Patterns of fatigue related to advanced disease and radiotherapy in patients with cancer-a comparative cross-sectional study of fatigue intensity and characteristics

Various interventions for cancer-related fatigue in patients with breast cancer: a systematic review and network meta-analysis

Purpose

To investigate the effects of various intervention approaches on cancer-related fatigue (CRF) in patients with breast cancer.

Method

Computer searches were conducted on PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), and Wanfang databases from their establishment to June 2023. Selection was made using inclusion and exclusion criteria, and 77 articles were included to compare the effects of 12 interventions on patients with breast cancer.

Results

Seventy-seven studies with 12 various interventions were examined. The network findings indicated that cognitive behavioral therapy (CBT) (SMD, -1.56; 95%CI, -3.08~-0.04), Chinese traditional exercises (CTE) (SMD, -0.85; 95%CI, -1.34~-0.36), aerobic exercise (AE) (SMD, -0.77; 95%CI, -1.09~-0.45), multimodal exercise (ME) (SMD, -0.75; 95%CI, -1.26~-0.25), music interventions (MI) (SMD, -0.74; 95%CI, -1.45~-0.03), and yoga (YG) (SMD, -0.44; 95%CI, -0.83 to -0.06) can reduce CRF more than the control group (CG). For relaxation exercises (RE) (MD, -6.69; 95%CI, -9.81~-3.57), MI (MD, -5.45; 95%CI, -7.98~-2.92), AE (MD, -4.34; 95%CI, -5.90~-2.78), ME (MD, -3.47; 95%CI, -4.95~-1.99), YG (MD, -2.07; 95%CI, -3.56~-0.57), and mindfulness training (MD, -1.68; 95%CI, -2.91~-0.46), PSQI improvement was superior to CG. In addition, for CTE (MD, 11.39; 95%CI, 4.11-18.66), YG (MD, 11.28; 95%CI, 1.63-20.93), and AE (MD, 9.34; 95%CI, 0.26~18.42), Functional Assessment of Cancer Therapy-Breast improvement was superior to CG.

Conclusion

Cognitive behavioral therapy (CBT) is the most effective measure for alleviating CRF in patients with breast cancer and Relaxation exercises (RE) is the most effective measure for improving sleep quality. In addition, Chinese traditional exercises (CTE) is the best measure for enhancing quality of life. Additional randomized controlled trials (RCTs) are expected to further investigate the efficacy and mechanisms of these interventions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023471574.

An 8-week exercise study to improve cancer treatment related fatigue and QOL among African American breast cancer patients undergoing radiation treatment: A pilot randomized clinical trial

BACKGROUND

Cancer treatment related fatigue (CTRF) is one of the most debilitating side effects of adjuvant radiation therapy (RT). Several studies have found that physical activity (PA) may be an effective intervention to decrease fatigue and enhance QOL in cancer survivors. The primary objective of the PEDLAR study is to test the feasibility of an easily administered 8-week structured moderate-intensity PA intervention, delivered concurrently with RT, in reducing CTRF and improving health-related QOL among African-American breast cancer patients. This study is also designed to provide pilot data on the acceptability and adherence of PA interventions in African-American women with breast cancer.

METHODS

It is a prospective, 2-arm, 8-week feasibility trial. Participants are randomized to either a structured, moderate-intensity aerobic training exercise regimen concurrent with radiotherapy or a control group.

RESULTS

Participants in intervention group reported high satisfaction with exercise and adherence was >75% for exercise sessions.

CONCLUSIONS

African-American breast cancer patients in a moderate-intensity 75 min/wk aerobic exercise intervention had marginally lower fatigue at 8-wk follow-up compared to baseline. The control group participants had marginally higher fatigue at 8-wk follow-up compared to baseline. Participants in the intervention group reported slightly better quality of life at 8-wk follow-up compared to baseline (P = 0.06).

