Are the effects of cognitive behavior therapy for severe fatigue in cancer survivors sustained up to 14 years after therapy?

Patients' experiences of cognitive behavioural therapy integrated with activity pacing: a qualitative study

BACKGROUND

Our previous trial integrating cognitive behavioural therapy with activity pacing (CBT-AP) demonstrated the efficacy of CBT-AP in reducing cancer-related fatigue and depression, as well as improving the quality of life for patients with breast cancer. However, the range of subjective patient experiences on the effect of CBT-AP, including its content, context, and approach, has not been fully explored. This study aimed to explore patients' experiences of CBT-AP among breast cancer patients.

METHODS

Patients with breast cancer who attended CBT-AP sessions were interviewed. The interviews continued until data saturation was achieved, with no new findings emerging. A total of 20 women, aged 24 to 62, at various stages of cancer and undergoing chemotherapy were involved in the study. The collected data was transcribed, translated and coded following themes developed in line with the objective of the study, ensuring sensitivity to context, rigour, transparency, and impact throughout the research process.

RESULTS

The data identified six major themes: the content of the therapy, the context of the therapy, experiences with the implementation of the therapy, benefits of the therapy, the therapeutic approach, and recommendations. Findings revealed that participants described all components of CBT-AP as important, with the content addressing common symptoms related to the disease and its treatment. Participants reported positive effects on their physical, psychological, and social health following the therapy. While the majority preferred face-to-face sessions, a significant number favoured a combination of face-to-face and telephone sessions. The participant's manual was found to be easily understandable and clear.

CONCLUSION

The findings suggest that participants had positive experiences with the therapy. Based on these experiences, it is recommended that specific components and delivery methods of CBT-AP, such as patient-centered content and flexible delivery options, be considered key factors to enhance its acceptability and feasibility. While this study highlights CBT-AP's potential to improve quality of life of breast cancer patients, further research is needed to evaluate its broader application and long-term impact in various healthcare settings, particularly for diverse patient populations.

Trajectories and risk factors of fatigue following colorectal cancer diagnosis

AIM

This study sought to identify groups of colorectal cancer patients based upon trajectories of fatigue and examine how demographic, clinical and behavioural risk factors differentiate these groups.

METHOD

Patients were from six cancer centres in the United States and Germany. Fatigue was measured using the fatigue subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at five time points (baseline/enrolment and 3, 6, 12 and 24 months after diagnosis). Piecewise growth mixture models identified latent trajectories of fatigue. Logistic regression models examined differences in demographic, clinical and behavioural characteristics between fatigue trajectory groups.

RESULTS

Among 1615 participants (57% men, 86% non-Hispanic White, mean age 61 ± 13 years at diagnosis), three distinct groups were identified. In the high fatigue group (36%), fatigue significantly increased in the first 6 months after diagnosis and then showed statistically and clinically significant improvement from 6 to 24 months (P values < 0.01). Throughout the study period, average fatigue met or exceeded cutoffs for clinical significance. In the moderate (34%) and low (30%) fatigue groups, fatigue levels remained below or near population norms across the study period. Patients who were diagnosed with Stage II-IV disease and/or current smokers were more likely to be in the high fatigue than in the moderate fatigue group (P values < 0.05).

CONCLUSION

A large proportion of colorectal cancer patients experienced sustained fatigue after initiation of cancer treatment. Patients with high fatigue at the time of diagnosis may benefit from early supportive care.

Psychosocial Interventions for the Treatment of Cancer-Related Fatigue: An Umbrella Review

Cancer-related fatigue is one of the most common symptoms of cancer and one of those referred by patients as the most disabling. However, we still do not have enough evidence to allow us to recommend effective and personalized approaches.

GOAL

To provide evidence on the efficacy of ASCO-recommended psychosocial interventions for reducing cancer-related fatigue.

METHODOLOGY

A general quantitative systematic review for nonprimary clinical interventions that allows the collection, synthesis and analysis of already published reviews. Systematic reviews of RTCs were selected as these make up the body of knowledge that provides the most evidence in an umbrella format. The results do not provide clear or comparable evidence regarding the different interventions, with moderate evidence standing out for cognitive interventions and mindfulness.

CONCLUSIONS

Research gaps, study biases and the need for further research to ask more precise questions and to make reliable recommendations to mitigate the impact of cancer-related fatigue are evident.

