A perfect storm and patient-provider breakdown in communication: two mechanisms underlying practice gaps in cancer-related fatigue guidelines implementation

Barriers to discussing fatigue in oncological care: a comparative study of patient perspectives after two decades

PURPOSE

Healthcare providers and oncology patients may assess fatigue differently without direct communication. This study was performed to compare patient barriers to discussing cancer-related fatigue with healthcare providers in 2002 and 2023/24 using the Polish adaptation of the Fatigue Management Barriers Questionnaire (FMBQ). The FMBQ measures the intensity of barriers in communicating with medical staff about fatigue.

METHODS

This cross-sectional study with a historical comparison utilized the FMBQ, the Chalder Fatigue Questionnaire (CFQ-PL), the Multidimensional Scale of Perceived Social Support (MSPSS), and a custom-designed questionnaire. The study was conducted at the turn of 2023 and 2024, with participants recruited during hospitalization in the preoperative period as part of their treatment process.

RESULTS

The study included 54 women with histopathologically confirmed reproductive organ malignancies (68% ovarian cancer, 28% endometrial and cervical cancer). The Polish adaptation of the FMBQ demonstrated good psychometric properties, which have been preliminarily confirmed. No significant correlations were found between barriers to communication and fatigue intensity, illness duration, or length of treatment. Two decades after the first study on barriers to discussing fatigue, these barriers persist and have intensified. This is particularly evident in concerns regarding the futility of addressing fatigue, the fear of jeopardizing cancer treatment, and the avoidance of the topic due to concerns that fatigue may signal disease progression. Additionally, patients report an increased need to maintain the image of a "good patient" by avoiding complaints, along with growing concerns about excessive medication use. The percentage of patients not asked about fatigue by medical staff has remained consistent over time (25%-33%). Present-day key barriers to discussing fatigue include the desire to limit medication intake (53%), the effort to maintain a "good patient" image (49%), the belief that fatigue is a less important issue (42%), and fears that it is either a side effect of treatment (38%) or an indicator of disease progression (36%).

CONCLUSIONS

Barriers to discussing fatigue remain a significant issue in cancer care. Addressing these barriers through education and structured communication strategies could enhance supportive care for oncology patients.

Nurses' Knowledge of Cancer-Related Fatigue and the Coverage of This Subject in Nursing Training: A Cross-Sectional Study

BACKGROUND

Although cancer-related fatigue has a major impact on daily functioning and quality of life of patients, it remains underestimated in cancer care. Nurses play a significant role in multidisciplinary approaches to fatigue care.

PURPOSE

This study was designed to investigate knowledge and attitudes among nurses regarding cancer-related fatigue and its management in daily clinical practice and training to suggest future actions for improvement.

METHODS

A cross-sectional design and an online questionnaire were used to assess nurses' perceived knowledge and self-efficacy, knowledge of guidelines and treatment options, and related coverage in education and training and to suggest how to improve training. The link to the study survey was distributed to cancer nurses working in Germany via mailing lists of randomly selected hospitals and rehabilitation centers, professional nursing associations, and social media. Data were analyzed descriptively as well as using the Mann-Whitney U test. Logistic regression analyses were conducted to identify variables linked to fatigue-related knowledge.

RESULTS

Nurses participating in the study were mainly working in certified cancer care institutions (70.1%). More than one-third of the 184 participants felt rather poorly or very poorly informed and reported low self-efficacy in counseling. Although working in certified institutions was found to increase the likelihood of accurately recalling the fatigue-related guidelines (OR = 6.24, 95% CI = [1.71, 22.74], p < .01), few of the participants in this study knew any. Despite this, the majority was aware of the empirical evidence supporting physical activity (92.4%), yoga (79.9%), psychotherapeutic interventions (76.7%), mindfulness-based interventions (69%), and exercise (60.3%). Recommendation rates were heterogeneous. Those participants working in certified institutions were more likely to know about the empirical evidence related to exercise (OR = 3.03, 95% CI = [1.49, 6.18], p < .01), which was positively associated with both recommending exercise and self-assessing one's subjective knowledge as high. Cancer-related fatigue is addressed minimally in basic nursing training and moderately (30.4%) to comprehensively (29.9%) in advanced nursing training. The participants suggested various strategies to improve related training.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Most of the participants work in certified institutions but lack guidelines-related knowledge. Nevertheless, the participants had a fairly good awareness of interventions effective in reducing fatigue. However, awareness of the empirical evidence for exercise as one of the most promising treatment options was relatively low. Based on these findings, guidelines-oriented training is needed to strengthen related knowledge, particularly regarding self-efficacy in counseling in nurses. Awareness of this frequent sequelae should be raised early during basic nursing training and be covered comprehensively in advanced oncology nursing training. In general, the role of nurses within multidisciplinary teams in fatigue care needs to be determined to enable effective collaboration.