Sex Differences in the Effect of Vitamin D on Fatigue in Palliative Cancer Care-A Post Hoc Analysis of the Randomized, Controlled Trial 'Palliative-D'

Simple Summary

Previous studies have shown an association between low 25-hydroxyvitamin D levels and fatigue in cancer patients. In the recently published randomized, placebo-controlled, double-blind, multicenter trial ‘Palliative-D’, the correction of vitamin D deficiency reduced opioid use and fatigue in vitamin-D-deficient cancer patients admitted to palliative care. No subgroup analyses in women and men were made in the Palliative-D study. This post hoc analysis suggests that the positive effect of vitamin D supplementation on cancer-related fatigue may be more pronounced in men than in women. The vitamin-D-induced effect on fatigue could not be explained by reduced opioid doses among the vitamin-D-treated patients. Future studies focused on analyzing sex differences in the effect of vitamin D in palliative cancer care is needed before firm conclusions can be drawn.

Abstract

In the randomized, placebo-controlled, double-blind trial ‘Palliative-D’, vitamin D treatment of 4000 IE/day for 12 weeks reduced opioid use and fatigue in vitamin-D-deficient cancer patients. In screening data from this trial, lower levels of vitamin D were associated with more fatigue in men but not in women. The aim of the present study was to investigate possible sex differences in the effect of vitamin D in patients with advanced cancer, with a specific focus on fatigue. A post hoc analysis of sex differences in patients completing the Palliative-D study (n = 150) was performed. Fatigue assessed with the Edmonton Symptom Assessment Scale (ESAS) was reduced in vitamin-D-treated men; −1.50 ESAS points (95%CI −2.57 to −0.43; p = 0.007) but not in women; −0.75 (95%CI −1.85 to 0.36; p = 0.18). Fatigue measured with EORTC QLQ-C15-PAL had a borderline significant effect in men (−0.33 (95%CI −0.67 to 0.03; p = 0.05)) but not in women (p = 0.55). The effect on fatigue measured with ESAS in men remained the same after adjustment for opioid doses (p = 0.01). In conclusion, the positive effect of the correction of vitamin D deficiency on fatigue may be more pronounced in men than in women. However, studies focused on analyzing sex differences in this context must be performed before firm conclusions can be drawn.

The Level of Distress From Fatigue Reported in the Final Two Months of Life by a Palliative Care Population: An Australian National Prospective, Consecutive Case Series

CONTEXT

Fatigue is the most commonly reported symptom in life-limiting illnesses, although not much is known about the distress it causes patients as they approach death.

OBJECTIVES

To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death.

METHODS

A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between July 1, 2013, and December 31, 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status.

RESULTS

A total of 116,604 patients from 203 specialist palliative care services were analyzed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and nonmalignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced.

CONCLUSIONS

Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.

Fatigue in Cancer Patients in Palliative Care-A Review on Pharmacological Interventions

Simple Summary

Cancer related fatigue is a common and distressing symptom for patients with cancer during and after primary treatment, and also in the palliative phase of the disease trajectory. This review focuses on the pharmacological treatment of cancer related fatigue in patients with advanced or metastatic cancer. There are few high-quality studies performed in this setting, but both methylphenidate and corticosteroids might be used to relieve fatigue.

Abstract

Fatigue is one of the most distressing symptoms experienced by cancer patients. The suggested biological mechanism for cancer related fatigue (CRF) includes immune activation triggered by tumor tissue or by anticancer treatment but other mechanisms have also been proposed. Previous large meta-analysis of interventions on fatigue focuses mostly on patients early in the disease trajectory, with only one tenth of included studies performed in palliative cohorts. The aim of this narrative review is therefore to present a background on CRF with focus on the palliative setting. A summary of recent randomized, controlled trials on pharmacological interventions on CRF in palliative care is presented, including studies on psychostimulants, corticosteroids, testosterone and melatonin. Interestingly, in several of these studies there was a positive and similar effect on fatigue in both the intervention and the placebo arm—indicating an important placebo effect for any pharmacological treatment. In addition, studies on dietary supplements and on pharmacological complementary medicines are discussed. To conclude, the evidence is still weak for using pharmacological treatments on CRF in palliative care patients—although methylphenidate and corticosteroids might be considered.

