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

Greater Symptom Burden and Poorer Quality of Life Outcomes Are Associated With The Co-Occurrence of Anxiety and Depression During Cancer Chemotherapy

OBJECTIVES

Anxiety and depression are common symptoms in oncology patients undergoing chemotherapy. Study purpose was to evaluate for differences in severity of common symptoms (ie, fatigue, energy, sleep disturbance, cognitive function, pain) and quality of life (QOL) outcomes among three subgroups of oncology outpatients with distinct joint anxiety and depression profiles.

METHODS

Oncology outpatients (N = 1328) completed measures of state anxiety and depression, six times over two cycles of chemotherapy. Latent profile analysis was done to identify subgroups of patients with distinct joint state anxiety AND depression profiles. Patients completed measures of trait anxiety, morning and evening fatigue, morning and evening energy, sleep disturbance, cognitive function, and pain, as well as generic and disease-specific measures of QOL at enrollment. Differences among the classes in symptom severity scores and QOL scores were evaluated using parametric and non-parametric tests.

RESULTS

Three distinct joint anxiety AND depression profiles were identified and named: Low Anxiety and Low Depression (57.5%, Both Low), Moderate Anxiety and Moderate Depression (33.7%, Both Moderate), and High Anxiety and High Depression (8.8%, Both High). All of the symptom severity scores showed a "dose-response effect" (ie, as the joint anxiety AND depression profiles worsened, the severity of all of the symptoms increased). Likewise, for both the general and disease-specific QOL (except spiritual well-being) measures, all of the scores decreased as the joint anxiety AND depression profiles worsened. Compared to the Both Low classes, the other two classes reported lower scores for the spiritual well-being domain.

CONCLUSIONS

More than 40% of patients receiving chemotherapy experience moderate to high levels of both anxiety AND depression. These patients report an extremely high symptom burden and significant decrements in all domains of QOL.

IMPLICATIONS FOR NURSING PRACTICE

Clinicians need to perform comprehensive assessments of depression and anxiety and other common symptoms and QOL outcomes during chemotherapy. In addition, referrals for targeted interventions are needed to manage multiple symptoms and improve patients' QOL.

Impact of Personalized Recovery Interventions on Spinal Instability and Psychological Distress in Oncological Patients with Vertebral Metastases

BACKGROUND

Patients with vertebral metastases often experience spinal instability, chronic pain, and psychological distress, all of which can significantly reduce quality of life. Spinal instability, measured by the Spinal Instability Neoplastic Score (SINS), may exacerbate functional impairment and emotional distress, underscoring the potential benefit of personalized recovery interventions.

MATERIAL AND METHODS

This prospective, observational study investigated the impact of personalized recovery interventions on spinal instability, psychological distress, and quality of life in oncological patients with vertebral metastases.

RESULTS

The experimental group received tailored rehabilitation strategies, while the control group underwent standard oncological care. Spinal instability was assessed using the Spinal Instability Neoplastic Score (SINS), psychological distress was measured with the Hopelessness Depression Symptom Questionnaire (HDSQ), and quality of life was evaluated using the European Quality of Life-5 Dimensions (EQ-5D). The experimental group demonstrated significantly lower mean SINS scores, indicating reduced spinal instability, and lower HDSQ scores, suggesting decreased psychological distress. They also exhibited improvements in mobility, self-care, usual activities, and anxiety/depression dimensions of the EQ-5D. Furthermore, the experimental group had longer survival times, lower fracture rates, and reduced prevalence of osteoporosis, anemia, and vomiting. These findings underscore the potential benefits of integrating physical and psychological rehabilitation into routine oncological management.

CONCLUSIONS

Personalized recovery interventions appear to enhance functional independence, emotional well-being, and overall quality of life in patients with vertebral metastases. Future research should focus on longitudinal, multicenter, randomized controlled trials to confirm these findings and further elucidate the complex interplay between spinal instability, psychological distress, and functional recovery.

