Depression and anxiety in colorectal cancer patients

Nervous system in colorectal cancer

A malignant tumor is a complex systemic disease involving the nervous system, which regulates nerve signals. Cancer neuroscience is a field that explores the interactions between tumors and the nervous system. The gastrointestinal tract is a typical peripheral organ with abundant neuroregulation and is regulated by the peripheral, enteric, and central nervous systems (PNS, ENS, and CNS, respectively). The physiological functions of the gastrointestinal tract are maintained via complex neuromodulation. Neuroregulatory imbalance is the primary cause of gastrointestinal diseases, including colorectal cancer (CRC). In CRC, there is a direct interaction between the nervous system and tumor cells. Moreover, this tumor-nerve interaction can indirectly regulate the tumor microenvironment, including the microbiota, immunity, and metabolism. In addition to the lower nerve centers, the stress response, emotion, and cognition represented by the higher nerve centers also participate in the occurrence and progression of CRC. Herein, we review some basic knowledge regarding cancer neuroscience and elucidate the mechanism underlying tumor-nerve interactions in CRC.

Temporal Trends in Mental Disorder Rates among Patients with Colorectal Cancer: A Comprehensive Analysis

Background: Colorectal cancer (CRC) stands as one of the most prevalent and burdensome malignancies worldwide. Similar to other cancers, CRC has been associated with the development of psychiatric diseases, including anxiety and depression. However, temporal trends in psychiatric disorders rates within CRC patients have not been investigated so far. Methods: The present study included 15,619 individuals with colorectal cancer and 78,095 propensity score-matched individuals without cancer, who were identified within the Disease Analyzer (IQVIA) database in Germany between 2005 and 2022. Cox regression analysis was conducted to assess the association between CHC and subsequent psychiatric diseases, including depression, anxiety disorders, and adjustment disorder, by period (2005-2010, 2011-2016, 2017-2022). Results: The 12-month cumulative incidence of any psychiatric disorder diagnosis in the CRC cohort increased from 6.3% in 2005-2010 to 8.2% in 2017-2022. The strongest increase was observed for reaction to severe stress and adjustment disorder (1.0% in 2005-2010 to 2.6% in 2017-2022). Notably, the strong increase in psychiatric disorders was not specific for cancer patients since a slight increase in psychiatric disorders was also observed in the non-cancer cohort. Regression analyses revealed that CRC was strongly and significantly associated with an increased risk of depression, anxiety disorders, reaction to severe stress and adjustment disorders, as well as any psychiatric disorder. Of note, the extent of the association was stronger in 2017-2022 compared to 2005-2010, clearly proving a "real" increase in the rates of psychiatric disorders over time. Conclusions: This study presents novel data from a large cohort of outpatients in Germany, providing strong evidence for an increase in psychiatric disorders in the recent years. These findings contribute to the existing body of literature and should trigger the recognition of psychiatric problems in cancer survivors.

Biopsychosocial Late Effects After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Metastases from Colorectal and Appendiceal Cancer: A National Prospective Cohort Study

BACKGROUND

Colorectal cancer with peritoneal metastases can be treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Treatment may result in biopsychosocial late effects (LEs). We explored the frequency and severity of the following biopsychosocial LEs: anxiety, depression, fear of cancer recurrence (FCR), insomnia, fatigue, cognitive impairment, and pain, and evaluated their impact on quality of life (QoL).

METHOD

This was a national prospective cohort study screening for LEs during the period January 2021-May 2023. Patients completed the following questionnaires: General Anxiety Disorder-7, Patient Health Questionnaire-9, FCR Inventory-Short Form, Insomnia Severity Index, Functional Assessment of Chronic Illness Therapy-Fatigue, cognitive impairment (six items from the European Organisation for Research and Treatment of Cancer Item Library), and the Rectal Cancer Pain Score. Preregistration was completed at ClinicalTrials.gov (NCT04956107).

RESULT

In total, 99 patients were included. The mean age was 61 years and 57% were women. At 3 months after surgery, the frequent LEs were fatigue (72%), FCR (58%), and pain (48%), and at 12 months after surgery, the frequent LEs were FCR (65%), fatigue (40%), and insomnia (33%). More than half of the patients (54%) reported at least two LEs after 12 months. Patients with moderate-to-severe LEs reported a lower QoL than patients with no/mild LEs. Patients with no/mild LEs had a similar QoL as the Danish norm population.

CONCLUSION

Biopsychosocial LEs were prevalent. The QoL of patients reporting LEs in the worst severity categories was negatively impacted. Screening and treatment for these LEs should be a focus in cancer survivor follow-up.

Anxiety and depression during 3-year follow-up period in postoperative gastrointestinal cancer patients: prevalence, vertical change, risk factors, and prognostic value

BACKGROUND

Anxiety and depression are common issues in gastrointestinal cancer, bringing negative impacts on patients' quality of life and long-term prognosis. This study aimed to identify the prevalence, longitudinal variation, risk factors, and prognostic value of anxiety and depression in postoperative gastrointestinal cancer patients.

METHODS

A total of 320 gastrointestinal cancer patients after surgical resection (210 colorectal cancer (CRC) patients and 110 gastric cancer (GC) patients) were enrolled in this study. During the 3-year follow-up period, Hospital Anxiety and Depression Scale (HADS)-anxiety (HADS-A) and HADS-depression (HADS-D) scores were determined at baseline, 12th month (M12), 24th month (M24), and 36th month (M36).

RESULTS

The prevalence of anxiety and depression at baseline was 39.7% and 33.4% in postoperative gastrointestinal cancer patients, respectively. Female (vs. male), single/divorced/widowed (vs. married), CRC (vs. GC), hypertension, higher TNM stage, neoadjuvant chemotherapy, and postoperative complications were independent risk factors of anxiety or depression in patients with gastrointestinal cancer (all P < 0.050). Furthermore, anxiety (P = 0.014) and depression (P < 0.001) were associated with shortened overall survival (OS); after further adjustment, depression was independently linked with shortened OS (P < 0.001), while anxiety was not. During the follow-up period, HADS-A score (from 7.78 ± 3.180 to 8.57 ± 2.854, P < 0.001), HADS-D score (from 7.23 ± 2.711 to 8.01 ± 2.786, P < 0.001), anxiety rate (from 39.7 to 49.2%, P = 0.019), and depression rate (from 33.4 to 42.6%, P = 0.023) were all gradually increased from baseline to M36.