Vitamin D and Fatigue in Palliative Cancer: A Cross-Sectional Study of Sex Difference in Baseline Data from the Palliative D Cohort

Background: Fatigue is one of the most distressing symptoms in patients with advanced cancer. Previous studies have shown an association between low vitamin D levels and fatigue. Objectives: The aim of this study was to investigate the association between vitamin D levels and self-assessed fatigue in cancer patients admitted to palliative care, with focus on possible sex differences. Design: This is a cross-sectional study. Subjects: Baseline data from 530 screened patients, 265 women and 265 men, from the randomized placebo-controlled trial "Palliative-D" were analyzed. Measurements: Vitamin D status was measured as 25-hydroxyvitamin D (25-OHD) and fatigue was assessed with EORTC-QLQ-PAL15 and with Edmonton Symptom Assessment System (ESAS). Results: In men, there was a significant correlation between 25-OHD and fatigue measured with the "Tiredness question" (Q11) in EORTC-QLQ-PAL15 (p < 0.05), where higher 25-OHD levels were associated with less fatigue. No correlation between 25-OHD and fatigue was seen for women. Fatigue measured with ESAS did not show any significant association with 25-OHD levels neither in men nor in women. Conclusion: Low vitamin D levels were associated with more fatigue in men but not in women. The study underscores the importance of subgroup analysis of men and women when evaluating the effect of vitamin D in clinical trials since the effect may differ between the sexes. The ongoing "Palliative-D study" will reveal whether vitamin D supplementation may counteract fatigue in both men and women. ClinicalTrial.gov: NCT03038516.

Fear of graft rejection after heart transplantation - a nationwide cross-sectional cohort study

BACKGROUND

Cellular rejection is most common 3-6 months after heart transplantation while chronic rejection, that is, cardiac allograft vasculopathy and malignancy are the most common causes of death in heart-transplant recipients beyond the third year after transplantation. However, the heart transplantation recipient's perceived threat of graft rejection has never been explored.

AIM

The aim was to explore perceived threat of the risk of graft rejection and its relationship to psychological wellbeing, fatigue, health literacy, adherence and self-efficacy 1-5 years after heart transplantation.

METHODS

In a nationwide, cross-sectional study that constituted part of the Self-management after thoracic transplantation project, 79 heart recipients (68% men and 32% women with a mean age of 52.6 years) were investigated after one year (n=28), two years (n=17), three years (n=11), four years (n=17) and five years (n=6). The instruments used were: the Perceived Threat of the Risk of Graft Rejection, the Psychological General Well-being, Self-efficacy for Managing Chronic Disease, the Multidimensional Fatigue Inventory, the Newest Vital Sign and the Basel Assessment of Adherence to Immunosuppressive Medication Scale.

RESULTS

Twenty-eight per cent of the heart transplantation recipients perceived graft rejection as a serious threat. Intrusive anxiety was low and 37% perceived the threat of the risk of graft rejection as being beyond their control. Heart transplant recipients with high level of fatigue and low psychological well-being reported stronger intrusive anxiety and less control.

CONCLUSION

A perceived threat of the risk of graft rejection is present in the everyday lives of heart transplantation recipients and is strongly related to overall psychological well-being.

Chronic pain 1-5 years after heart transplantation-A nationwide cross-sectional cohort study

Aim

To provide a multidimensional assessment of self-reported chronic pain 1-5 years after heart transplantation and its relationship with self-reported well-being, fatigue, recovery, self-efficacy and socio-economic factors and to explore differences between heart recipients and a cohort of lung recipients.

Design

This multicentre, cross-sectional, cohort study is a part of the Swedish national Self-management after thoracic transplantation study.