A practical framework for the design of resistance exercise interventions in oncology research settings-a narrative review

Resistance exercise (RE) has been demonstrated to result in a myriad of benefits for individuals treated for cancer, including improvements in muscle mass, strength, physical function, and quality of life. Though this has resulted in the development of recommendations for RE in cancer management from various international governing bodies, there is also increasing recognition of the need to improve the design of RE interventions in oncology. The design and execution of RE trials are notoriously complex, attempting to account for numerous cancer/treatment related symptoms/side effects. Further, the design of exercise trials in oncology also present numerous logistical challenges, particularly those that are scaled for effectiveness, where multi-site trials with numerous exercise facilities are almost a necessity. As such, this review paper highlights these considerations, and takes evidence from relevant areas (RE trials/recommendations in oncology, older adults, and other clinical populations), and provide a practical framework for consideration in the design and delivery of RE trials. Ultimately, the purpose of this framework is to provide suggestions for researchers on how to design/conduct RE trials for individuals with cancer, rather than synthesizing evidence for guidelines/recommendations on the optimal RE dose/program.

Knowledge, attitude, opinion, perspective, and agreement of Palestinian medical students on strategies/recommendations to curb plagiarism: A multicenter cross-sectional study

Plagiarism is a common issue in written academic assignments and graduation theses. This multicenter study was conducted to assess the knowledge, attitude, opinion, perspective, and agreement of Palestinian medical students on strategies/recommendations to curb plagiarism. The study was conducted in a cross-sectional design using a questionnaire in all universities with medical education programs. The questionnaire contained 12 knowledge items, 8 attitude items, 6 opinion/perspective items, and 8 strategies/recommendations to curb plagiarism. Of the 550 invited medical students, 474 completed the study tool. Knowledge, attitude, opinion, perspective, and agreement on strategies/recommendations scores correlated positively. Higher knowledge, attitude, opinion, perspective, and agreement on strategies/recommendations scores were significantly associated with higher academic/training year, grade point average, satisfaction with academic achievement, academic writing skills, informational skills, using citation managers, receiving courses/workshops/lecturers on plagiarism, using plagiarism checking tools, and participation in a scientific paper/graduation thesis writing. Gaps in knowledge about plagiarism were identified among Palestinian medical students. Educators/trainers and other decision-makers in medical schools and higher academic institutions might use the strategies on which the students agreed to curb plagiarism.

Dynamic Associations Between Daily Pain and Mood during Chemotherapy for Gynecologic Cancers

BACKGROUND

Pain and mood disturbances, such as anxiety and depression, are common symptoms in gynecologic cancer. Their associations and the role of personality traits in pain adaptation during chemotherapy remain unclear. This ancillary data analysis aimed to investigate these relationships.

AIM

To (1) depict the temporal trend of daily pain severity; (2) evaluate dynamic associations between mood and pain; and (3) explore personality traits (neuroticism and conscientiousness) as moderators of the mood-pain relationship during chemotherapy for gynecologic cancer.

METHOD

Symptom severity was assessed daily throughout chemotherapy, while personality, clinical, and demographic characteristics were assessed at baseline. Twenty-seven women with gynecologic cancer who completed daily symptom assessments for at least four cycles were included in the analyses.

RESULTS

Pain severity decreased slightly during chemotherapy. Multilevel modeling supported significant associations between pain and anxiety (b = 0.24, standard error [SE] = 0.06, p = .001) and depression (b = 0.30, SE = 0.08, p = .002). Time-varying effect modeling showed significant associations between anxiety and pain that initially increased and then decreased; and significant associations between depression and pain steadily decreased over the first four cycles of chemotherapy. Neuroticism moderated the association between anxiety and pain (b = 0.15, SE = 0.06, p < .05), with anxiety more strongly associated with pain in those with higher neuroticism.

CONCLUSIONS

This study highlights the dynamic nature of pain and its associations with anxiety and depression in individuals with gynecologic cancer undergoing chemotherapy. The findings have implications for understanding pain and developing tailored psychosocial symptom management interventions to prevent pain during chemotherapy.