The effect of cognitive behavioural therapy integrated with activity pacing on cancer-related fatigue, depression and quality of life among patients with breast cancer undergoing chemotherapy in Ethiopia: A randomised clinical trial

Fatigue is a common symptom experienced by 80% of individuals who receive chemotherapy and is one of the major factors that affect quality of life (QoL) of patients with breast cancer. Our study aimed to assess the effect of cognitive behavioural therapy integrated with activity pacing (CBT-AP) on cancer-related fatigue among patients with breast cancer undergoing chemotherapy. A parallel-group, randomised controlled trial was conducted. Severely fatigued patients were randomly assigned to the CBT-AP or usual care (UC) groups using a computer-generated random sequence. The new intervention was designed for seven sessions: three 2-hour face-to-face and four 30-minute telephone sessions. The primary outcome (fatigue severity) and the secondary outcomes (depression and QoL) were assessed at the end of the intervention and after 3 months. The data were analysed by repeated measures analyses of covariance (RM-ANCOVA). CBT-AP had a significant time effect (P < .001, ηp²  = 0.233) in reducing fatigue from baseline (adjusted mean = 7.48) to the end of the intervention (adjusted mean = 6.37) and the 3-month follow-up (adjusted mean = 6.54). Compared to the UC group, the CBT-AP group had lower fatigue and depression scores, and higher global health status scores. The group × time interaction revealed a significant reduction in fatigue and depression in the CBT-AP group compared to the UC group. Therefore, CBT-AP appears to be effective in reducing fatigue and depression and improving QoL in patients with breast cancer undergoing chemotherapy. It is highly recommended to integrate a CBT-AP intervention in routine cancer care.

The relation between cognitive-behavioural responses to symptoms in patients with long term medical conditions and the outcome of cognitive behavioural therapy for fatigue - A secondary analysis of four RCTs

BACKGROUND

Cognitive behavioural therapy (CBT) is effective in reducing fatigue across long-term conditions (LTCs). This study evaluated whether cognitive and behavioural responses to symptoms: 1) differ between LTCs and 2) moderate and/or mediate the effect of CBT on fatigue.

METHOD

Data were used from four Randomized Controlled Trials testing the efficacy of CBT for fatigue in Chronic Fatigue Syndrome/ME (N = 240), Multiple Sclerosis (N = 90), Type 1 Diabetes Mellitus (N = 120) and Q-fever fatigue syndrome (N = 155). Fatigue severity, assessed with the Checklist Individual Strength, was the primary outcome. Differences in fatigue perpetuating factors, assessed with the Cognitive Behavioural Responses to Symptoms Questionnaire (CBRQ), between diagnostic groups were tested using ANCOVAs. Linear regression and mediation analyses were used to investigate moderation and mediation by CBRQ scores of the treatment effect.

RESULTS

There were small to moderate differences in CBRQ scores between LTCs. Patients with higher scores on the subscales damage beliefs and avoidance/resting behaviour at baseline showed less improvement following CBT, irrespective of diagnosis. Reduction in fear avoidance, catastrophising and avoidance/resting behaviour mediated the positive effect of CBT on fatigue across diagnostic groups.

DISCUSSION

The same cognitive-behavioural responses to fatigue moderate and mediate treatment outcome across conditions, supporting a transdiagnostic approach to fatigue.

A pilot study of cognitive behavioural therapy integrated with activity pacing for fatigued breast cancer patients undergoing chemotherapy in Ethiopia

Background

Fatigue is a common symptom in breast cancer patients, and it is one of the major factors that influence the quality of life (QoL). Cognitive behavioural therapy (CBT) has been recommended to manage cancer-related fatigue. In this study, CBT will be integrated with activity pacing (AP), which can help breast cancer patients achieve a balance between activity and rest. Therefore, this pilot study aimed to investigate the acceptability, feasibility, and efficacy of the CBT-AP intervention.

Methods

A total of 10 fatigued breast cancer patients undergoing chemotherapy were included in the study. The acceptability and feasibility of the study were measured by the patient recruitment rate, attrition rate, intervention fidelity, intervention compliance, and therapist’s and participant’s evaluations of the intervention. The outcomes were measured at baseline and at 6 weeks of intervention.