CONCLUSION

Anxiety and depression gradually exacerbate and relate to poor survival in postoperative gastrointestinal cancer patients.

Risk factors for new antidepressant use after surgery in Sweden: a nationwide, observational cohort study

Background

Whilst somatic complications after major surgery are being increasingly investigated, the research field has scarce data on psychiatric outcomes such as postoperative depression. This study evaluates the impact of patient and surgical factors on the risk of depression after surgery using the proxy measure of prescribed and collected antidepressants.

Methods

An observational, registry-based, national multicentre cohort study of individuals ≥18 yr of age who underwent noncardiac surgery between 2007 and 2014. Exclusion criteria included history of antidepressant use defined by collection of a prescription within 5 yr before surgery. Participants were identified using a surgical database from 23 Swedish hospitals and data were linked to National Board of Health and Welfare registers for collection of prescribed antidepressants. Descriptive statistics were used for baseline data and logistic regression for predictive factors.

Results

Of 223 617 patients, 4.9% had a new prescription of antidepressants collected 31-365 days after surgery. Antidepressant prescription was associated with increasing age, female sex, and more comorbidities. The incidence of antidepressant prescription was highest after neurosurgery, vascular, and thoracic surgery. Affective and anxiety disorders were risk factors. In the whole cohort and within the aforementioned surgical subtypes, acute and cancer surgery increased the risk of antidepressant prescription.

Conclusions

This study brings novel insights to the epidemiology of postoperative antidepressant treatment in antidepressant-naive patients. One in 20 postoperative patients are prescribed antidepressants but with knowledge of risk factors, interventional strategies can be tested.

Effect of multidisciplinary collaborative empowerment education on psychological distress and quality of life in patients with colorectal cancer undergoing chemotherapy

PURPOSE

To evaluate the effects of multidisciplinary collaborative empowerment education on psychological distress and quality of life (QoL) in patients with colorectal cancer undergoing chemotherapy.

METHODS

A quasi-experimental study was conducted using repeated measures at pre- and post-intervention in the fourth chemotherapy cycle. Sixty patients with colorectal cancer aged 36-84 years were allocated to the intervention and control groups. The intervention group received multidisciplinary empowerment education, while the control group received routine health education. Psychological distress involving depression and anxiety symptoms was assessed using The Kessler Psychological Distress Scale (K10) and QoL was measured using The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTCQLQ-C30). Repeated-measures analysis of variance was used to examine intervention effects. Statistical analyses were performed using the SPSS software (version 26.0).

RESULTS

Psychological distress was considerably lower and QoL was considerably better in patients following multidisciplinary empowerment education in the intervention group than those in the control group. In addition, psychological distress significantly decreased and QoL improved in the intervention group compared to baseline.

CONCLUSION

Multidisciplinary collaborative empowerment education was effective in improving the psychological distress and QoL among patients with colorectal cancer undergoing chemotherapy. These findings suggest that the establishment of multidisciplinary collaborative empowerment education might be considered as an innovative means of clinical patient education during combination chemotherapy to improve health outcomes in patients with colorectal cancer. However, our results should be interpreted with caution because of the small sample size. Further validation in a larger sample or randomized controlled design is necessary in the future.

A systematic review and meta-analysis on the effectiveness of web-based psychosocial interventions among patients with colorectal cancer

AIMS

To synthesize the effectiveness of web-based psychosocial interventions on self-efficacy, anxiety, depression, quality of life (QoL), non-specific psychological and cancer-specific distress among patients with colorectal cancer (CRC).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Six databases (PubMed, PsycINFO, Embase, Scopus, CINAHL and CNKI) were searched from inception to December 2021.

REVIEW METHODS

Experimental/quasi-experimental studies involving patients with CRC for the improvement of aforementioned outcomes were included. Two reviewers screened and extracted the data, and assessed studies' methodological quality using risk of bias tools. Meta-analyses and narrative syntheses were performed.

RESULTS

Nineteen studies consisting of 1386 participants were identified. Cognitive-behavioural therapy delivered online was the most common trialled web-based psychosocial intervention. Meta-analyses revealed no positive effect for self-efficacy (standardized mean difference 0.93, 95% CI: 0.52 to 1.35, p < .01) and minimal benefit for QoL (mean difference [MD] 2.83, 95% CI: -0.31 to 5.98, p = .08) but significant positive effects for anxiety (MD -2.23, 95% CI: -3.31 to -1.14, p < .01) and depression (MD -2.84, 95% CI: -4.09 to -1.59, p < .01) among CRC survivors in the intervention group as compared with the control group. Narrative synthesis suggested possible benefits in reducing distress.

CONCLUSION

Web-based psychosocial interventions are promising alternatives to conventional delivery methods in reducing patients' anxiety, depression and distress. However, evidence on self-efficacy and QoL remains inconsistent. More adequately powered, well-designed trials with targeted and theory-based interventions are required to ascertain findings.

IMPACT

By highlighting the potential of web-based psychosocial interventions in reducing anxiety and depression among CRC survivors, this review has put forth beneficial information supporting the use and acceptance of web-based care delivery in light of COVID-19 restrictions and nationwide lockdowns. Meanwhile, the paucity of empirical support reflects the necessity of more extensive research to test and improve other health outcomes. PROSPERO registration number: CRD42021261396.

Effects of a Single Sub-Anesthetic Dose of Ketamine on Postoperative Emotional Responses and Inflammatory Factors in Colorectal Cancer Patients