Assessment of sensorimotor and strength related function of breast cancer patients during systemic drug therapy: a prospective observational study

BACKGROUND

Chemotherapy is a well-known risk factor for sensorial and motor disturbances. Chemotherapy induced peripheral neuropathy (CIPN) which predominantly affects sensory nerves might cause a diminished fine motor function. This prospective observational study aimed to assess the sensorimotor functions of breast cancer patients before, during, and after chemotherapy.

METHODS

A total of 56 breast cancer patients were evaluated at three different times as follows: T1 (before chemotherapy), T2 (middle chemotherapy), and T3 (completion of chemotherapy). Motor function was assessed with handgrip strength (HGS), peripheral muscle strength (PMS), and the Minnesota Manual Dexterity Test (MMDT). Semmes Weinstein Monofilament Test (SWMT) was performed to assess the sensory function. Fatigue was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Module Cancer Related Fatigue (EORTC-QLQ-FA12), respectively.

RESULTS

HGS and MMDT were found significant (χ2: 11.279, p = 0.004 and χ2: 9.893, p = 0.007, respectively) whereas PMS was not found significant (F (2,110) = 1.914, p = 0.152). Pairwise comparisons with Bonferroni adjustments revealed that HGS was found significant between T1 and T3, while significant results were obtained between T1 and T2 as well as T2 and T3 in MMDT (p = 0.01 and p = 0.042). There were significant results in some reference points of SWMT, though they were not found after pairwise comparisons with Bonferroni adjustment (p > 0.05). Fatigue was found significantly increased from T1 through T3 (Median: 19.44 vs 27.77, z: -2.347, p = 0.019, Wilcoxon test).

CONCLUSION

Our study showed that decreased handgrip strength and fine motor function, as well as increased fatigue, are evident during the chemotherapy. SWMT can be an optional assessment in the context of tracking changes in cutaneous sensation during chemotherapy due to its non-invasive, cheap, and easily repeatable features among cancer patients. To preserve functional capacity as well as independence in daily living, precautions and follow up assessments during the systemic therapy process should be integrated as early as possible to prevent future deteriorations in daily life for patients who undergo chemotherapy.

TRIAL REGISTRATION

NCT04799080.

Relationships among Inflammatory Biomarkers and Self-Reported Treatment-Related Symptoms in Patients Treated with Chemotherapy for Gynecologic Cancer: A Controlled Comparison

Previous research suggests that inflammation triggers cancer-treatment-related symptoms (i.e., fatigue, depression, and disruptions in sleep and physical activity), but evidence is mixed. This study examined relationships between inflammatory biomarkers and symptoms in patients with gynecologic cancer compared to age-matched women with no cancer history (i.e., controls). Patients (n = 121) completed assessments before chemotherapy cycles 1, 3, and 6, and 6 and 12 months later. Controls (n = 105) completed assessments at similar timepoints. Changes in inflammation and symptomatology were evaluated using random-effects mixed models, and cross-sectional differences between patients and controls in inflammatory biomarkers and symptoms were evaluated using least squares means. Associations among inflammatory biomarkers and symptoms were evaluated using random-effects fluctuation mixed models. The results indicated that compared to controls, patients typically have higher inflammatory biomarkers (i.e., TNF-alpha, TNFR1, TNFR2, CRP, IL-1ra) and worse fatigue, depression, and sleep (ps < 0.05). Patients reported lower levels of baseline physical activity (p = 0.02) that became more similar to controls over time. Significant associations were observed between CRP, depression, and physical activity (ps < 0.05), but not between inflammation and other symptoms. The results suggest that inflammation may not play a significant role in fatigue or sleep disturbance among gynecologic cancer patients but may contribute to depression and physical inactivity.

Prediction of morning fatigue severity in outpatients receiving chemotherapy: less may still be more

INTRODUCTION

Fatigue is the most common and debilitating symptom experienced by cancer patients undergoing chemotherapy (CTX). Prediction of symptom severity can assist clinicians to identify high-risk patients and provide education to decrease symptom severity. The purpose of this study was to predict the severity of morning fatigue in the week following the administration of CTX.