Results

The pre–post study suggested that CBT-AP was found to be acceptable and feasible for fatigued breast cancer patients undergoing chemotherapy. Among 27 eligible participants, 10 (37.03%) participants accepted our invitation to participate in the study. One participant dropped out from the intervention because of serious illness, and the dropout rate was 10%.

Both the intervention fidelity and intervention compliance were found to be satisfactory.

Fatigue severity [Brief Fatigue Inventory (BFI)] was reduced in 77.77% of participants from baseline to 6 weeks of intervention. The global health status/QoL scale and physical, emotional, and social functioning scales were improved from baseline to 6 weeks of intervention. All symptom scales, except constipation, diarrhea, and financial difficulties, were decreased after the intervention. Depression [Public Health Questionnaire (PHQ)-9] was reduced in 55.55% of participants.

Conclusion

This study suggested that CBT-AP is an acceptable, feasible, and potentially efficacious intervention to reduce fatigue and improve the QoL of breast cancer patients. The efficacy of a CBT-AP programme is going to be investigated in subsequent larger randomized clinical trials.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

A randomised controlled trial testing the efficacy of Fit after COVID, a cognitive behavioural therapy targeting severe post-infectious fatigue following COVID-19 (ReCOVer): study protocol

BACKGROUND

Coronavirus disease 2019 (COVID-19) results in debilitating long-term symptoms, often referred to as Post-Acute Sequelae of SARS-CoV-2 Infection (PASC), in a substantial subgroup of patients. One of the most prevalent symptoms following COVID-19 is severe fatigue. Prompt delivery of cognitive behavioural therapy (CBT), an evidence-based treatment that has shown benefit in reducing severe fatigue in other conditions, may reduce post-COVID-19 fatigue. Based on an existing CBT protocol, a blended intervention of 17 weeks, Fit after COVID, was developed to treat severe fatigue after the acute phase of infection with SARS-CoV-2.

METHOD

The ReCOVer study is a multicentre 2-arm randomised controlled trial (RCT) to test the efficacy of Fit after COVID on severe post-infectious fatigue. Participants are eligible if they report severe fatigue 3 up to and including 12 months following COVID-19. One hundred and fourteen participants will be randomised to either Fit after COVID or care as usual (ratio 1:1). The primary outcome, the fatigue severity subscale of the Checklist Individual Strength (CIS-fatigue), is assessed in both groups before randomisation (T0), directly post CBT or following care as usual (T1), and at follow-up 6 months after the second assessment (T2). In addition, a long-term follow-up (T3), 12 months after the second assessment, is performed in the CBT group only. The primary objective is to investigate whether CBT will lead to a significantly lower mean fatigue severity score measured with the CIS-fatigue across the first two follow-up assessments (T1 and T2) as compared to care as usual. Secondary objectives are to determine the proportion of participants no longer being severely fatigued (operationalised in different ways) at T1 and T2 and to investigate changes in physical and social functioning, in the number and severity of somatic symptoms and in problems concentrating across T1 and T2.

DISCUSSION

This is the first trial testing a cognitive behavioural intervention targeting severe fatigue after COVID-19. If Fit after COVID is effective in reducing fatigue severity following COVID-19, this intervention could contribute to alleviating the long-term health consequences of COVID-19 by relieving one of its most prevalent and distressing long-term symptoms.

TRIAL REGISTRATION

Netherlands Trial Register NL8947 . Registered on 14 October 2020.

Effect of Solution-Focused Therapy on Cancer-Related Fatigue in Patients With Colorectal Cancer Undergoing Chemotherapy: A Randomized Controlled Trial

BACKGROUND

Cancer-related fatigue (CRF) has gained increased attention in the past decade but remains difficult to treat. It is a predictor of patients' overall health and quality of life (QoL). Therefore, controlling fatigue is important for patients with cancer.

OBJECTIVE

The aim of this study was to test the effect of solution-focused therapy (SFT) in reducing CRF and improving QoL in patients with colorectal cancer (CRC) undergoing chemotherapy.

METHODS

A total of 124 patients with CRC undergoing chemotherapy were recruited and randomized to the SFT group or control group. Cancer-related fatigue was measured with the Cancer Fatigue Scale-Chinese version (CFS-C) at baseline, 3 months, and 6 months. Quality of life was measured with the Quality of Life Instruments for Colorectal Cancer Patients at baseline and 6 months.