Supporting cancer-related fatigue self-management: A conversation analytic study of nurse counsellor and cancer survivor consultations

PURPOSE

Cancer-related fatigue (CRF) is a prevalent and distressing symptom experienced by people affected by cancer. A breakdown of the clinician-patient partnership and suboptimal clinician communication has been identified as a significant barrier to implementing into clinical practice effective self-management strategies for CRF. This study examined the use and impact of communication practices employed by trained cancer nurse counsellors when providing CRF self-management support to cancer survivors.

METHODS

Interactions from 41 telehealth consultations between three nurse counsellors and 23 cancer survivors in a CRF self-management support clinic in Queensland, Australia were recorded and analysed using conversation analysis methods.

RESULTS

Analysis found that in instances where nurses established the agenda of a consultation from the outset of a session (e.g., focusing on fatigue self-management support), cancer survivors displayed clearer understandings of their self-management role, the tasks, and goals of a session; and displayed less difficulty engaging in supportive care discussions. Furthermore, clinicians used formulation practices, such as summarising dialogue, to sustain focus on fatigue during consultations, and to close discussion matters not ostensibly pertinent to fatigue self-management planning supporting the goals of the CRF SMS clinic consultations.

CONCLUSION

For supportive care sessions targeting fatigue management, clinicians should ideally focus discussion on CRF support early, by clearly introducing the agenda at the outset of the consultation while also asking for client agreement. Periodically summarising patient's talk allows clinicians to maintain a focus on matters relevant for self-management fatigue planning and provide support within the typically constrained timeframes allocated for addressing CRF.

Physicians' perspectives on cancer-related fatigue management and their suggestions for improvements in medical training: a cross-sectional survey study in Germany

PURPOSE

Contrary to guidelines, many cancer patients are not screened for cancer-related fatigue (CRF) and do not receive information or adequate treatment. As physicians play a key role in cancer therapy, their knowledge of this common sequela and perspectives on its management are of major interest.

METHODS

For an online survey, physicians working in oncology in Germany were systematically drawn from registers and invited by using institutional newsletters or colleagues. Descriptive analyses, logistic regression analysis of physicians' knowledge, and Mann‒Whitney U tests were performed.

RESULTS

Two-thirds of the 148 surveyed physicians felt (rather) well informed about CRF and capable of counseling patients. Only 32% of the sample were aware of CRF-specific guidelines. Despite of this, participants rated the scientific evidence for recommending physical activity, exercise programs, and psychotherapeutic interventions in accordance with guidelines as being mostly (very) strong. However, despite 82.4% of the physicians being (rather) aware of its evidence, only 56.1% often to almost always recommended psychotherapeutic interventions. CRF was rarely covered in medical studies and medical specialist training. The completion of advanced training for palliative care increased the likelihood of knowing guidelines (OR = 2.6, 95% CI [1.1-6.0], p < 0.05). Suggestions for improving training included the mandatory coverage of CRF in medical training or its consideration in interprofessional supportive care workshops.

CONCLUSION

Although awareness and recommendation rates were adequate for some interventions in CRF treatment (such as physical activity), there were lower recommendation rates for others, including psychotherapy. Studies are required assessing for the reasons of this knowledge-to-practice gap. Moreover, training is needed among physicians in order to enhance knowledge of CRF guidelines.

TRIAL REGISTRATION

Clinicaltrials.gov , identifier: NCT04921644. Registered in June 2021.

[Fatigue in chronic physical diseases]

The term fatigue is used to describe states of unusual tiredness and exhaustion that can occur in connection with various chronic diseases, particularly cancer, multiple sclerosis, Parkinson's disease and rheumatoid arthritis. In contrast to states of exhaustion in healthy people, fatigue is characterized by the fact that it can last for long periods, is disproportionate to previous activities and does not subside after recovery phases. Fatigue is described as a multidimensional problem that encompasses physical, emotional and cognitive aspects and is associated with a high level of subjective suffering. Depending on the severity and course of the symptoms, fatigue is associated with a severely reduced quality of life and it impairs participation and coping with everyday life. It also makes professional reintegration and reemployment more difficult. Although we cannot yet fully explain the aetiology and pathogenesis, fatigue in physical illnesses must be understood based on a multifactorial biopsychosocial model. The possibilities of diagnostics and an overview of various measures for clarifying fatigue are presented. The challenges for medical care are also outlined and advice is given on how to deal with them in everyday clinical practice.