METHODS

Outpatients (n = 1217) completed questionnaires 1 week prior to and 1 week following administration of CTX. Morning fatigue was measured using the Lee Fatigue Scale (LFS). Separate prediction models for morning fatigue severity were created using 157 demographic, clinical, symptom, and psychosocial adjustment characteristics and either morning fatigue scores or individual fatigue item scores. Prediction models were created using two regression and five machine learning approaches.

RESULTS

Elastic net models provided the best fit across all models. For the EN model using individual LFS item scores, two of the 13 individual LFS items (i.e., "worn out," "exhausted") were the strongest predictors.

CONCLUSIONS

This study is the first to use machine learning techniques to accurately predict the severity of morning fatigue from prior to through the week following the administration of CTX using total and individual item scores from the Lee Fatigue Scale (LFS). Our findings suggest that the language used to assess clinical fatigue in oncology patients is important and that two simple questions may be used to predict morning fatigue severity.

An Examination of the Longitudinal Relationship Between Cognitive Function and Physical Activity Among Older Breast Cancer Survivors in the Thinking and Living With Cancer Study

BACKGROUND

Older cancer survivors are at risk for cognitive decline. Physical activity can improve cognition, and better cognitive function may facilitate greater physical activity.

PURPOSE

We examined the potential bidirectional relationship between cognitive function and physical activity in older breast cancer survivors and controls.

METHODS

The sample included women with newly diagnosed, nonmetastatic breast cancer (n = 395) and women without cancer (n = 374) ages 60-98. Participants were recruited as part of a larger multisite study, assessed prior to systemic therapy, and followed yearly for 36 months. Attention, processing speed, and executive function was measured using six neuropsychological tests, self-reported cognitive function using the Perceived Cognitive Impairments subscale of the Functional Assessment of Cancer Therapy-Cognitive Function , and physical activity using the International Physical Activity Questionnaire-Short Form. Separate random intercepts cross-lagged panel models were used to examine the between- and within-person effects for survivors and controls, controlling for age, education, and study site.

RESULTS

Survivors reported significantly less physical activity than controls at baseline (1,284.92 vs. 2,085.98 MET min/week, p < .05). When survivors reported higher activity, they simultaneously had better objective cognition at 12 months (β = 0.24, p = .04) and reported better perceived cognition at 12 and 24 months (β = 0.25, p = .03), but this relationship was not seen in controls. Cognition did not predict subsequent physical activity or vice versa in either group.

CONCLUSIONS

Cognition and physical activity are cross-sectionally associated in survivors, but the expected prospective relationships were not found.

Considerations for designing trials targeting muscle dysfunction in exercise oncology

Individuals diagnosed with cancer commonly experience a significant decline in muscle mass and physical function collectively referred to as cancer related muscle dysfunction. This is concerning because impairments in functional capacity are associated with an increased risk for the development of disability and subsequent mortality. Notably, exercise offers a potential intervention to combat cancer related muscle dysfunction. Despite this, research is limited on the efficacy of exercise when implemented in such a population. Thus, the purpose of this mini review is to offer critical considerations for researchers seeking to design studies pertaining to cancer related muscle dysfunction. Namely, 1) defining the condition of interest, 2) determining the most appropriate outcome and methods of assessment, 3) establishing the best timepoint (along the cancer continuum) to intervene, and 4) understanding how exercise prescription can be configured to optimize outcomes.

Associations among frailty and quality of life in older patients with cancer treated with chemotherapy

INTRODUCTION

Previous studies have suggested that frailty among older adults with cancer is associated with a variety of negative outcomes, including greater chemotherapy toxicity and worse survival. However, results often do not include patient-reported outcomes, such as quality of life (QOL). The objective of this study was to evaluate frailty prior to receipt of moderately- or highly-emetogenic chemotherapy and acute changes in QOL in patients at least 65 years of age. It was hypothesized that frail patients would report greater declines in QOL.

MATERIALS AND METHODS

Participants completed questionnaires before receiving their first infusion and again five days later. A 59-item deficit accumulation index score was created at baseline using a modified Rockwood frailty index. QOL was assessed using the Functional Assessment of Cancer Therapy-General (FACT-G). The relationship between baseline frailty and QOL was evaluated using a dichotomized deficit accumulation index (frail vs. robust) in repeated measures ANOVA.