Objective: To investigate the effect of a single sub-anesthetic dose of ketamine on postoperative anxiety, depression, and inflammatory factors in patients with colorectal cancer. Methods: A total of 104 patients undergoing selective colorectal surgery in our hospital from Jan 2015 to Oct 2017 were included and randomly assigned (1:1:1:1) into a 0.1 mg kg^-1 ketamine group (K1 group), 0.2 mg kg^-1 ketamine group (K2 group), 0.3 mg kg^-1 ketamine group (K3 group), or control group (C group). Corresponding doses of ketamine were given intravenously in the K groups (K1, K2, and K3 groups) 5 min before operation, and the same amount of normal saline was given in the C group. The intravenous analgesia program was identical in the four groups. The patients' emotional reactions (anxiety and depression) were assessed by the Hospital Anxiety and Depression Scale (HAD), the quality of postoperative recovery was evaluated by the Quality of Recovery-40 (QoR-40) questionnaire, and the levels of IL-6, IL-8, and TNF-α in peripheral blood were detected by enzyme-linked immunosorbent assay (ELISA) on the day before operation and within 24, 48, and 72 h post-operation respectively. Pain was estimated by the visual analog scale (VAS), and sedation was assessed with Ramsay score 30 min after extubation. The time points of anesthetic end and extubation were recorded. The complications during anesthesia and recovery such as cough and agitation 30 min after extubation were recorded. Results: The anxiety score (HAD-A) and depression score (HAD-D) of the K3 group were significantly lower than those of the C group post-operation (p < 0.05). The QoR-40 score of the K3 group was significantly higher than that of the C group (p < 0.05). The serum levels of IL-6, IL-8, and TNF-α in the K3 group were significantly lower than those in the C group (p < 0.05 and p < 0.01). There were no significant differences in HAD-A, HAD-D, and QoR-40 scores or serum levels of IL-6, IL-8, and TNF-α between the K1 and K2 groups and the C group. There were no significant differences in VAS pain score or Ramsay sedation score among the four groups 30 min after extubation. There were no significant differences in extubation time, postoperative cough, emergence agitation, or delirium among the four groups. Dizziness, nausea, vomiting, diplopia, or other adverse reactions were not found 30 min after extubation. Conclusion: A single sub-anesthetic dose (0.3 mg kg^-1) of ketamine can significantly improve the postoperative anxiety and depression of colorectal cancer patients and reduce the levels of IL-6, IL-8, and TNF-α.

A Randomized Controlled Pilot Study of Yoga Skills Training Versus an Attention Control Delivered During Chemotherapy Administration

CONTEXT

It is important to address fatigue and co-occurring symptoms during chemotherapy to preserve quality of life in patients with gastrointestinal (GI) cancer.

OBJECTIVE

To conduct a randomized controlled pilot study of a Yoga Skills Training (YST) intervention compared to an attention control (AC) among adults diagnosed with GI cancer.

METHODS

YST consisted of four 30-minute sessions delivered individually during chemotherapy plus home practice. AC provided empathic attention plus home diaries. Patient-reported (PROMIS T-score) assessments of fatigue, depressive symptoms, sleep disturbances, and psychological stress (Perceived Stress Scale) were collected at chemotherapy visits: baseline, Week 8, Week 10 and Week 14, and analyzed using a mixed effects model. Inflammatory cytokines were assessed at baseline and Week 10.

RESULTS

Forty-four of 77 adults approached agreed to participate (57%; YST n = 23; AC n = 21). Participants' mean age was 58 years and 48% were men. Participants randomized to YST reported a larger decline in fatigue (-2.4 difference, d = 0.30) and depressive symptoms (-2.5 difference, d = 0.30) than AC participants from baseline to Week 10 and sleep disturbances at Week 8 (-3.9 difference, d = 0.50). Differences in magnitude of change in symptoms were consistent with or exceeded a minimally important difference. Psychological stress decreased more in the AC at Week 10 (d = 0.30). Reductions in inflammatory cytokines (IL-6, sTNF R1) were larger in the YST group than AC.

CONCLUSION

YST showed promise for improving fatigue, depressive symptoms, sleep disturbances, and inflammation. YST is also feasible and reaches patients underrepresented in yoga research (i.e., GI cancer, men), thus warranting further examination.

Exploring the effectiveness of a patient-tailored integrative oncology program on emotional distress during chemotherapy for localized cancer

STUDY OBJECTIVE

There is a need to explore how patient-tailored integrative oncology (IO) programs reduce emotional distress. This study set out to bridge the IO research gap between non-specific, quality of life-related and specific emotional-related concerns in chemotherapy-treated patients.

METHODS

This pragmatic, prospective and preference-controlled study examined patients attending an integrative-physician consultation and weekly IO treatments during adjuvant/neo-adjuvant chemotherapy for localized cancer. Patients choosing to attend ≥4 IO sessions (highly adherent to integrative care, AIC) were compared to low AIC patients using the ESAS (Edmonton Symptom Assessment Scale) anxiety, depression and sleep; and the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) emotional functioning scale, at baseline, 6 and 12 weeks. Emotional distress was assessed by ESAS anxiety and depression, considered as the primary study outcomes.

RESULTS

Of 439 participants, 260 (59%) were high-AIC and 179 low-AIC, both with similar baseline demographic and cancer-related characteristics. At 6 weeks, high-AIC patients reported greater improvement on ESAS sleep (p = 0.044); within-group improvement on ESAS anxiety and; and EORTC emotional functioning. Compared with low-AIC, high-AIC patients showed greater improvement on ESAS depression (p = 0.022) and sleep (p = 0.015) in those with high baseline ESAS anxiety scores (≥7); and ESAS anxiety (p = 0.049) for patients moderately anxious (4-6) at baseline.

CONCLUSIONS

High-AIC was associated with significantly reduced anxiety, depression and sleep severity at 6 weeks, especially those with high-to-moderate baseline anxiety levels. These findings reduce the research gap, suggesting specific emotional-related effects of IO.

Food Insecurity Is an Independent Risk Factor for Depressive Symptoms in Survivors of Digestive Cancers

BACKGROUND

Colorectal and other digestive cancer survivors are at increased risk of depression, which can negatively affect health outcomes. Food insecurity (FI), the lack of consistent access to enough food, can also contribute to these health complications. The objective of this study was to determine the relationship between FI and depressive symptoms within this population.

METHODS

We conducted a cross-sectional analysis of data from the 2007-2016 National Health and Nutrition Examination Survey. We included all adults (≥20 years) with a self-reported history of a digestive cancer (including colorectal, esophageal, stomach, liver, and pancreas cancer). Our primary exposure was household FI, and our outcome of interest was depressive symptoms, as measured by the validated 9-item Patient Health Questionnaire. We used multivariable ordinal logistic regression to test the association between FI and depressive symptoms, controlling for demographic and clinical covariates.

RESULTS

We included 229 adult digestive cancer survivors (weighted N = 1,510,579). The majority of the study sample was female and non-Hispanic White with mean of 11.0 years since cancer diagnosis; 14.3% reported FI. In multivariable models controlling for demographic and clinical covariates, we found that food insecure digestive cancer survivors had significantly higher odds of depressive symptoms than food secure digestive cancer survivors (OR: 3.25; 95% confidence interval: 1.24-8.55; P = 0.02).