RESULTS

Of 124 patients, 119 (95.9%) were evaluable. The SFT group showed significantly lower Cancer Fatigue Scale-Chinese version scores than the control group in all subscales and the total scores at 3 months (P < .001). At 6 months, the SFT group had significantly lower scores in cognitive fatigue (P < .001) and total fatigue (P = .005). The CRF of the SFT group decreased in the first 3 months (P = .012) but increased at 6 months (P < .001). The SFT group had significantly higher scores in the physical and psychological domains and overall QoL (P = .002, P <.001, and P = .02) than the control group at 6 months.

CONCLUSION

Solution-focused therapy may decrease the CRF and improve QoL during chemotherapy for patients with CRC.

IMPLICATION FOR PRACTICE

Solution-focused therapy can be implemented to relieve fatigue and improve QoL in patients with CRC.

Study Protocol of CBT-AP Trial: A Randomized Controlled Trial of Cognitive Behavioral Therapy Integrated with Activity Pacing for Fatigued Breast Cancer Patients Undergoing Chemotherapy

PURPOSE

This paper reports the methodology for undertaking a randomized controlled trial to assess the combined effect of cognitive behavioral therapy (CBT) and activity pacing on fatigue experienced by breast cancer patients undergoing chemotherapy.

METHOD

Fifty-eight patients experiencing severe fatigue will be randomized to a CBT group or usual care group. The intervention will be given for 6 sessions by a trained oncology nurse. Primary and secondary outcome measures will be assessed at baseline, the sixth week of intervention and at the third month post intervention. The primary outcome measure is fatigue (Brief Fatigue Inventory) and secondary outcome measures include depression (Patient Health Questionnaire) and quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire). The protocol is designed using the SPIRIT guidelines which is one of the EQUATOR checklists.

DISCUSSION

This is the first RCT that will determine the efficacy of CBT by integrating with activity pacing to reduce fatigue among breast cancer patients receiving chemotherapy. The intervention design is novel in addressing multiple precipitating and perpetuating factors of fatigue and integrated with activity pacing in CBT.

CONCLUSION

If the intervention is effective, this therapeutic approach can be incorporated into a routine health care for breast cancer patients receiving chemotherapy.

TRIAL REGISTRATION

The study have been registered in Pan-African Clinical Trial Registry (website) on August 24, 2020. The trial registration number is PACTR202008881026130.

Breviscapine Alleviates Cognitive Impairments Induced by Transient Cerebral Ischemia/Reperfusion through Its Anti-Inflammatory and Anti-Oxidant Properties in a Rat Model

Cerebral ischemia/reperfusion (I/R)-induced injury is a common phenomenon of stroke, and the effective treatment for I/R-induced brain tissue damage is limited. Breviscapine has been widely used in China as herbal medicine to treat cardiovascular diseases for hundreds of years and has been demonstrated to possess potent cardiovascular pharmacological effects. This study aims to investigate the neuroprotective effect of breviscapine on cerebral I/R-induced injury. The rat model of middle cerebral artery occlusion (MCAO) was applied in our study. The cerebral I/R rats received multiple injections of breviscapine. All rats were subject to neurological behavior tests by open field test and Morris water maze test. The pro-inflammatory cytokines and oxidative stress marker levels were determined by ELISA and colorimetric analysis, respectively. We demonstrated that administration of breviscapine dose-dependently ameliorated cerebral I/R-induced injury and improved the neurological performance of cerebral I/R rats. Further studies illustrated that breviscapine treatment effectively attenuated inflammatory cytokine expression, reduced oxidative stress, and pro-apoptosis protein expression and inhibited the activation of NF-κB signaling and microglia in the I/R injury tissues. Breviscapine may serve as a single drug or a promising adjuvant that can be used in conjunction with other medicine for the treatment of cerebral I/R-induced injury.

Internet-assisted cognitive behavioral intervention for targeted therapy-related fatigue in chronic myeloid leukemia: Results from a pilot randomized trial

BACKGROUND

Fatigue is a common and disabling side effect of targeted therapies such as tyrosine kinase inhibitors (TKIs) used to treat chronic myeloid leukemia (CML). The goal of the current study was to conduct a pilot randomized trial of the first cognitive behavioral intervention developed for fatigue due to targeted therapy.

