Management of Fatigue in Patients with Advanced Cancer

Network analysis of fatigue symptoms in Chinese patients with advanced cancer

Objective

This study was aimed at investigating the network structures of fatigue symptoms in patients with advanced cancer, with a focus on identifying the central symptom-an aspect crucial for targeted and effective fatigue symptom management.

Methods

In this cross-sectional study, patients with advanced cancer were recruited from the cancer treatment center of a tertiary hospital in China between January and December of 2022. Symptom occurrence and severity were assessed with the Cancer Fatigue Scale. Network analysis was conducted to explore the network structure and identify the core fatigue symptoms.

Results

The study included 416 patients with advanced cancer. Lack of energy (2.25 ​± ​1.24), lack of interest in anything (2.20 ​± ​1.22), and lack of self-encouragement (2.03 ​± ​1.25) were the most severe fatigue symptoms and belonged to the affective fatigue dimension. In the overall network, reluctance (r s  ​= ​5.622), a heavy and tired body (r s  ​= ​5.424), and tiring easily (r s  ​= ​5.319) had the highest strength values. All these core symptoms were classified within the physical fatigue dimension and remained stable before and after adjustment for covariates.

Conclusions

This study identified reluctance, a heavy and tired body, and tiring easily as the core fatigue symptoms in patients with advanced cancer, thus providing valuable insight to help clinical nurses formulate more effective symptom management strategies. Future interventions could assess the efficacy of targeting the central symptom cluster in alleviating other symptoms and patient burden.

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.

Relationship between physical activity and quality of life among patients with respiratory and digestive system cancer during and outside the COVID-19 pandemic

PURPOSE

To investigate the relationship between physical activity (PA) and quality of life (QOL) among patients with respiratory and digestive system cancers during and outside of the COVID-19 pandemic.

METHODS

A longitudinal, repeated-measures observational design was employed, and data were collected from outpatient clinics and wards during both the pandemic and a nonpandemic period at baseline (T1) and 3 months postrecruitment (T2). The Bouchard 3-Day Physical Activity Record questionnaire and the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire (physical function subscale) were used to measure PA and QOL, respectively.

RESULTS

A total of 313 patients with various cancers (including lung, esophageal, gastric, pancreatic, and colon cancers) participated in this study. Light-intensity PA was significantly and positively correlated with the physical function dimension of QOL during both the pandemic (r = 0.31, p < 0.001) and nonpandemic (r = 0.15, p = 0.010) periods. Furthermore, light-intensity PA was a significant predictor of the physical function dimension of QOL during both the pandemic and nonpandemic periods (B = 0.04, p < 0.001; B = 0.02, p = 0.007, respectively).

CONCLUSIONS

Light-intensity PA is a critical predictor of the physical function domain of QOL in patients with respiratory and digestive system cancers during both pandemic and nonpandemic periods. Promoting engagement in tolerable PA may improve the health of these patients.

Effects of Jianpi therapy for cancer-related fatigue:a meta-analysis of randomized controlled trials

Purpose

The Jianpi therapeutic strategy in traditional Chinese medicine aims to enhance the spleen's digestive function and overall wellness. It has shown promise in improving cancer-related fatigue (CRF). This research systematically evaluates the effectiveness of Jianpi therapy in reducing fatigue in cancer patients through a meta-analytic review.

Methods

An exhaustive search was performed within PubMed, Embase, Web of Science, Cochrane Library, SinoMed, Wanfang Data, China Science and Technology Journal Database, and China National Knowledge Infrastructure (CNKI) for randomized controlled trials concerning the application of Jianpi therapy to address CRF. The search spanned from the commencement of each database's records to April 1, 2024. The extracted data were subjected to analysis using Stata (Version 15.1), with the selection of either a random-effects or fixed-effects model based on the heterogeneity among studies. Outcome measures were demonstrated with standardized mean differences (SMDs) or mean differences (MDs), and each complemented by a 95% confidence interval (CI). The Cochrane Risk of Bias Assessment Tool 2.0 was utilized to assess the potential biases within the studies.