Methods

Six questionnaires were distributed at the heart recipients yearly follow-up (1-5 years) at three Swedish university hospitals 2014-2017.

Results

The study group comprised of 79 heart recipients, 25 women and 54 men with a mean age of 52.68 years. Chronic pain among heart recipients was common and those not in paid employment as well as those with low psychological well-being and high general fatigue reported significantly more pain. Female heart recipients were more affected by pain. General health and vitality, general fatigue, physical fatigue and reduced activity were related to the pain intensity score.

Relevance to clinical practice

As it is the duty of the healthcare system to provide adequate pain treatment, screening for pain should be a mandatory part of long-term follow-up.

Fatigue 1–5 years after lung transplantation: A multicenter cross-sectional cohort study

The aim of this study was to investigate the prevalence of fatigue among lung recipients 1–5 years after transplantation (LuTx) and to explore its relationship to distressing symptoms such as dyspnea, sleep problems, pain, and decreased appetite, as well as psychological and transplant specific wellbeing. A cross-sectional, multicenter cohort study was conducted. A total of 117 lung recipients with a mean age of 54 years ( SD 13 years) who were due for their annual follow-up were included at 1 year ( n = 35), 2 years ( n = 28), 3 years ( n = 23), 4 years ( n = 20), and 5 years ( n = 11) after lung transplantation. Several instruments were used: the Multidimensional Fatigue Inventory, the Organ Transplant and Symptom Well-being Instrument (OTSWI), the Pain-O-Meter, and the Psychological General Well-Being Index. Overall 56% reported high or severe fatigue. The Psychological General Well-Being sum score makes the strongest contribution ( p < .0001) to explaining the variance in general fatigue (Beta –.628). The results of the study indicate that efforts both to identify fatigue and to test interventions are needed after LuTx.

Prevalence and Associated Factors of Cancer-Related Fatigue Among Cancer Patients in Eastern China

BACKGROUND

Cancer-related fatigue (CRF) is a subjective and distressing symptom, and its associated factors in developing countries remain ambiguous. The goal of this study was to determine the prevalence of and factors associated with CRF among cancer patients in China.

METHODS

This study was designed as a cross-sectional study to determine the prevalence of and factors associated with CRF among cancer patients in eastern China, regardless of their diagnoses. Data were collected by using a questionnaire survey (including demographic information and brief fatigue inventory) after informed written consent was obtained. A chi-square test was used to analyze the correlations between single categorical factors and CRF, and multiple logistic regression analysis was used to evaluate the associations of potential risk factors with the presence of CRF.

RESULTS

Out of a total population of 1,938 cancer patients, 1,749 had completed the study questionnaire; 52.07% (n = 904) reported clinically significant fatigue (score ≥4 on Brief Fatigue Inventory). Four hundred twenty-seven (48.47%) patients younger than age 58 years (the median age) and 475 (55.69%) patients age 58 years or older reported clinically significant fatigue. In multivariate analysis, higher sleep quality (p < .01) was negatively associated with CRF, whereas never engaging in physical exercise (p < .01) and higher clinical stage of cancer (p < .01) were positively associated factors that could increase the odds of CRF.

CONCLUSION

The results of this study suggest that effective management of the two changeable contributing factors of CRF may reduce CRF and thus could be used as references for CRF management.

IMPLICATIONS FOR PRACTICE

The two modifiable factors of cancer-related fatigue (CRF)-sleep disturbance and physical exercise-should be specifically assessed and managed to mitigate CRF.

An exercise trial to reduce cancer related fatigue in African American breast cancer patients undergoing radiation therapy: Design, rationale, and methods

BACKGROUND

Cancer related fatigue (CRF) is a common and debilitating side-effect of radiotherapy in breast cancer patients. Physical activity interventions can attenuate CRF but evidence in African-American women with breast cancer is lacking.