METHODS

Patients with CML treated with a TKI who were reporting moderate to severe fatigue were recruited and randomized 2:1 to cognitive behavioral therapy for targeted therapy-related fatigue (CBT-TTF) delivered via FaceTime for the iPad or to a waitlist control (WLC) group. The outcomes were acceptability, feasibility, and preliminary efficacy for fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue; primary outcome) and quality of life (Functional Assessment of Cancer Therapy-General; secondary outcome). Participants were assessed before randomization and after treatment (ie, approximately 18 weeks later).

RESULTS

A total of 44 patients (mean age, 55 years; 48% female) were assigned to CBT-TTF (n = 29) or WLC (n = 15). The study participation rate was 59%. Among the patients assigned to CBT-TTF, 79% completed the intervention. Intent-to-treat analyses indicated that patients assigned to CBT-TTF demonstrated greater improvements in fatigue (d = 1.06; P < .001) and overall quality of life (d = 1.15; P = .005) than those assigned to WLC. More patients randomized to CBT-TTF than WLC demonstrated clinically significant improvements in fatigue (85% vs 29%) and quality of life (88% vs 54%; P values ≤ .016).

CONCLUSIONS

CBT-TTF displays preliminary efficacy in improving fatigue and quality of life among fatigued patients with CML treated with TKIs. The findings suggest that a larger randomized study is warranted.

Graded activity is an important component in cognitive behavioral therapy to reduce severe fatigue: results of a pragmatic crossover trial in cancer survivors

Background: Fatigue is one of the most common and distressing long-term effects of cancer treatment. Cognitive behavioral therapy (CBT) is an evidence-based intervention for patients with severe post-cancer fatigue. CBT for fatigue is a complex intervention consisting of multiple elements like a graded activity program, regulation of the sleep-wake rhythm and reformulation of fatigue-related cognitions. The contribution of the separate elements to the positive effect of CBT on fatigue is unclear. The main objective of this pragmatic crossover trial was comparing the efficacy of graded activity with the other elements of CBT in reducing post-cancer fatigue.Material and methods: Severely fatigued cancer survivors were randomized to (i) graded activity followed by the other elements of CBT after crossover (n = 41), or (ii) the two components in reverse order (n = 48). Fatigue severity was measured at baseline, before crossover and after CBT (Checklist Individual Strength (CIS), Fatigue Severity subscale). Differences in effects on fatigue were examined with a linear regression analysis. Objective physical activity, perceived activity and self-efficacy were explored as mediators of the effect of graded activity.Results: Before crossover, the reduction in fatigue was significantly larger after graded activity than after the other elements (β = 4.75, 95% confidence interval (95% CI) = -9.19; -0.32). An increase in perceived activity mediated this effect (β = -4.17, 95% CI = -7.37; -1.37).Conclusions: Graded activity is an important component of CBT for post-cancer fatigue as it resulted in a larger reduction in fatigue compared with the other elements, mediated by an increased level of perceived activity. Results indicated that the other elements of CBT are of added value in reducing fatigue.

The relationship between acceptance, fatigue, and subjective cognitive impairment in hematologic cancer survivors

Background/Objective: Cancer and its treatment can have a detrimental impact on psychological well-being. Acceptance as the basis of acceptance and commitment therapy (ACT) has shown beneficial effects on depression and anxiety. However, its relationship to fatigue and cognitive impairment has not been investigated. A protective effect of acceptance may open up a new target for psychological intervention. Method: A cross-sectional postal survey was undertaken. 922 hematological cancer survivors (≥ 2.5 years post diagnosis) were recruited through two regional cancer registries in Germany. Acceptance (AAQ-II), fatigue (BFI) and subjective cognitive impairment (AFI) were assessed. Results: Higher levels of acceptance were negatively associated with fatigue and subjective cognitive impairment (R² = .34 and R² = .26, respectively). The relationship between fatigue and fatigue-related impairment of daily life was weaker for survivors with high acceptance. Conclusions: Acceptance is strongly associated with fatigue and subjective cognitive impairment. ACT may be useful to reduce symptoms of fatigue and subjective cognitive impairment in cancer survivors.