Results

A comprehensive analysis was performed on 45 eligible studies, all of which were conducted within China and encompassed a total of 3,596 participants. The meta-analysis indicated that Jianpi decoction alone exhibited the most significant improvement in the proportion of CD4 cells (SMD=1.34, 95% CI 0.54 to 2.31, P<0.001) and hemoglobin (MD=7.45, 95% CI 4.18 to 10.72, Z=4.47, P<0.001), while also more significantly reducing Piper Fatigue Scale scores (SMD=-2.05, 95% CI -2.71 to -1.39, P<0.001). The combined therapy, which integrated Jianpi therapy with standard care, demonstrated the greatest advantage in enhancing the proportion of CD3 cells (SMD=1.25, 95% CI 0.46 to 2.04, P<0.001). Furthermore, Jianpi therapy was found to be effective in lowering tumor necrosis factor-alpha levels (MD=-7.79, 95% CI -11.24 to -4.34, P<0.001) and concurrently enhancing interferon-gamma (MD=5.15, 95% CI 3.20 to 7.09, P=0.002), interleukin-2 (MD=8.37, 95% CI 6.14 to 10.59, P<0.001).

Conclusion

Our research indicates that Jianpi therapy effectively alleviates CRF, reduces inflammation, and strengthens immune function. However, further high-quality, multicenter randomized controlled trials are essential to confirm these findings and strengthen the evidence.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024566739.

Putting Methylphenidate for Cancer-Related Fatigue to Rest?

In the article that accompanies this editorial, Stone et al. present a randomized, double-blind, placebo-controlled trial of individually dose-titrated methylphenidate for treatment of fatigue in patients with advanced cancer, finding that methylphenidate, while safe and well-tolerated, was no more effective than placebo at relieving fatigue after 6 (±2) weeks. Future studies should consider the multifaceted nature of cancer-related fatigue, as well as the substantial placebo effects of psychostimulants, and may benefit from focusing on methylphenidate in combination with non-pharmacological interventions, or for fatigue with a predominant emotional or cognitive component.

Methylphenidate Versus Placebo for Treating Fatigue in Patients With Advanced Cancer: Randomized, Double-Blind, Multicenter, Placebo-Controlled Trial

PURPOSE

To compare effects and side effects of 6 weeks of individually dose-titrated methylphenidate or placebo on fatigue in palliative care patients with advanced cancer.

METHODS

This is a randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients had advanced incurable cancer and fatigue >3/10. Principal exclusions were hypertension; psychiatric, cardiovascular, cerebrovascular, renal, liver, or blood disorders; substance dependency; and epilepsy. Patients were randomly assigned 1:1 methylphenidate or placebo starting at 5 mg twice daily. Dose of methylphenidate/placebo was titrated once per week, over 6 weeks, up to a maximum of 20 mg three times daily. Trial ended at 10 weeks. Primary outcome was the difference in Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scores between groups at 6 ± 2 weeks. Secondary outcomes included adverse effects, quality of life, and mood.

RESULTS

One hundred sixty-two patients (73 men; mean, 65.8; standard deviation [SD], 10.3 years) were randomly assigned, and three were excluded from analysis. Seventy-seven were allocated placebo (baseline FACIT-F = 22 [SD, 10]); 82 were allocated methylphenidate (FACIT-F = 20 [SD, 9]). After 6 ± 2 weeks, FACIT-F scores were 1.97 points (95% CI, -0.95 to 4.90; P = .186) higher (better) on methylphenidate than placebo. Across 10 weeks of the study, FACIT-F was nominally higher in the methylphenidate group versus placebo (Diff, 2.20 [95% CI, 0.39 to 4.01]), but this did not reach the minimally clinically important difference (5-points). At 6 weeks, there were no differences between groups in quality-of-life or symptom domains except for depression scores (nominally reduced in the methylphenidate group: Diff, -1.35 [95% CI, -2.41 to -0.30]). There were no differences in mortality or serious adverse events.

CONCLUSION

After 6 ± 2 weeks of treatment, methylphenidate was not superior to placebo for treating fatigue in advanced cancer. Methylphenidate was safe and well-tolerated.

Feasibility of a physical exercise intervention for patients on a palliative care unit: a critical analysis

BACKGROUND

Recent exercise intervention studies have shown promising results in improving quality of life (QoL) and physical function (PF) in diverse chronic disease and advanced cancer patients. However, the effects of structured exercise in palliative care patients, having different therapeutic needs, lower life expectancies and PFs remain unknown. This study primarily aimed to assess the feasibility of an exercise intervention with follow-up by analysing recruitment numbers, screening procedures, acceptability, preferences, and safety of the exercise intervention as well as retention in follow-up. Our secondary aims related to changes in QoL and PF.