CONCLUSIONS

Among a nationally representative sample of colorectal cancer and other digestive cancer survivors, FI was associated with increased odds of depressive symptoms.

IMPACT

This study adds further evidence to the negative impact FI may have on survivors' physical and mental health.

Factors Related to Resilience, Anxiety/Depression, and Quality of Life in Patients with Colorectal Cancer Undergoing Chemotherapy in Japan

Objective:

This study clarifies the relationship between resilience and anxiety and depression, quality of life (QOL), and other related factors that influence colorectal cancer patients undergoing chemotherapy.

Methods:

This cross-sectional study focused on outpatients with colorectal cancer undergoing chemotherapy. A questionnaire including the Connor-Davidson Resilience Scale, Hospital Anxiety and Depression Scale, the MOS 12-item Short-Form Health Survey, and items based on a literature review was administered between August 2019 and August 2020. SPSS version 26 was used for data analysis. Correlation analysis and t-test were applied. In addition, Amos version 26 was used and structural equation modeling was applied to create a causal model.

Results:

A total of 121 participants (94.5%) were included in the study. The goodness of fit (GFI) of the causal model was GFI = 0.94, adjusted GFI = 0.906, comparative fit index = 0.997, and root mean square error of approximation = 0.011. Resilience had a negative effect on anxiety and depression and a positive effect on QOL. Depression had a negative effect on QOL.

Conclusions:

The results of this study indicate that resilience is a predictor of anxiety, depression, and QOL in colorectal cancer patients undergoing chemotherapy. Therefore, I believe that it is important to enhance resilience in order to maintain and improve patients’ mental health and QOL. In addition, since resilience was affected by cancer metastasis and the presence of metastasis was a predictor of resilience, it is a challenge to explore interventions to enhance resilience, especially in patients with metastasis.

The effect of reminiscence therapy-involved care on anxiety, depression, life quality and survival in colorectal cancer patients

OBJECTIVES

This study aimed to investigate the effect of reminiscence therapy-involved care (RTC) program on anxiety, depression, quality of life and survival in colorectal cancer (CRC) patients.

METHODS

There were 210 post-resection CRC patients recruited and randomly received RTC (N = 105) or control care (CC) (N = 105) for 12 months. Their anxiety, depression and quality of life were assessed using Hospital Anxiety and Depression Scale (HADS) and European Organization for Research and Treatment of Cancer quality of life Questionnaire-Core 30 (QLQ-C30) at baseline (Month (M) 0), M3, M6 and M12. Patients were further followed up to 36 months, followed by the overall survival (OS) calculation.

RESULTS

HADS-anxiety score was decreased at M6/M12 and anxiety patients' percentage was reduced at M12 in RTC group compared with CC group; HADS-depression score was lower at M6/M12, while depression patients' percentage was similar at each time point in RTC group compared with CC group; QLQ-C30 global health status score and QLQ-C30 functions score were increased at M6/M12, while QLQ-C30 symptoms score was similar at each time point in RTC group compared with CC group. Further sub-group analysis displayed that: in patients with age ≥65 years, patients with pathological grade G2 and patients with TNM stage Ⅱ-Ⅲ, RTC showed more remarkable effect. Additionally, OS showed a higher trend in RTC group compared with CC group, but without statistical difference.

CONCLUSION

RTC contributes to anxiety and depression alleviations as well as the quality of life improvement in CRC patients.

Interleukin 8 as predictive factor for response to chemotherapy in colorectal cancer patients

Background: Colorectal cancer (CRC) represents a major public health problem owing to the fact that many patients are diagnosed in locally advanced or metastatic stage when chemotherapy is the only remaining option. However, treatment response is still unpredictable and depends upon a diversity of factors such as tumor inherited or acquired drug resistance and the host immune response to the malignant cells. The aim of this study was to evaluate the serum levels of interleukin 6, 8, 10 (IL-6, 8, 10) as possible predictive factors for response to chemotherapy and the correlation between the cytokines and the psychological distress.Methods: Forty-nine patients undergoing chemotherapy for locally advanced or metastatic CRC were included, for each patient IL-6, 8 and 10 were assessed through ELISA. Depression and anxiety were quantified through questionnaires. Statistical data were performed with GraphPad.Results: Patients with CRC had high serum levels of IL-8 and IL-6 compared to the healthy control group. High levels of IL-8 before treatment were correlated with progressive disease. There was a high incidence of psychological complication in CRC patients, especially in young male patients, from an urban area, with a positive correlation between serum levels of IL-8 and depression.Conclusions: These results indicate that high serum levels of IL-8 are predictive factors in CRC patients that undergo chemotherapy, but also could be useful in identifying psychological distress associated with this pathology.

Associations among marijuana use, health-related quality of life, exercise, depression and sleep in cancer survivors

AIMS

To assess associations among cannabis use, health-related quality of life, exercise, depression and sleep among a nationally representative sample of US adults living with cancer.

DESIGN

A cross-sectional correlational study.

METHODS

We used survey data from the 2016-2018 Behavioral Risk Factor Surveillance System. Analyses were considered for sample weights and the complex designs. Logistic regression was performed to assess associations among cannabis use (0, 1-19, vs. 20-30 [frequent] days), health-related quality of life (0-13 vs. ≥14 mentally or physically unhealthy days in the past 30 days; 0-13 vs. ≥14 functionally limited days), exercise, depression, and sleep after accounting for covariates. Reason for cannabis use (medical vs. non-medical) was also assessed.

RESULTS

Frequent users had significantly more physically unhealthy days (adjusted odds ratio [OR]: 1.79, 95% CI: 1.28-2.51, p < .01) and reported ≥ 14 mentally unhealthy days (adjusted OR: 2.43, 95% CI: 1.78-3.32, p < .001) and depression (adjusted OR: 2.65, 95% CI: 1.97-3.57, p < .001) compared with non-users. A positive relationship between frequency of cannabis use and depression existed only among non-medical cannabis users.

CONCLUSION

Cancer survivors using cannabis frequently (20 days+ in the past month) had poorer mental health-related quality of life. The reason for cannabis use as well as frequency of use may be important considerations in predicting depression.