RESULTS

Study participants (n = 151) had a mean age of 72 (SD = 4.5) and 62% were female. Nearly half (42%) were frail at baseline. Frail participants reported worse QOL at baseline compared to robust participants. Frail patients reported smaller declines in overall and physical (p < 0.0001) and emotional (p = 0.006) QOL from baseline to five days after receiving chemotherapy. At five days, frail participants reported better emotional and physical QOL compared to robust participants.

DISCUSSION

Contrary to expectations, frail patients reported smaller declines in QOL compared to robust patients using a deficit accumulation index. These results can be used to help educate frail patients on what to expect during treatment.

Cumulative burden of symptomatology in patients with gynecologic malignancies undergoing chemotherapy

OBJECTIVE

Patients with gynecologic malignancies commonly experience distressing symptoms during chemotherapy. This study sought to evaluate whether symptoms accumulated over the course of several chemotherapy cycles, which could provide essential information for planning supportive interventions.

METHOD

Patients with gynecologic malignancies completed questionnaires about fatigue, depressive symptoms, sleep, and physical activity 1 week before and after chemotherapy cycles 1, 3, and 6. Multilevel models examined the effects of time (pre- and postchemotherapy), treatment cycle (1, 3, 6), and their interaction on symptoms. Logistic regression models examined the effects of time, treatment cycle, and their interaction on the proportion of participants exceeding thresholds for clinically meaningful symptomatology.

RESULTS

Most participants (N = 140; Mage = 60.8 years, SD = 10.4) had ovarian cancer (49%) and Stage III disease (55%). Participants reported worse fatigue, depressive symptoms, sleep disturbance, and sleep efficiency from pre- to posttreatment at each cycle (ps < .001). With each successive cycle, participants reported worse pretreatment fatigue (p < .001) and depressive symptoms (p < .01) but better sleep efficiency (p = .02). Fatigue increases attenuated across cycles (p = .04). There were no changes in physical activity. Across time points, at least half of participants met clinical thresholds for fatigue, sleep disturbance, and low sleep efficiency and were minimally physically active. Postchemotherapy cycle 6, 23% of participants reported clinically meaningful depressive symptoms.

CONCLUSIONS

Patients with gynecologic malignancies have high rates of clinically meaningful symptomatology during chemotherapy. Patients may experience a cumulative burden of symptomatology as treatment progresses, which could have therapeutic implications. Early implementation of supportive interventions should be considered to prevent or mitigate cumulative treatment burden. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Circadian disruption and cancer- and treatment-related symptoms

Cancer patients experience a number of co-occurring side- and late-effects due to cancer and its treatment including fatigue, sleep difficulties, depressive symptoms, and cognitive impairment. These symptoms can impair quality of life and may persist long after treatment completion. Furthermore, they may exacerbate each other's intensity and development over time. The co-occurrence and interdependent nature of these symptoms suggests a possible shared underlying mechanism. Thus far, hypothesized mechanisms that have been purported to underlie these symptoms include disruptions to the immune and endocrine systems. Recently circadian rhythm disruption has emerged as a related pathophysiological mechanism underlying cancer- and cancer-treatment related symptoms. Circadian rhythms are endogenous biobehavioral cycles lasting approximately 24 hours in humans and generated by the circadian master clock - the hypothalamic suprachiasmatic nucleus. The suprachiasmatic nucleus orchestrates rhythmicity in a wide range of bodily functions including hormone levels, body temperature, immune response, and rest-activity behaviors. In this review, we describe four common approaches to the measurement of circadian rhythms, highlight key research findings on the presence of circadian disruption in cancer patients, and provide a review of the literature on associations between circadian rhythm disruption and cancer- and treatment-related symptoms. Implications for future research and interventions will be discussed.

Quality of life, distress, anxiety and depression of ambulatory cancer patients receiving chemotherapy

Objective and aim

Cancer and its treatment have substantial physical and psychological consequences that severely affect the patients' quality of life (QoL) and emotional status. This study aimed to investigate the relationship between distress, anxiety, depression, and QoL of ambulatory cancer patients undergoing chemotherapy.