Patient and Physician Communication in the Allogeneic Transplantation Setting: Challenges and Potential Solutions

Allogeneic hematopoietic cell transplantation is a challenging treatment characterized by multiple morbidities, the need for long-term care, and a significant mortality risk. Consequently, close patient and physician communication throughout treatment is crucial. We aimed to review the literature examining patient and physician communication around critical aspects experienced by allogeneic survivors over the transplantation trajectory, such as the informed consent process, transplantation-related morbidity (eg, psychosocial distress, cognitive dysfunction, sexuality), adherence to treatment, and the use of complementary and alternative medicine, as well as interventions and strategies to improve patient and physician communication. We found a paucity of studies examining communication on these topics. Nevertheless, there is evidence of significant communication gaps around morbidities often experienced by allogeneic survivors, such as psychosocial distress, fatigue, and sexual functioning, due to both patient and physician barriers. Similarly, there is a concern that gaps also exist when addressing the informed consent process, cognitive dysfunction, adherence to treatment, and use of complementary and alternative medicine. The use and discussion of patient-reported outcome measures as part of clinical care is associated with patient and physician satisfaction with communication and better detection and management of symptoms. Although other strategies, such as decision aids, question prompt lists, and communication skills training, have improved communication in oncology, they have not been tested in the allogeneic setting. Future research is clearly needed to examine patient and physician communication in the allogeneic transplantation setting and test strategies to improve communication during this challenging treatment.

An Ideal Intervention for Cancer-Related Fatigue: Qualitative Findings from Patients, Community Partners, and Healthcare Providers

Patients consistently rate cancer-related fatigue (CrF) as the most prevalent and debilitating symptom. CrF is an important but often neglected patient concern, partly due to barriers to implementing evidence-based interventions. This study explored what an ideal intervention for CrF would look like from the perspectives of different stakeholders and the barriers to its implementation. Three participant populations were recruited: healthcare providers (HCPs; n = 32), community support providers (CSPs; n = 14), and cancer patients (n = 16). Data were collected via nine focus groups and four semi-structured interviews. Data were coded into themes using content analysis. Two main themes emerged around addressing CrF: "It takes a village" and "This will not be easy". Participants discussed an intervention for CrF could be anywhere, offered by anyone and everyone, and provided early and frequently throughout the cancer experience and could include peer support, psychoeducation, physical activity, mind-body interventions, and interdisciplinary care. Patients, HCPs, and CSPs described several potential barriers to implementation, including patient barriers (i.e., patient variability, accessibility, online literacy, and overload of information) and systems barriers (i.e., costs, lack of HCP knowledge, system insufficiency, and time). As CrF is a common post-treatment symptom, it is imperative to offer patients adequate support to manage CrF. This study lays the groundwork for the implementation of a patient-centered intervention for CrF in Canada and possibly elsewhere.

Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update

PURPOSE

To update the ASCO guideline on the management of cancer-related fatigue (CRF) in adult survivors of cancer.

METHODS

A multidisciplinary panel of medical oncology, geriatric oncology, internal medicine, psychology, psychiatry, exercise oncology, integrative medicine, behavioral oncology, nursing, and advocacy experts was convened. Guideline development involved a systematic literature review of randomized controlled trials (RCTs) published in 2013-2023.

RESULTS

The evidence base consisted of 113 RCTs. Exercise, cognitive behavioral therapy (CBT), and mindfulness-based programs led to improvements in CRF both during and after the completion of cancer treatment. Tai chi, qigong, and American ginseng showed benefits during treatment, whereas yoga, acupressure, and moxibustion helped to manage CRF after completion of treatment. Use of other dietary supplements did not improve CRF during or after cancer treatment. In patients at the end of life, CBT and corticosteroids showed benefits. Certainty and quality of evidence were low to moderate for CRF management interventions.