METHODS/DESIGN

The "Pedlar" Study is a prospective, 8-week structured moderate-intensity exercise intervention, delivered concurrently with radiotherapy, to reduce CRF and improve health-related quality of life among African American breast cancer patients. Forty African American women with breast cancer scheduled to receive radiation therapy at MedStar Washington Hospital Center will be randomized to one of the two trial arms: 1) a facility-based aerobic exercise utilizing a portable stationary pedal exerciser; and 2) a control group. Intervention arm participants will exercise at the hospital either before or after their radiation treatment. Assessments will be conducted at baseline, 4, and 8 weeks. The outcome variables are CRF, biomarkers of inflammation, and health-related quality of life.

DISCUSSION

The Pedlar Study will provide preliminary evidence on whether a short-term moderate-intensity exercise intervention might be effective in reducing CRF in African American women undergoing radiotherapy for breast cancer, and whether this effect is mediated by inflammation.

Self-care strategies to relieve fatigue in patients receiving radiation therapy

Despite advances in symptom management, patients commonly experience fatigue during radiation therapy (RT). Minimal research has been conducted to determine how evidence-based recommendations are put into clinical practice and used by patients to manage fatigue. The aims of the current study were to identify the self-care strategies used by patients receiving RT, explore the effectiveness of those strategies, and identify how patients learned about fatigue management. Participants reported using multiple recommended interventions to relieve fatigue. The majority of participants reported they primarily rested or slept to improve fatigue. They also reported decreasing their activity level, exercising, using stimulants and complementary therapies, and eating and drinking nutritious items. More than half of the participants reported some relief of fatigue regardless of the intervention used. The majority of participants reported that they learned how to manage their fatigue mostly through experience and trial and error. Nurses need to explore the complex dynamics of each patient's fatigue and tailor multiple evidence-based interventions to maximize each patient's functional status and quality of life. When assessing and teaching about fatigue, nurses need to explore patients' daytime activity level and daytime sleep to be sure that excessive inactivity is not contributing to fatigue.

Differences in fatigue experiences among patients with advanced cancer, cancer survivors, and the general population

CONTEXT

Fatigue is a multidimensional symptom experienced physically, cognitively, and emotionally. Research on fatigue experiences in various stages of cancer might help to elucidate the nature of cancer-related fatigue.

OBJECTIVES

To compare fatigue experiences in advanced cancer patients (ACPs), cancer survivors (CSs), and controls from the general population (GenPop).

METHODS

Sixty-three ACPs (no antitumor therapy in the last month and no options for future therapy) were matched for age, sex and diagnosis with 63 CSs (last treatment one to five years ago) and 315 controls. Fatigue was measured unidimensionally with the Numeric Rating Scale and multidimensionally with the Multidimensional Fatigue Inventory.

RESULTS

All fatigue levels (general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue) were higher in ACPs than in CSs and controls (P<0.01), whereas fatigue levels were not different between CSs and controls. NRS scores in ACPs and CSs were significantly predicted by the fatigue dimensions physical fatigue and mental fatigue only. Although physical fatigue and mental fatigue were strongly related in the GenPop, the relation was weaker in CSs and not significant in ACPs. In multivariate analyses, only physical fatigue differentiated ACPs from CSs and controls (P<0.01).

CONCLUSION

ACPs experience fatigue more intensely than CSs and controls when fatigue is measured multidimensionally. Although mental and physical dimensions of fatigue contribute to the overall experience of fatigue in both groups of cancer patients, physical fatigue best differentiated ACPs from both CSs and controls.

Validation of the Chinese version of Multidimensional Fatigue Inventory-20 in Chinese patients with cancer

GOALS OF WORK

The purpose of this research is to study the validation of the Chinese version of Multidimensional Fatigue Inventory-20 in measuring fatigue status of the patients with cancer in China.

MATERIALS AND METHODS

The original English version of the Multidimensional Fatigue Inventory-20 was translated into a Chinese version, which was applied to measure the fatigue status of cancer patients prior to commencing chemotherapy and during the last week of chemotherapy, respectively. The reliability and criterion-related validity of the Chinese version of the Multidimensional Fatigue Inventory-20 were assessed by calculating Cronbach's α and Pearson correlation coefficients. The construct validity was analyzed by employing factor analysis.