Methods

A descriptive, cross-sectional study of 150 cancer patients who were receiving chemotherapy in the outpatient unit of a central anticancer hospital in Athens. The data were collected through convenience sampling between November 2017 and January 2018, using a demographic and clinical characteristics questionnaire, the Distress Thermometer (DT) and Problem List (PL), the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment for Cancer QoL assessment Questionnaire (EORTC QLQ-C30).

Results

Variability characterized the sample's demographic and clinical characteristics. The majority of patients were women (64%), married (66%), high school graduates (43%), had breast cancer (35%), with a mean age of 60.07 ± 11.42. 83% reported anxiety, 75% reported fear, 51% nervousness and sadness, 34% depression and 84.7% fatigue. The DT was positively correlated with HADS (p<0.001) and with almost all EORTC QLQ-C30 functional subscales and symptoms (p<0.001). The HADS-Anxiety was significantly correlated with overall QoL and with almost all the EORTC QLQ-C30 functional scales and symptoms (p<0.001). HADS-Depression was significantly correlated with overall QoL and all the EORTC QLQ-C30 functional scales and symptoms (p<0.001). Women tended to have higher level of distress (p=0.003). There was a statistically significant relationship between educational level, the cognitive functioning scale (p=0.017) and financial difficulties (p=0.026).

Conclusions

Ambulatory cancer patients undergoing chemotherapy are at risk of facing distress in all aspects of daily living, along with anxiety and depression, which decreases their QoL. Oncology nurses as members of multidisciplinary teams should assess the affected aspects of patients' QoL and appropriate interventions should be implemented at community level.

Challenges in Using Recommended Quality of Life Measures to Assess Fluctuating Health: A Think-Aloud Study to Understand How Recall and Timing of Assessment Influence Patient Responses

BACKGROUND

It can be challenging to measure quality of life to calculate quality-adjusted life-years in recurrent fluctuating health states, as quality of life can constantly change. It is not clear how patients who experience fluctuations complete measures and how assessment timing and recall influence responses.

OBJECTIVE

We aimed to understand how patients with fluctuating health complete widely recommended and commonly used measures (EQ-5D-5L, EORTC QLQ-C30 and SF-12) and the extent to which the recall period ('health today', 'past week' and 'past 4 weeks') and timing of assessment influence the way that patients complete these questionnaires.

METHODS

Twenty-four adult patients undergoing chemotherapy for urological, gynaecological or bowel cancers in the UK participated in think-aloud interviews, while completing the measures, completed a pictorial task illustrating how quality of life changed during the chemotherapy cycle and took part in semi-structured interviews. Transcripts were analysed using constant comparison.

RESULTS

Patients were consistent in describing their quality of life as changing considerably throughout a chemotherapy cycle. The shorter recall period of 'health today' does not adequately represent patients' quality of life because of fluctuations, patients remarked they could give a different answer depending on the timing of assessment, and many struggled to combine the "ups and downs" to answer measures with longer recall ('past week' and 'past 4 weeks'). Across all measures, patients attempted to provide averages, adopt the peak-end rule or focus on the best part of their experience. Patients commonly used more than one approach when completing a given questionnaire as well as across questionnaires.

CONCLUSIONS

Patients who experience recurrent fluctuations in health are unable to provide meaningful responses about their quality of life when completing quality-of-life measures due to the recall period and timing of assessment. The use of such responses to calculate health state values in economic evaluations to inform resource allocation decisions in fluctuating conditions must be questioned.