RECOMMENDATIONS

Clinicians should recommend exercise, CBT, mindfulness-based programs, and tai chi or qigong to reduce the severity of fatigue during cancer treatment. Psychoeducation and American ginseng may be recommended in adults undergoing cancer treatment. For survivors after completion of treatment, clinicians should recommend exercise, CBT, and mindfulness-based programs; in particular, CBT and mindfulness-based programs have shown efficacy for managing moderate to severe fatigue after treatment. Yoga, acupressure, and moxibustion may also be recommended. Patients at the end of life may be offered CBT and corticosteroids. Clinicians should not recommend L-carnitine, antidepressants, wakefulness agents, or routinely recommend psychostimulants to manage symptoms of CRF. There is insufficient evidence to make recommendations for or against other psychosocial, integrative, or pharmacological interventions for the management of fatigue.Additional information is available at www.asco.org/survivorship-guidelines.

Development of a self-management support practice framework for addressing cancer-related fatigue: a modified Delphi study

PURPOSE

Managing cancer-related fatigue requires individuals to adopt a range of self-management behaviours. However, clinicians report the lack of clear guidance on self-management support practices hinders their provision of supportive care. To develop consensus on a framework of core practices required by health professionals to deliver effective self-management support to cancer patients and survivors experiencing cancer-related fatigue.

METHODS

A preliminary framework of 47 practice items (14 Key Practices, 33 Practice Components) was derived from a systematic review, and a self-management support capability outline for primary care professionals. This preliminary framework was presented for consensus rating and comment in a two-round modified Delphi study conducted with a panel of health professionals, research academics, and cancer consumers.

RESULTS

Fifty-two panel participants comprising consumers (n = 25), health professionals (n = 19), and researchers (n = 16) were included in Round 1 of the modified Delphi study. Feedback from the panel produced consensus on retaining 27 of 47 original practice items without change. Seventeen items (including 12 modified, and 5 newly created practice items) were sent to the panel for rating in Round 2. Thirty-six experts produced consensus on retaining all 17 practice items in Round 2. The final framework comprised 44 items (13 Key Practices, 31 Practice Components).

CONCLUSIONS

The practice framework offers an evidence- and consensus-based model of best practice for health professionals providing self-management support for cancer-related fatigue.

IMPLICATIONS FOR CANCER SURVIVORS

This framework is the first to focus on quality provision of self-management support in managing cancer-related fatigue, one of the most prevalent symptoms experienced by cancer patients and survivors.

Afraid and tired: A longitudinal study of the relationship between cancer-related fatigue and fear of cancer recurrence in long-term cancer survivors

OBJECTIVE

Cancer-related fatigue (CRF) and fear of cancer recurrence (FCR) are two common concerns experienced by cancer survivors. However, the relationship between these two concerns is poorly understood, and whether CRF and FCR influence each other over time is unclear.

METHODS

Data were from a national, prospective, longitudinal study, the American Cancer Society's Study of Cancer Survivors-I (SCS-I). Surveys were completed by 1395 survivors of 10 different cancer types at three time-points, including assessment 1.3 years (T1), 2.2 years (T2) and 8.8 years (T3) following their cancer diagnosis. CRF was assessed using the fatigue-inertia subscale of the Profile of Mood States, and FCR by the FCR subscale of the Cancer Problems in Living Scale. Multiple group random intercepts cross-lagged panel models investigated prospective associations between CRF and FCR.

RESULTS

For younger participants (at or below median age of 55 years, n = 697), CRF at T1 and T2 marginally and significantly predicted FCR at T2 and T3, respectively, but no lagged effects of FCR on subsequent CRF were observed. Cross-lagged effects were not observed for survivors over 55 years of age.

CONCLUSION

Both CRF and FCR are debilitating side effects of cancer and its treatments. Given that CRF may be predictive of FCR, it possible that early detection and intervention for CRF could contribute to lowering FCR severity.

Cancer-Related Fatigue and Circulating Biomarkers in Breast Cancer Survivors

PURPOSE

Cancer-related fatigue (CRF) is the most common and disruptive symptom experienced by cancer survivors and because of its frequency and severity is especially worrisome in breast cancer survivors (BCS). Despite a great deal of research, the mechanisms underlying CRF have not been determined. The present study aims to describe associations between CRF in BCS and different blood biomarkers.

METHODS

A descriptive and cross-sectional study was conducted. A set of biomarkers assessing inflammation were measured in BCS: C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR), IL-1β, IL-6, IL-8, IL-10, tumor necrosis factor (TNF); HPA axis dysfunction (cortisol), autonomic dysfunction (noradrenaline); oxidative stress (8-OH deoxyguanosine); insulin resistance markers (insulin, IGF-I, IGFBP3) and sexual hormones (estrogens, progesterone, testosterone).

