigue management in many patients. In addition to older therapies, such as hematopoietics, antidepressants, corticosteroids, and psychostimulants, the effectiveness of the new wake-promoting agent modafinil is currently being studied. A more thorough evaluation of the various therapeutic options is required to better define their efficacy and safety profiles in this patient population.

Heavy to carry: a survey of parents' and healthcare professionals' perceptions of cancer-related fatigue in children and young people

Cancer-related fatigue is a prevalent, but often under-recognized, symptom with the potential to impact the lives of both the child and the family. There is little known about the biological and the behavioral dimensions of fatigue, and not about the patterns of this symptom. The aim of this study was to investigate cancer-related fatigue from the perspective of parents of children and young people with cancer and from the perspective of healthcare professionals (HCPs) and to examine its impact on quality of life. A cross-sectional, questionnaire-based survey was undertaken with parents of patients attending 4 of the 22 United Kingdom Childhood Cancer Study Group centers; HCPs from 20 of these centers were also surveyed. Response rates were 42% for parents and caregivers (95/224) and 35% for HCPs (235/679). Results showed that fatigue was prevalent. Fifty-six percent of HCPs thought "most" or "all" patients experienced moderate fatigue; 57% of parents said that the patient experienced fatigue at least once a week. Data demonstrate that fatigue was perceived to be a significant problem by parents and HCPs. Healthcare professionals indicated that the mean percentage of patients who experience fatigue, to whom they recommended a treatment, was 29%. Rest and relaxation were recommended by the majority (59%; 138). The overall impression is that both HCPs and parents acknowledge that children and young people are likely to experience fatigue. Recognition of the significance of this symptom is a crucial first step in improving future management and offering strategies that can help both child and family.

Assessing fatigue and self-care strategies in patients receiving radiotherapy for non-small cell lung cancer

Lung cancer represents a major public health problem worldwide (ISD 2000) with approximately 80% of patients presenting with locally advanced or metastatic disease. Treatment is essentially palliative; therefore, symptom management is important. This paper describes the findings from a prospective study of fatigue in newly diagnosed patients with non-small cell lung cancer. Fifty-three patients undergoing radical or high-dose palliative radiotherapy for Stage I, II and III disease were recruited to the study. Patients completed a structured health diary throughout radiotherapy and for up to 1 month post-treatment. Tape-recorded interviews were conducted with a sub-sample (n=11) to explore the nature of fatigue. Complete data sets were available on 46 patients. Consistent with current literature, the study findings demonstrated the progressive nature of this symptom throughout treatment; however, the levels of distress reported and interference with daily living were not found to be as overwhelming in this group of patients as the literature thus far suggests.