Using a Network Physiology Approach to Prescribe Exercise for Exercise Oncology

Current American College of Sports Medicine (ACSM) exercise guidelines for exercise oncology survivors are generic one-size fits all recommendations, which assume ideal or prototypic health and fitness state in order to prescribe. Individualization is based on the objective evaluation of the patient's baseline physiological status based on a linear dose response relationship of endpoints. This is only a partial snapshot of both the acute and chronic responses exercise can provide. Each acute exercise session represents a unique challenge to whole-body homeostasis and complex acute and adaptive responses occur at the cellular and systemic levels. Additionally, external factors must be considered when prescribing exercise. Network physiology views the human organism in terms of physiological and organ systems, each with structural organization and functional complexity. This organizational approach leads to complex, transient, fluctuating and nonlinear output dynamics which should be utilized in exercise prescription across health states. Targeting health outcomes requires a multi-system approach as change doesn't happen in only one system at a time or in one direction Utilizing a multi-system or person-centered approach, allows for targeting and personalization and understands and targets non-linear dynamics of change. Therefore, the aims of this review are to propose a paradigm shift towards a Network Physiology approach for exercise prescription for cancer survivors. Cancer treatment affects multiple systems that interact to create symptoms and disruptions across these and therefore, prescribing exercise utilizing both external daily factors and internal physiological networks is of the highest order.

Fatigue after neurosurgery in patients with a brain tumor: The role of autonomic dysregulation and disturbed sleep

Background Fatigue is prevalent in patients with a brain tumor and high levels of fatigue persist after neurosurgical tumor resection. The underlying mechanisms are insufficiently understood and this study examines the role of autonomic nervous system dysregulation and objective sleep characteristics in fatigue among post-surgical patients. Methods Patients undergoing craniotomy (N = 52; age 52.1 ± 15.0 years; 44% women) were evaluated at 3 months after surgery (median = 86 days). Fatigue was measured using the Multidimensional Fatigue Inventory. Autonomic nervous system indices were based on 24-h heart rate variability (HRV) analysis. Sleep parameters were measured using actigraphy: total sleep duration, efficiency, onset latency and wake after sleep onset (WASO). Data analyses of this cross-sectional study included correlation and multiple regression analysis. Results Fatigue scores were significantly elevated in tumor resection patients compared to healthy reference norms (p's < 0.05) with no differences between patients with glioma (N = 32) versus meningioma (N = 20). Associations between HRV indices and fatigue were non-significant (r values <0.16, p values > 0.25). Sleep duration was associated with physical fatigue (r = 0.35, p = 0.02), whereas WASO was associated with mental fatigue levels (r = 0.40, p = 0.006). Disturbed sleep measures were associated with HRV indices of reduced parasympathetic nervous system activity in glioma patients but not in meningioma patients. Conclusions Multiple nocturnal awakenings may result in mental fatigue and longer sleep time was associated with physical fatigue, which may reflect compensatory sleep patterns. Future intervention studies addressing sleep quality may be beneficial in treating fatigue in patients following neurosurgery for tumor resection.

Auricular Acupuncture During Chemotherapy Infusion in Breast Cancer Patients: A Feasibility Study

Introduction: Breast cancer patients undergoing chemotherapy experience multiple distressing symptoms. The authors investigated the feasibility and potential benefits of auricular acupuncture during chemotherapy infusion in this population. Materials and Methods: Women with stage I-III breast cancer undergoing chemotherapy were enrolled and followed for three chemotherapy cycles. During the first cycle of chemotherapy that participants received after study enrollment, they were provided with educational materials. During the second and third cycles of chemotherapy after enrollment, they received auricular acupuncture. The primary outcome was feasibility, assessed by recruitment, retention, and completion of assessments. Secondary outcomes included symptom burden (Edmonton Symptom Assessment System-Revised Version) and anxiety (State-Trait Anxiety Inventory-State), assessed at four timepoints for each cycle: day 1, pre-education/acupuncture (T1); day 1, post-education/acupuncture (T2); day 2 (T3); and day 5 (T4). Nausea and vomiting (Multinational Association of Supportive Care in Cancer [MASCC] Antiemesis Tool) were assessed on days 2 and 5. Paired t test was used to compare patient-reported outcomes during cycle 1 (education) versus an average of outcomes during cycles 2 and 3 (acupuncture). Results: Twenty-six patients were enrolled, of which 24 completed all acupuncture sessions and 22 completed all outcome assessments. In cycles 2 and 3 versus cycle 1, participants experienced significant reductions in symptom burden (change from T1 to T4: -7.9 ± 13.6, p = 0.02), anxiety (change from T1 to T2: -3.3 ± 6.5, p = 0.02), and nausea severity on day 2 (-1.3 ± 2.6, p = 0.04). Conclusions: The delivery of auricular acupuncture during chemotherapy infusion was feasible and associated with reduction of symptom burden, anxiety, and nausea in breast cancer patients. Larger-scale clinical studies are needed to confirm these findings. Clinical Trial Registration number: NCT03170648.