RESULTS

NLR (p = .00) and cortisol (p = .02) were positive and negatively associated with CRF, respectively. The rest of the blood markers were not associated with CRF.

CONCLUSION

Our results increase the evidence on pathophysiological mechanisms driving CRF in BCS. However, longitudinal studies are needed to explore the role of these factors as potential causal mechanisms.

Cancer-related fatigue: Quality, credibility, usability, and readability of information on websites of health care institutions in Germany

OBJECTIVES

This study aimed to portray available information on cancer-related fatigue on German health care institution websites considering the idea of patient empowerment.

METHODS

Based on website quality criteria, we developed a website-rating tool comprising 18 items. Descriptive analyses, a KruskalWallis test, and corresponding post hoc tests comparing rating sum scores between institution groups were performed.

RESULTS

Websites of 283 systematically compiled health care institutions were included in the rating. Cancer-related fatigue was introduced on 21.9% and detailed information was provided on 27.9% of the websites. Information material was offered on 9.2% of the websites, while fatigue treatment offers were presented on 21.6% of the websites. The rating sum scores differed between institution groups (p < 0.001), with Comprehensive Cancer Centers scoring significantly higher than the others.

CONCLUSION

The rating revealed an overall sparse provision of information, with fatigue being addressed on less than half of the websites.

PRACTICE IMPLICATIONS

For patients who have access to at least one introduction about fatigue, institutions need to extend their websites. Patients could further be referred to external institutions or information booklets. The naming of contact persons may help linking patients to providers.

A qualitative analysis of algorithm-based decision support usability testing for symptom management across the trajectory of cancer care: one size does not fit all

BACKGROUND

Adults with cancer experience symptoms that change across the disease trajectory. Due to the distress and cost associated with uncontrolled symptoms, improving symptom management is an important component of quality cancer care. Clinical decision support (CDS) is a promising strategy to integrate clinical practice guideline (CPG)-based symptom management recommendations at the point of care.

METHODS

The objectives of this project were to develop and evaluate the usability of two symptom management algorithms (constipation and fatigue) across the trajectory of cancer care in patients with active disease treated in comprehensive or community cancer care settings to surveillance of cancer survivors in primary care practices. A modified ADAPTE process was used to develop algorithms based on national CPGs. Usability testing involved semi-structured interviews with clinicians from varied care settings, including comprehensive and community cancer centers, and primary care. The transcripts were analyzed with MAXQDA using Braun and Clarke's thematic analysis method. A cross tabs analysis was also performed to assess the prevalence of themes and subthemes by cancer care setting.

RESULTS

A total of 17 clinicians (physicians, nurse practitioners, and physician assistants) were interviewed for usability testing. Three main themes emerged: (1) Algorithms as useful, (2) Symptom management differences, and (3) Different target end-users. The cross-tabs analysis demonstrated differences among care trajectories and settings that originated in the Symptom management differences theme. The sub-themes of "Differences between diseases" and "Differences between care trajectories" originated from participants working in a comprehensive cancer center, which tends to be disease-specific locations for patients on active treatment. Meanwhile, participants from primary care identified the sub-theme of "Differences in settings," indicating that symptom management strategies are care setting specific.

CONCLUSIONS

While CDS can help promote evidence-based symptom management, systems providing care recommendations need to be specifically developed to fit patient characteristics and clinical context. Findings suggest that one set of algorithms will not be applicable throughout the entire cancer trajectory. Unique CDS for symptom management will be needed for patients who are cancer survivors being followed in primary care settings.

Patient-physician communication about cancer-related fatigue: a survey of patient-perceived barriers

PURPOSE

Cancer-related fatigue is a subjective, distressing, and common sequela of cancer which is often disregarded and underdiagnosed. Fatigue is assessed by self-report requiring communication between patient and physician. In this study, we investigated the patients' perspective on the patient-physician communication about fatigue.

METHODS

On average five months after diagnosis 1179 cancer patients, recruited in Germany, completed a survey as part of the LIFT project. The survey included questions on sociodemographic data, fatigue, depression, fatigue management, patient-physician communication, and communication barriers. Data were analyzed descriptively and using logistic regression analyses.