MAIN RESULTS

There were three dimensions in the Chinese version of the MFI-20, which measures the physical, mental, and spiritual fatigue of patients with cancer. All of the correlation coefficients between EORTC QLQ-C30V3.0 and MFI-20 were statistically significant (P < 0.0001). The Cronbach's α coefficient was more than 0.8 and 0.7 for total MFI-20 and for the three dimensions of the Chinese version of the MFI-20, respectively.

CONCLUSIONS

The Chinese version of the MFI-20 is a reliable and valid instrument to assess fatigue in Chinese patients with cancer.

Age- and sex-standardised prevalence rates of fatigue in a large hospital-based sample of cancer patients

BACKGROUND

The aim of this longitudinal study was to determine age- and sex-standardised prevalence rates of cancer-related fatigue in different groups of patients.

METHODS

This was a prospective study in a cohort of N=1494 cancer patients investigating fatigue at three time points t1-t3 (t1: admission to hospital, t2: discharge, t3: half a year after t1). Fatigue was measured with the Multidimensional Fatigue Inventory. Age- and sex-adjusted norms were derived from a representative community sample of N=2037, using a cutoff at the 75th percentile.

RESULTS

At admission to the hospital, 32% of the patients were classified as fatigued. At discharge, the overall prevalence rate was 40%, and at half a year after t1, prevalence was 34%. Fatigue prevalence rates differed according to tumour stage, site, age, and sex of the patients.

CONCLUSION

The prevalence rates provided by this study can be used for the planning of research and clinical routine.

Age- and sex-standardised prevalence rates of fatigue in a large hospital-based sample of cancer patients

BACKGROUND

The aim of this longitudinal study was to determine age- and sex-standardised prevalence rates of cancer-related fatigue in different groups of patients.

METHODS

This was a prospective study in a cohort of N=1494 cancer patients investigating fatigue at three time points t1-t3 (t1: admission to hospital, t2: discharge, t3: half a year after t1). Fatigue was measured with the Multidimensional Fatigue Inventory. Age- and sex-adjusted norms were derived from a representative community sample of N=2037, using a cutoff at the 75th percentile.

RESULTS

At admission to the hospital, 32% of the patients were classified as fatigued. At discharge, the overall prevalence rate was 40%, and at half a year after t1, prevalence was 34%. Fatigue prevalence rates differed according to tumour stage, site, age, and sex of the patients.

CONCLUSION

The prevalence rates provided by this study can be used for the planning of research and clinical routine.

Hope in the context of lung cancer: relationships of hope to symptoms and psychological distress

CONTEXT

Hope may be important in explaining the variability in how patients adjust to lung cancer.

OBJECTIVES

The aim of this study was to examine how hope, as conceptualized by Snyder et al., is associated with multiple indices of adjustment to lung cancer. This theoretical model of hope suggests that people with high levels of hope are able to think about the pathways to goals (pathways) and feel confident that they can pursue those pathways to reach their goals (agency).

METHODS

We hypothesized that higher levels of hope, as measured by Snyder et al.'s hope scale, would be related to lower levels of pain and other lung cancer symptoms (i.e., fatigue and cough) and lower psychological distress (i.e., depression). Participants in this study included patients with a diagnosis of lung cancer (n=51). All participants provided demographic and medical information and completed measures of hope, lung cancer symptoms, and psychological distress.

RESULTS

Data analyses found that hope was inversely associated with major symptoms of cancer (i.e., pain, fatigue, and cough) and psychological distress (i.e., depression), even after accounting for important demographic and medical variables (i.e., age and cancer stage).

CONCLUSION

The findings of this cross-sectional study highlight the potential importance of hope in understanding adjustment to lung cancer. Future longitudinal research could help reveal how hope and adjustment interact over the course of cancer survivorship.