METHODS

This study comprised of a one-arm design without a control group. Over 6 months, every in-hospital palliative care unit (PCU) patient was screened for eligibility. Eligible patients were asked to participate in a 2-week exercise intervention consisting of resistance training and/or endurance training with moderate or high intensity based on personal preferences and a 4-week follow-up. Before and after the exercise intervention, QoL and PF were assessed and a qualitative interview after the intervention addressed expectations and experiences of the exercise intervention. For follow-up, patients were provided with information on independent training and after 1 and 4 weeks a QoL assessment and qualitative interview were conducted.

RESULTS

Of 124 patients screened, 10 completed the intervention with an adherence rate of (80 ± 25%), of which 6 patients completed follow-up. Endurance training was the most performed training type and only a few minor adverse events occurred in certain or likely connection to the exercise intervention. While physical QoL and PF measured by arm curl strength and time up and go performance improved, mental QoL and the other PF tests remained unchanged.

CONCLUSION

Despite the challenges that were faced in our screening and testing process, that are specific to the palliative patient population with their unique therapeutic requirements and varying mental-/ physical capabilities, we discovered the 2-week exercise intervention to be feasible, safe, and well tolerated by palliative care patients. Moreover, it seems that short-term improvements in QoL and PF are possible. Further full scale studies are required to confirm our findings.

TRIAL REGISTRATION

The study was retrospectively registered on 25.01.2022 in the German Clinical Trials Register (DRKS00027861).

Comparing the sensitivity of fatigue and sleep disturbance assessment tools in women with advanced cancer undergoing chemotherapy

Objective

This study aims to investigate the variations in fatigue and sleep disturbances among female patients with advanced lung cancer (ALC) and advanced breast cancer (ABC) during chemotherapy.

Methods

A total of 36 female patients with ALC and 36 with ABC, all of whom had completed their first cycle of chemotherapy, were included. Fatigue was assessed using the General Fatigue Scale (GFS), and sleep disturbances were evaluated using the Pittsburgh Sleep Quality Index (PSQI) at designated time points throughout the chemotherapy process.

Results

Linear regression analysis indicated that variables such as age, education level, employment status, cancer type, clinical stage, and symptom distress had no significant correlation with either fatigue or sleep disturbances. The GFS significantly discriminated fatigue among the ALC, ABC, and combined groups, while the PSQI demonstrated a significant distinction in sleep disturbance only within the ALC and combined groups.

Conclusions

In summary, when considering the findings of both assessments in this study, the GFS score exhibited greater sensitivity in detecting fatigue than the PSQI score did for identifying sleep disturbances in advanced cancer patients undergoing chemotherapy.

The Effect of Psychoeducational Interventions on Cancer-Related Fatigue: A Systematic Review and Meta-analysis of Randomized Controlled Studies

BACKGROUND

Cancer-related fatigue is one of the most common symptoms of cancer patients. Psychoeducation is often used in the management of cancer-related fatigue.

OBJECTIVE

The aim of this study was to synthesize the effects of psychoeducational interventions on cancer-related fatigue.

METHODS

This article is a systematic review and meta-analysis of randomized controlled studies. The 11 electronic databases were searched, and studies using psychoeducational interventions to manage cancer-related fatigue were included. Data synthesis was performed using Comprehensive Meta-Analysis software version 3.0. The random-effects model was used to pool the effect size for intervention. The subgroup analysis was conducted to investigate the effect of the characteristics of psychoeducational interventions. This study was reported according to the Cochrane Handbook for Systematic Reviews of Intervention version 6.3 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines.

RESULTS

This analysis included 10 studies with a total of 1369 participants. Most of the included studies compared the psychoeducational intervention group with the passive control group. Our meta-analysis revealed that psychoeducational intervention has a positive medium effect on improving cancer-related fatigue with a low quality of evidence. Subgroup analyses indicated no difference between group and individual interventions, between face-to-face and digital interventions, or between ≤3 and >3 sessions.

CONCLUSIONS

Psychoeducational interventions can improve cancer-related fatigue. Additional well-designed randomized controlled studies are needed to upgrade the quality of evidence for psychoeducational interventions on cancer-related fatigue.

IMPLICATIONS FOR PRACTICE

Nurses may practice psychoeducational interventions to manage cancer-related fatigue and may use this study design for randomized controlled studies for psychoeducational interventions on cancer-related fatigue.

Mental health needs in cancer - a call for change

There is continued under-recognition and underinvestment in the psychological and mental health aspects of care for cancer patients, despite the fact that increased patient survival rates in cancer mean that patients are living longer after diagnosis. In this article, we advocate for better integration and joint working between clinicians across all areas, including education and research, impacting positively on the outcomes and care of cancer patients.