RESULTS

Half of the participants reported that their physician had never asked them whether they felt exhausted. Patients undergoing chemo-, radio-, or immunotherapy were more likely to be asked about fatigue, while older age and major depression decreased the likelihood. Sixty-four percent of the patients felt impeded by communication barriers. Common barriers were not knowing who to turn to for fatigue (39%), time constraints (31%), and the fear of being perceived as weak (22%). Almost half of the participants indicated that their physicians were not appreciative and did not deal adequately with fatigue-related questions.

CONCLUSION

This study revealed gaps in the patient-physician communication regarding cancer-related fatigue. Contrary to guideline recommendations a minority of physicians addressed fatigue. On the other hand, cancer patients felt reluctant to bring up this topic due to structural barriers and fears. Physicians should routinely address fatigue and adopt a communication style which encourages patients to likewise state their symptoms and raise their questions.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT04921644. Registered in June 2021.

Psycho-oncologists' knowledge of cancer-related fatigue and the targets for improving education and training: results from a cross-sectional survey study

PURPOSE

To explore psycho-oncologists' knowledge of cancer-related fatigue and their self-efficacy to intervene for fatigue. We further aimed to examine the role of fatigue in psycho-oncological training and derive specific suggestions for improvements.

METHODS

For this cross-sectional survey study, psycho-oncologists working in Germany were systematically recruited via an address directory or invited by training institutes or colleagues. The online survey encompassed questions on knowledge of fatigue guidelines and interventions, self-efficacy, counseling, and fatigue in professional training. Data were analyzed descriptively and using Mann-Whitney U tests. A logistic regression analysis was performed to identify variables linked to fatigue guideline knowledge.

RESULTS

Seventy two percent of the 144 surveyed psycho-oncologists stated not knowing any fatigue-specific guidelines. Those unaware of guidelines reported a lower self-efficacy to intervene for fatigue. However, despite low knowledge of the guidelines, more than 80% of the participants felt well informed about fatigue and reported high self-efficacy. Most participants were aware of the empirical evidence for psychotherapeutic interventions (95%); everyday physical activity, e.g., taking a walk (98%); yoga (82%); and mindfulness-based interventions (82%). Knowledge gaps existed concerning the evidence of resistance/endurance training for treating fatigue. Knowing that resistance/endurance training is an effective treatment was related to an increased frequency to recommend it to patients. Suggestions to improve training for psycho-oncologists included raising awareness earlier in the career path and offering multidisciplinary trainings for fatigue.

CONCLUSION

To improve fatigue-related guideline knowledge among psycho-oncologists and enhance implementation into clinical practice multidisciplinary trainings are needed. Psycho-oncologists should play an important role in fatigue management.

TRIAL REGISTRATION

Clinicaltrials.gov , identifier: NCT04921644. Registered in June 2021.

Identifying strategies for implementing a clinical guideline for cancer-related fatigue: a qualitative study

BACKGROUND

Clinical practice guidelines assist health professionals' (HPs) decisions. Costly to develop, many guidelines are not implemented in clinical settings. This paper describes an evaluation of contextual factors to inform clinical guideline implementation strategies for the common and distressing problem of cancer-related fatigue (CRF) at an Australian cancer hospital.

METHODS

A qualitative inquiry involving interviews and focus groups with consumers and multidisciplinary HPs explored key Canadian CRF guideline recommendations. Four HP focus groups examined the feasibility of a specific recommendation, while a consumer focus group examined experiences and preferences for managing CRF. Audio recordings were analysed using a rapid method of content analysis designed to accelerate implementation research. Strategies for implementation were guided by the Consolidated Framework for Implementation Research.

RESULTS

Five consumers and 31 multidisciplinary HPs participated in eight interviews and five focus groups. Key HP barriers to fatigue management were insufficient knowledge and time; and lack of accessible screening and management tools or referral pathways. Consumer barriers included priority for cancer control during short health consultations, limited stamina for extended or extra visits addressing fatigue, and HP attitudes towards fatigue. Enablers of optimal fatigue management were alignment with existing healthcare practices, increased HP knowledge of CRF guidelines and tools, and improved referral pathways. Consumers valued their HPs addressing fatigue as part of treatment, with a personal fatigue prevention or management plan including self-monitoring. Consumers preferred fatigue management outside clinic appointments and use of telehealth consultations.

CONCLUSIONS

Strategies that reduce barriers and leverage enablers to guideline use should be trialled. Approaches should include (1) accessible knowledge and practice resources for busy HPs, (2) time efficient processes for patients and their HPs and (3) alignment of processes with existing practice. Funding for cancer care must enable best practice supportive care.