IMPACT

This is the first study that evaluates the associations among cannabis use, the purpose of cannabis use, HRQoL, exercise, depression and sleep in a nationally representative sample of US adults living with cancer. Frequent cannabis users are likely vulnerable to poorer mental health-related quality of life and depression, and non-medical cannabis use in frequent users was associated with depression. Given expanding medical cannabis legalization, these findings warrant further attention so that this information can be used by people living with cancer in decision-making for symptom self-management.

Incremental patient care program decreases anxiety, reduces depression and improves the quality of life in patients with colorectal cancer receiving adjuvant chemotherapy

Colorectal cancer (CRC) is a serious disease that may lead to the occurrence of anxiety and depression; however, at present, little is known about the role of care intervention in the mental health of patients with CRC receiving adjuvant chemotherapy. Hence, an incremental patient care program (IPCP) was designed and its effects on anxiety, depression and quality of life (QoL) in patients with CRC receiving adjuvant chemotherapy was assessed. A total of consecutivel 298 patients with CRC who had undergone surgery were recruited for the present randomized, controlled study. Patients were randomly assigned to the IPCP group or the control group at a 1:1 ratio. In the IPCP group, patients received IPCP and conventional care, whereas in the control group, patients received only conventional care. The sp ecific interventions included in IPCP were patient health education, physical exercise, telephone counseling, regular examinations and care activities. Anxiety, depression and QoL were assessed using the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment of Cancer QoL Questionnaire (QLQ-C30) scale. IPCP slightly decreased the anxiety grade at month (M) 6 compared with that of the controls (P=0.070). The IPCP group exhibited a significant improvement in the HADS depression score at M6 vs. M0 (P<0.001), and the depression grade was reduced in the IPCP group compared with that in the controls (P=0.037). Regarding QoL, the QLQ-C30 global health status score at M6 vs. M0 was increased (P=0.035) and the QLQ-C30 symptoms score at M6 vs. M0 was decreased (P=0.002) in the IPCP group compared with that in the controls, but no difference was observed in the QLQ-C30 function score between the two groups. Subgroup analysis by tumor-nodes-metastasis stage (II or III) demonstrated similar trends to those mentioned above. In conclusion, participation in the IPCP led to a slight decrease in anxiety, and contributed to a significant reduction in depression and an improvement in QoL in patients with CRC receiving adjuvant chemotherapy.

Prevalence of Depression and Anxiety in Colorectal Cancer Patients: A Literature Review

Background: We aimed to review published studies to obtain the best estimate of the risk of depression and anxiety among colorectal cancer (CRC) patients. Methods: We searched the PubMed/Medline database, Web of Science, and Google Scholar on the prevalence of depression or anxiety in CRC patients. A review of 15 studies published between June 1967 and June 2018 were conducted, and 93,805 CRC patients were included. Results: The prevalence of depression among patients diagnosed with CRC ranged from 1.6%⁻57%, and those of anxiety ranged from 1.0%⁻47.2%. Studies in which an expert (psychiatrist) administered the interviews reported lower prevalence of both depression and anxiety. Conclusion: The findings of this review suggest that patients with CRC exhibited a significantly high prevalence of both depression and anxiety, and these symptoms can persist even after cancer treatment is completed. However, the correlation of age and the emergence of depression or anxiety in CRC patients still remain controversial.

Demographic Pattern and Hospitalization Outcomes of Depression among 2.1 Million Americans with Four Major Cancers in the United States

OBJECTIVE

To compare the prevalence of depression in the four most common cancers in the US and evaluate differences in demographics and hospital outcomes.

METHODS

This was a cross-sectional study using the Nationwide Inpatient Sample (2010⁻2014). We selected patients who had received ICD-9 codes of breast, lung, prostate, and colorectal cancers and major depressive disorder (MDD). Pearson's chi-square test and independent sample t-test were used for categorical and continuous data, respectively.

RESULTS

MDD prevalence rate was highest in lung cancer (11.5%), followed by breast (10.3%), colorectal (8.1%), and prostate cancer (4.9%). Within colorectal and lung cancer groups, patients with MDD were significantly older (>80 years, p < 0.001) than non-MDD patients. Breast, lung, and colorectal cancer showed a higher proportion of female and Caucasian in the MDD group. Severe morbidity was seen in a greater proportion of the MDD group in all cancer types. The mean inpatient stay and cost were higher in the MDD compared to non-MDD group.

CONCLUSION

Particular attention should be given to elderly, female, and to lung cancer patients with depression. Further studies of each cancer type are needed to expand our understanding of the different risk factors for depression as a higher proportion of patients had severe morbidity.

Intervention Protocol for Investigating Yoga Implemented During Chemotherapy

OBJECTIVE

Fatigue and other treatment-related symptoms are critical therapeutic targets for improving quality of life in patients with colorectal cancer during chemotherapy. Yoga is a promising intervention for improving these therapeutic targets and has been primarily investigated in the group-class format, which is less feasible for cancer patients with high symptom burden to attend. Thus, we developed a protocol for implementing yoga individually in the clinic among patients receiving chemotherapy.

METHODS

We followed recommended domains for developing a yoga protocol to be used in an efficacy trial. These recommendations include consideration to the style, delivery, components of the intervention, dose, specific class sequences, facilitation of home practice, measurement of intervention fidelity, selection of instructors, and dealing with modifications. The intervention protocol was developed by an interdisciplinary team.

PROTOCOL

Yoga Skills Training (YST) consists of four 30-minute in-person sessions and was implemented while in the chair during chemotherapy infusions for colorectal cancer with recommended daily home practice for eight weeks. Therapeutic goals of the YST are to reduce fatigue, circadian disruption, and psychological distress. Elements of the YST are awareness meditation, gentle seated movement, breathing practice, and relaxation meditation. Attention, comfort, and ease are also highlighted.

CONCLUSION

This description of a protocol for integrating yoga with conventional cancer treatment will inform future study designs and clinical practice. The design of the YST is novel because it implements yoga-most commonly studied when taught to groups outside of the clinical setting- individually during clinical care.

The effect of therapeutic listening on anxiety and fear among surgical patients: randomized controlled trial

OBJECTIVE

To investigate the effect of therapeutic listening on state anxiety and surgical fears in preoperative colorectal cancer patients.

METHOD

A randomized controlled trial with 50 patients randomly allocated in the intervention group (therapeutic listening) (n = 25) or in the control group (n = 25). The study evaluated the changes in the variables state anxiety, surgical fears and physiological variables (salivary alpha-amylase, salivary cortisol, heart rate, respiratory rate and blood pressure).