Fatigue in Hematopoietic Cell Transplantation Survivors: Correlates, Care Team Communication, and Patient-Identified Mitigation Strategies

With improved survival after hematopoietic cell transplantation (HCT), the number of individuals at risk for persistent or late effects is increasing. The importance of optimizing HCT survivor health and well-being is mounting. Fatigue is a common post-transplantation symptom that impairs quality of life, yet it remains poorly understood and inadequately addressed. Multiple challenges to addressing fatigue exist, including its multidimensional presentation, multiple (often concomitant) causes, patient-clinician communication barriers, and few highly effective, evidence-based interventions that can be readily implemented. To address these challenges, we sought to better describe the impact and potential causes of fatigue in the post-transplantation setting, fatigue-related communication with clinicians, and the most effective patient-identified mitigation strategies (PIMS) for fatigue. A total of 1703 adult HCT recipients from a single center completed a survey including the Medical Outcomes Survey Short Form-36 (SF-36), PROMIS Fatigue, and other fatigue-related items between July 2017-June 2018. The survey was offered to recipients at their post-transplantation anniversary occurring during this interval. Two independent raters categorized free-text responses about fatigue PIMS. PROMIS Fatigue scores were dichotomized into low (≤55) or high (>55). Associations between high fatigue and participant characteristics and health outcomes were evaluated using the Fisher exact test for categorical variables and the Student 2-sample t test for continuous variables. Among the 1660 respondents with evaluable fatigue scores, 67% underwent allogeneic HCT. The majority of these (n = 1588; 96%) had a malignancy, with hematologic malignancy the most common diagnostic category (n = 1555; 94%). The median time post-transplantation was 11 years (interquartile range, 4 to 20 years). PROMIS item responses indicate that 44% of patients were at least somewhat fatigued and 37% were at least somewhat bothered by it. The mean fatigue score was 50.2 ± 11; 591 patients (36%) had high fatigue, which was associated with worse SF-36 scores across all domains (General Health, Physical Functioning, Emotional Well-being/Mental Health, Social Functioning, Role Limitation due to Physical Health, Role Limitation due to Emotional Health, Vitality [eg, energy], and Bodily Pain). High fatigue also was associated with self-reported chronic graft-versus-host disease, anxiety, depression and sleep problems. Diagnosis of plasma cell disorder and receipt of an autologous transplant were associated with high fatigue (P = .001). Among the 553 individuals who received an autologous transplant, 226 (41%) had multiple myeloma. Compared with the autologous transplant recipients without myeloma group, those with multiple myeloma were significantly more likely to have high fatigue (109 of 226 [48%] versus 118 of 325 [36%]; P < .01). Twenty percent of the patients with high fatigue did not discuss it with their care team. Among the 89 different reasons provided for not discussing it, the most common was "thought they already knew the answer" (n = 21). The 370 survivors with high fatigue who identified at least 1 most effective PIMS generated a total of 639 PIMS. Although the PIMS for fatigue spanned a wide array of strategies, most PIMS were related to sleep/rest (n = 192; 30%) or exercise (n = 139; 22%). Although fatigue is associated with worse HCT survivor-reported outcomes, it is only sometimes discussed with care teams. Survivors identify specific strategies that are most effective. Given its prevalence and impact, clinicians should promote communication about fatigue, treat underlying causes, and recommend sleep/rest and exercise, recognizing that individualized approaches also may be beneficial.

Predictors of Unrelieved Symptoms in All of Us Research Program Participants With Chronic Conditions

CONTEXT

Over half of American adults are diagnosed with a chronic condition, with an increasing prevalence being diagnosed with multiple chronic conditions. These adults are at higher risk for having unrelieved, co-occurring symptoms, known as symptom clusters.

OBJECTIVES

To identify symptom phenotypes of patients diagnosed with four common chronic conditions, specifically, cancer, chronic obstructive pulmonary disease, heart failure, and/or type 2 diabetes mellitus, and to understand factors that predict membership in symptomatic phenotypes.

METHODS

We conducted a retrospective, cross-sectional analysis using participant responses (N=14,127) to All of Us Research Program, a National Institutes of Health biomedical database, survey questions. We performed hierarchical clustering to generate symptom phenotypes of fatigue, emotional distress, and pain and used multinomial regression to determine if demographic, healthcare access and utilization, and health-related variables predict symptom phenotype.