RESULTS

In the comparison of the variables in the control and intervention groups in pre- and post-intervention, differences between the two periods for the variables cortisol (p=0.043), heart rate (p=0.034) and surgical fears (p=0.030) were found in the control group, which presented reduction in the values ​​of these variables.

CONCLUSION

There was no reduction in the levels of the variables state anxiety and surgical fears resulting from the therapeutic listening intervention, either through the physiological or psychological indicators. However, the contact with the researcher during data collection, without stimulus to reflect on the situation, may have generated the results of the control group. Clinical Trial Registration: NCT02455128.

Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival

By ignoring the root causes of disease and neglecting to prioritize lifestyle measures for prevention, the medical community is placing people at harm. Advanced nations, influenced by a Western lifestyle, are in the midst of a health crisis, resulting largely from poor lifestyle choices. Epidemiologic, ecologic, and interventional studies have repeatedly indicated that most chronic illnesses, including cardiovascular disease, cancer, and type 2 diabetes, are the result of lifestyles fueled by poor nutrition and physical inactivity.In this article, we describe the practice of lifestyle medicine and its powerful effect on these modern instigators of premature disability and death. We address the economic benefits of prevention-based lifestyle medicine and its effect on our health care system: A system on the verge of bankruptcy. We recommend vital changes to a disastrous course. Many deaths and many causes of pain, suffering, and disability could be circumvented if the medical community could effectively implement and share the power of healthy lifestyle choices. We believe that lifestyle medicine should become the primary approach to the management of chronic conditions and, more importantly, their prevention. For future generations, for our own health, and for the Hippocratic Oath we swore to uphold ("First do no harm"), the medical community must take action. It is our hope that the information presented will inspire our colleagues to pursue lifestyle medicine research and incorporate such practices into their daily care of patients. The time to make this change is now.

Study protocol of the CORRECT multicenter trial: the efficacy of blended cognitive behavioral therapy for reducing psychological distress in colorectal cancer survivors

BACKGROUND

Approximately one third of the colorectal cancer survivors (CRCS) experience high levels of psychological distress. Common concerns experienced by CRCS include distress related to physical problems, anxiety, fear of cancer recurrence (FCR) and depressive symptoms. However, psychological interventions for distressed CRCS are scarce. Therefore, a blended therapy was developed, combining face-to-face cognitive behavioral therapy (CBT) with online self-management activities and telephone consultations. The aim of the study is to evaluate the efficacy and cost-effectiveness of this blended therapy in reducing psychological distress in CRCS.

METHODS/DESIGN

The CORRECT study is a two-arm multicenter randomized controlled trial (RCT). A sample of 160 highly distressed CRCS (a score on the Distress Thermometer of 5 or higher) will be recruited from several hospitals in the Netherlands. CRCS will be randomized to either the intervention condition (blended CBT) or the control condition (care as usual). The blended therapy covers approximately 14 weeks and combines five face-to-face sessions and three telephone consultations with a psychologist, with access to an interactive self-management website. It includes three modules which are individually-tailored to patient concerns and aimed at decreasing: 1) distress caused by physical consequences of CRC, 2) anxiety and FCR, 3) depressive symptoms. Patients can choose between the optional modules. The primary outcome is general distress (Brief Symptom Inventory-18). Secondary outcomes are quality of life and general psychological wellbeing. Assessments will take place at baseline prior to randomization, after 4 and 7 months.

DISCUSSION

Blended CBT is an innovative and promising approach for providing tailored supportive care to reduce high distress in CRCS. If the intervention proves to be effective, an evidence-based intervention will become available for implementation in clinical practice.

TRIAL REGISTRATION

This trial is registered in the Netherlands Trial Register ( NTR6025 ) on August 3, 2016.

Effect of psychosocial interventions on the quality of life of patients with colorectal cancer: a systematic review and meta-analysis

Background

We conducted a systematic review and meta-analysis of randomized controlled trials examining the effect of psychosocial interventions on the quality of life of patients with colorectal cancer.

Methods

We searched the main health-related databases for relevant papers. Then, we examined the titles and abstracts of the retrieved papers, applying exclusion criteria to filter out irrelevant papers; a more in-depth filtering process was then conducted by reading the full texts. Eight studies remained at the end of this process. Next, we performed data extraction and assessed the methodological quality of the selected studies. This was followed by computation of effect sizes and the heterogeneity of the results, and then an assessment of the potential bias.

Results

The systematic review found that most of the interventions in these eight studies did not have a significant effect on quality of life. Meanwhile, the meta-analysis, the overall effect of psychosocial interventions at the post-intervention period was found to be statistically significant but small.

Conclusions

This meta-analysis provides evidence for the beneficial effect of face-to-face psychosocial interventions on the quality of life of colorectal cancer patients. It is, however, suggested that further studies be conducted on this topic to assess the roles of physical functioning and severity of symptoms before utilizing such face-to-face interventions.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0943-6) contains supplementary material, which is available to authorized users.

Pelvic floor outcomes in patients who have undergone general rehabilitation following surgery for colorectal cancer: A pilot study

BACKGROUND

There is a paucity of evidence on changes in pelvic floor outcomes in patients with colorectal cancer (CRC) following general oncology rehabilitation.

OBJECTIVE

In patients following surgery for CRC, to explore changes in pelvic floor muscle function before and after a general oncology rehabilitation program; and to compare pelvic floor symptoms in patients undergoing the rehabilitation program to a matched control group.

METHODS

This pilot study was conducted as an observational study nested within a prospective study evaluating the feasibility of a general oncology rehabilitation program for patients following surgery for abdomino-pelvic cancer. In this nested study, pelvic floor muscle function was measured in 10 participants with CRC (rehabilitation group) before and immediately after the 8-week rehabilitation program and at 6-month follow-up. Data of 10 matched participants from the prospective study who completed questionnaires only at the same assessment time points were used as a control group. Symptom measurement tools were the Australian Pelvic Floor Questionnaire (APFQ) and the International Consultation on Incontinence Questionnaire-Bowel module (ICIQ-B). Descriptive statistics were used to summarize data on pelvic floor muscle function of the rehabilitation group, and repeated measures analysis of variance was used to assess within- and between-group changes in pelvic floor symptom scores over time in the rehabilitation group and control group matched for gender and level of tumor.