RESULTS

Four phenotypes, one asymptomatic or mildly symptomatic and three highly symptomatic (characterized by severe symptoms, severe pain, and severe emotional distress), were identified. The percentage of participants belonging to the severe symptoms phenotype increased with the number of chronic conditions. Most notably, foregoing or delaying medical care and rating mental health as poor or fair increased the odds of belonging to a highly symptomatic phenotype.

CONCLUSION

We found meaningful relationships between demographic, healthcare access and utilization, and health-related factors and symptom phenotypes. With the increasing trends of American adults with one or more chronic conditions and a demand to individualize care in the precision health era, it is critical to understand the factors that lead to unrelieved symptoms.

Communication between persons with multiple sclerosis and their health care providers: A scoping review

OBJECTIVES

This study undertakes a scoping review of research about communication between persons with MS and their health care providers.

DESIGN

PubMed, PsycInfo, Communication Source, Socindex, Sociological Abstracts, Cinahl, and Proquest Dissertations and Theses were used to identify studies since each database's inception. Research team members engaged in study selection, coding for communication issues, and data extraction for descriptive information.

RESULTS

Of the 419 empirical articles identified, 175 were included. Codes represented all elements of ecological and pathway models, emphasizing emerging technologies for facilitating communication, uncertainty and anxiety for persons with MS, and communication issues surrounding diagnosis, information seeking, and decision making.

CONCLUSION

This review synthesizes and organizes influences on communication, communication processes, and health outcomes of communication for persons with MS and their providers. Findings extend the ecological model with illness context and the pathway model with communication breakdowns and provider outcomes.

PRACTICE IMPLICATIONS

Health care providers should consider the complexity of communication when interacting with persons with MS, including the larger context in which it occurs, communication processes and their purposes, and short-term and long-term consequences of interactions. Ecological and pathway models can be frameworks for developing educational materials, as they succinctly capture key communication issues and outcomes.

Cancer-related fatigue: benefits of information booklets to improve patients' knowledge and empowerment

PURPOSE

To investigate cancer patients' knowledge and attitudes regarding fatigue and the potential benefits and acceptability of a brief information booklet.

METHODS

The CARPE DIEM study assessed knowledge and attitudes regarding fatigue in a diverse group of 50 cancer patients before (T0) and about one (T1) and four months (T2) after reading the booklet. At T1, participants additionally rated its usefulness.

RESULTS

At baseline, 37.5% of respondents did not know the term "fatigue" or what it meant. Those who already knew something about fatigue mainly had obtained their information from booklets, books, or articles (63.3%) and/or the internet (46.7%). Overall, knowledge gaps existed, particularly about potential fatigue treatment options and whether fatigue is an indicator of cancer progression. Furthermore, 56.4% felt poorly informed, and 46.1% reported feeling helpless in the face of fatigue. Lower knowledge at baseline was significantly associated with lower education and older age. At T1 and T2, there were significant improvements in several knowledge questions and attitudes. Patient-reported benefits included getting new information about fatigue (91.1%), awareness of not being alone with their problems (89.7%), taking appropriate actions (72.9%), and encouragement to talk about their fatigue with family/friends (55.3%) or with a health professional (52.7%).

CONCLUSIONS

Specific gaps were identified in the provision of information and education for cancer patients about fatigue. A low-cost intervention asking to read a brief information booklet was associated with improved knowledge. This could be considered as a first step offered as part of a bundle of further efforts to improve knowledge and care of fatigue.

Supportive care practice: do we need guidelines?

PURPOSE OF REVIEW

To review the role of evidence-based clinical practice guidelines in promoting the quality and consistency of supportive care in oncology to meet the needs of practitioners and patients.

RECENT FINDINGS

To maintain quality, guidelines must be regularly updated in terms of content as new treatment modalities like immunotherapy are introduced, adapted to new methodologies such as the application of artificial intelligence, adoption of multiple symptoms or orphan symptoms and capture new endpoints such a patient-reported outcomes. This helps prevent a major barrier to implementation; negative attitudes of practitioners towards guidelines. Digital guidelines provide greater opportunities for dissemination, ease of updating and can be linked to education modules. The quality must be assured by critically appraising the literature and then grading the level of evidence of the guidelines. The benefits of supportive care guidelines include guidance for clinical decision-making in a changing field, continuing professional development of practitioners, a source of information for patients and in highlighting the gaps where further research is necessary.

SUMMARY

The implications are that guidelines are required for supportive care in cancer but they must be constantly updated and evolve in their structure, the rigour of appraisal and content to promote quality care.