RESULTS

Scores in the bowel domain of the APFQ (p = 0.037) and bowel control domain of the ICIQ-B (p = 0.026) improved in the rehabilitation group only and the improvement in ICIQ-B was sustained at 6-month follow-up. There were no significant differences in bladder and bowel symptoms between the rehabilitation and matched control groups (p > 0.05) at any assessment time-point.

CONCLUSIONS

Patients undergoing a general rehabilitation program following surgery for CRC demonstrated improved bowel symptoms from pre- to post-rehabilitation program; however, there were no differences when compared with matched controls who did not undertake rehabilitation. Further studies with larger sample sizes and longer-term follow-up are needed confirm these findings.

Efficacy and safety of celecoxib monotherapy for mild to moderate depression in patients with colorectal cancer: A randomized double-blind, placebo controlled trial

Cancer-related inflammation is an essential process in malignancies. Celecoxib, a nonsteroidal anti-inflammatory drug that acts via the selective inhibition of cyclooxygenase (COX)-2, has shown favorable effects in several psychiatric disorders. The present study aimed to assess the safety and efficacy of celecoxib single therapy on depressive symptoms of patients with colorectal cancer who underwent chemotherapy. The study was conducted as a 6-week, parallel-group, randomized, double-blind, placebo-controlled trial. Forty participants randomly received either 400mg/day celecoxib or placebo. Treatment effect was assessed using the Hamilton Depression Rating Scale (HDRS) and Visual Analogue Scale (VAS) score at baseline and at week 2, 4 and 6 of the trial. Over 6 weeks, patients who received celecoxib showed significant improvement in scores of the Hamilton Depression rating Scale (P=0.003). When comparing the Mean Difference (95% CI) between the two groups of therapy, the celecoxib group demonstrated greater reduction in HDRS score during the study period at weeks 4 (1.95, 95% CI 0.27-3.63, P value =0.024) and 6 (2.60, 95% CI 0.96-4.23, P=0.003). This study indicates celecoxib as a potential monotherapy treatment strategy for mild to moderate depression in patients with colorectal cancer who underwent chemotherapy.

Association of KRAS gene mutations with depression in older metastatic colorectal cancer patients

BACKGROUND

Cancer patients with depression or anxiety have poor survival, and the interaction between mental and physical problems in older patients may exacerbate this problem. K-ras oncogene (KRAS) mutation may play a role in the development of psychosocial distress and may be associated with poor survival of metastatic colorectal cancer (mCRC) patients. This study investigated the association between KRAS gene mutations and psychosocial morbidity to explore the possible cancer/psychosis relationship in older mCRC patients.

METHODS

In this study, 62 newly diagnosed mCRC patients were recruited and completed the Hospital Anxiety and Depression Scale (HADS). Demographic data were also collected, and clinicopathological data were retrieved from medical records. KRAS mutations were assessed via PCR analysis of tissue specimens from the patients.

RESULTS

The results showed that 28 of the 62 participants (45.2%) had positive screens for possible depression, and 45 of the 62 participants (72.6%) had positive screens for anxiety. The KRAS mutation rate was 40.3% (25/62), and 19 of the 25 patients with KRAS mutations (76.0%) had probable depression, whereas only 24.3% of the patients with wild-type KRAS were probably depressed (p < 0.05). The KRAS mutation was associated with higher HADS depression scores, independent of gender and performance status (p < 0.05), but not with higher HADS anxiety or total scores.

CONCLUSIONS

KRAS mutations were associated with depression severity and higher rates of probable depression in older mCRC patients. Depression should be assessed and treated as early as possible in older mCRC patients with the KRAS mutation. Further studies are needed to verify our current findings using a larger sample size.

Depressive symptoms in older long-term colorectal cancer survivors: a population-based analysis using the SEER-Medicare healthcare outcomes survey

PURPOSE

Colorectal cancer survivorship has improved significantly over the last 20 years; however, few studies have evaluated depression among older colorectal cancer survivors, especially using a population-based sample. The aim of this study was to identify correlates for positive depression screen among colorectal cancer survivors who underwent potentially curative surgery.

METHODS

Using the 1998-2007 Surveillance, Epidemiology, and End-Result registry and the Medicare Health Outcome Survey linked dataset, we identified patients over 65 with pathology confirmed and resected colorectal cancer enrolled in Medicare. Using univariate and multiple variable analyses, we identified characteristics of patients with and without positive depression screen.

RESULTS

Resected colorectal cancer patients (1785) (median age 77, 50.8 % female) were identified in the dataset with 278 (15.6 %) screening positive for symptoms of depression. Median time from diagnosis to survey was 62 months. On univariate analysis, larger tumor size, advanced cancer stage, and extent of resection were not correlates of depressive symptoms (all p > 0.05). After adjusting for confounders, income less than US$30,000 per year (OR 1.50, 1.02-2.22, 95 % CI, p = 0.042), non-white race (OR 1.51, 1.05-2.17, 95 % CI, p = 0.027), two or more comorbidities (OR 1.78, 1.25-2.52, 95 % CI, p = 0.001), and impairment in activities of daily living (OR 5.28, 3.67-7.60, 95 % CI, p < 0.001) were identified as independent correlates of depressive symptoms in colorectal cancer survivors.

CONCLUSIONS

In the current study, socioeconomic status and features of physical health rather than tumor characteristics were associated with symptoms of depression among long-term colorectal cancer survivors.

Web-based collaborative care intervention to manage cancer-related symptoms in the palliative care setting

BACKGROUND

The aim of this study was to examine the efficacy of a collaborative care intervention in reducing depression, pain, and fatigue and improve quality of life.

METHODS

A total of 261 patients with advanced cancer and 179 family caregivers were randomized to a web-based collaborative care intervention or enhanced usual care. The intervention included the following: 1) a web site with written and audiovisual self-management strategies, a bulletin board, and other resources; 2) visits with a care coordinator during a physician's appointment every 2 months; and 3) telephone follow-up every 2 weeks. Primary patient outcomes included measures of depression, pain, fatigue, and health-related quality of life. Secondary outcomes included Interleukin (IL)-1α, IL-1β, IL-6, and IL-8 levels, Natural Killer (NK) cell numbers, and caregiver stress and depression.

RESULTS

At the baseline, 51% of the patients reported 1 or more symptoms in the clinical range. For patients who presented with clinical levels of symptoms and were randomized to the intervention, reductions in depression (Cohen's d = 0.71), pain (Cohen's d = 0.62), and fatigue (Cohen's d = 0.26) and improvements in quality of life (Cohen's d = 0.99) were observed when compared to those in the enhanced usual car arm at 6 months. Reductions in IL-6 (φ = 0.18), IL-1β (φ = 0.35), IL-1α (φ = 0.19), and IL-8 (φ = 0.15) and increases in NK cell numbers (φ = 0.23) were observed in comparison with enhanced usual care arm at 6 months. Reductions in caregiver stress (Cohen's d = 0.75) and depression (Cohen's d = 0.37) were observed at 6 months for caregivers whose loved ones were randomized to the intervention arm.

CONCLUSIONS

The integration of screening and symptom management into cancer care is recommended.

Depression, Fatigue, and QoL in Colorectal Cancer Patients During and After Treatment

In this study, we sought to explore the prevalence of depression and fatigue in colorectal cancer patients during and after treatment to examine how these variables affect quality of life (QoL). In total, 170 patients with colorectal cancer participated in this study. The study population was divided into two groups: one receiving treatment and another that had finished treatment. The results showed that depression and fatigue measurements were higher in patients receiving treatment. Depression was a strong and significant predictor of QoL in both groups, whereas fatigue was not, with the exception of the symptom score. These findings underscore the importance of early detection and management of depression and fatigue during the treatment and survival stages of patients with colorectal cancer. Our findings indicate that health care professionals should provide appropriate nursing intervention to decrease depression and fatigue and enhance patient QoL.

American Cancer Society Colorectal Cancer Survivorship Care Guidelines

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer death in both men and women and second leading cause of cancer death when men and women are combined in the United States (US). Almost two-thirds of CRC survivors are living 5 years after diagnosis. Considering the recent decline in both incidence and mortality, the prevalence of CRC survivors is likely to increase dramatically over the coming decades with the increase in rates of CRC screening, further advances in early detection and treatment and the aging and growth of the US population. Survivors are at risk for a CRC recurrence, a new primary CRC, other cancers, as well as both short-term and long-term adverse effects of the CRC and the modalities used to treat it. CRC survivors may also have psychological, reproductive, genetic, social, and employment concerns after treatment. Communication and coordination of care between the treating oncologist and the primary care clinician is critical to effectively and efficiently manage the long-term care of CRC survivors. The guidelines in this article are intended to assist primary care clinicians in delivering risk-based health care for CRC survivors who have completed active therapy.

Proinflammatory cytokines correlate with depression and anxiety in colorectal cancer patients

The objective of this study was to investigate whether serum cytokine levels correlate with depression and anxiety in colorectal cancer (CRC) patients. Twenty patients hospitalized for surgical resection of CRC were included in the study group and twenty healthy volunteers comprised the control group. Depression and anxiety were analyzed using the Hospital Anxiety and Depression Scale (HADS), and serum levels of IL-1β, IL-6, IL-8, IL-10, IL-12, TNF-α, and TGF-β were measured by Cytometric Bead Array. We found that more than half of CRC patients presented clinically significant levels of anxiety or depression, and 65% of them manifested a combination of severe anxiety and depression. CRC patients had increased serum levels of IL-1β, IL-6, IL-8, and TNF-α but lower IL-10 concentrations. Correlation analysis between HADS score and cytokine levels revealed a positive association of anxiety and/or depression with IL-1β, IL-6, IL-8, and TNF-α and a negative correlation with IL-10. These results indicate that circulating proinflammatory cytokines are involved in the pathophysiology of anxiety and depression in CRC patients. A better understanding of the molecular mechanisms involved in these psychological disorders will allow the design of therapeutic interventions that lead to an improved quality of life and overall survival of CRC patients.

Prevalence of anxiety and depression and their risk factors in Chinese cancer patients

PURPOSE

This paper aimed to obtain information on the levels of anxiety and depression among cancer patients in China. The factors influencing these psychological problems were also analyzed.

METHODS

A total of 1,217 cancer patients were interviewed, and each participant was asked to complete a self-administered questionnaire. The anxiety status, depression status, disease stage, tumor site, pain status, and performance status of the patients during the week prior to the interview were assessed.

RESULTS

The anxiety and depression prevalence rates were 6.49 and 66.72 %, respectively. The prevalence rates of depression were 60.62 % for head and neck cancer, 77.19 % for lung cancer, 57.9 % for breast cancer, 75.81 % for esophagus cancer, 63.40 % for stomach cancer, 68.42 % for liver cancer, 54.37 % for colorectal cancer, and 71.13 % for cervix cancer. The factors influencing depression of patients were performance status (P < 0.0001), pain (P = 0.0003), age (P < 0.0001), and education level (P < 0.0001). The risk factors of anxiety were performance status (P = 0.0007), age (P < 0.0001), and gender (P < 0.0001).

CONCLUSIONS

Depression was a more important psychological problem than anxiety in cancer patients. Compared with 3.8 % of the prevalence of depression in normal population, depression level was high among Chinese cancer patients. Patients with lung, esophagus, and cervix cancers were the high-risk groups for depression. Poor performance status, pain, old age, and low-level education were the predicting factors for depression.

Fatigue, depression, sleep, and activity during chemotherapy: daily and intraday variation and relationships among symptom changes

BACKGROUND

Previous research suggests that cancer patients frequently experience multiple symptoms during chemotherapy; however, relationships among symptom changes are largely unknown.

PURPOSE

The aim of the current study was to examine daily and intraday changes and interrelationships among fatigue, depression, and objectively measured disruptions in sleep and activity during chemotherapy.

METHODS

Participants were 78 women with gynecologic cancer. Fatigue, depression, sleep, and activity were assessed the week before and the week after the participants' first three infusions.

RESULTS

Significant changes in fatigue, depression, sleep, and activity were observed over time. Before infusions, increases in fatigue were associated with increases in depression. After infusions, increases in fatigue were associated with increases in depression and minutes awake at night, as well as decreases in daytime activity and regularity of sleep/activity patterns (ps < .05).

CONCLUSIONS

This study is among the first to track daily and intraday changes in symptoms and interrelationships during chemotherapy. Results indicate that symptoms are interrelated and return to baseline levels after infusions.