Synergistic Interactions Among Fatigue, Sleep Disturbance, and Depression in Women With Breast Cancer: A Cross-Sectional Study

OBJECTIVES

To assess the symptom cluster of fatigue, sleep disturbance, and depression among female patients with breast cancer receiving chemotherapy, and to evaluate its impact on quality of life (QOL) and symptom severity.

SAMPLE & SETTING

372 patients receiving adjuvant chemotherapy recruited from two tertiary hospitals in China.

METHODS & VARIABLES

Symptom severity and QOL were evaluated using the Brief Fatigue Inventory, Pittsburgh Sleep Quality Index, Patient Health Questionnaire-9, and Functional Assessment of Cancer Therapy-Breast on the eighth day after receiving chemotherapy.

RESULTS

All symptoms positively correlated with each other. Although the symptom cluster was significantly associated with decreased QOL, individualized symptom severity worsened as the number of symptoms increased.

IMPLICATIONS FOR NURSING

The prevalence of and interactions among fatigue, sleep disturbance, and depression negatively affect symptom severity and patients' QOL. Conducting early assessment followed by effective cluster-based interventions is needed to manage this symptom cluster.

Nurse-led exercise and cognitive-behavioral care against nurse-led usual care between and after chemotherapy cycles in Han Chinese women of ovarian cancer with moderate to severe levels of cancer-related fatigue: A retrospective analysis of the effectiveness

Women with ovarian cancer are reported to fatigue over time. Moderate to severe levels of cancer-related fatigue is fluent in Han Chinese patients with cancer. Comprehensive Cancer Network guidelines are recommending exercise and cognitive behavioral therapy to reduce cancer-related fatigue. Exercise is an easy, cost-effective, and non-pharmacological approach. The objective of the study was to evaluate the effectiveness of nurse-led exercise and cognitive-behavioral care against nurse-led usual care in Han Chinese women of ovarian cancer regarding cancer-related fatigue, depressive symptoms, and sleep quality.Han Chinese women with moderate to severe levels of cancer-related fatigue have received 30 minutes, 5 times/week nurse-led exercise and 60 min/week cognitive-behavioral care (EC cohort, n = 118) or nurse-led usual care regarding educations and recommendations only (UC cohort, n = 126) or have not received nurse-led exercise, cognitive-behavioral care, educations, and recommendations (NC cohort, n = 145) between and after chemotherapy cycles. The Piper Fatigue Scale, the Zung Self-rating Depression Scale, and Pittsburgh Sleep Quality Index questionnaires were evaluated at the start and the end of non-pharmacological treatment.At the end of treatment as compared to the start of treatment, only women of EC cohort had decrease Piper Fatigue Scale (5.40 ± 1.49/woman vs 6.06 ± 1.49/woman, P < .0001, q = 4.973) and Zung Self-rating Depression Scale score (48.67 ± 4.24/woman vs 49.93 ± 4.29/woman, P = .001, q = 3.449). Also, at the end of treatment, as compared to the start of treatment, only women of EC cohort have increased Pittsburgh Sleep Quality Index score (14.76 ± 2.18/woman vs 13.94 ± 2.90/woman, P = .045, q = 3.523). Only exercise and cognitive-behavioral care were successful in a decrease in the numbers of women with depression (the Mandarin Chinese version of the Zung Self-rating Depression Scale score >53, 32 vs 16, P = .015).Nurse-led exercise and cognitive-behavioral care can help Han Chinese women with ovarian cancer to decrease cancer-related fatigue and depression. Also, it can improve the quality of sleep.Evidence Level: 4.Technical Efficacy: Stage 5.

Contribution of Sleep Disruption and Sedentary Behavior to Fatigue in Survivors of Allogeneic Hematopoietic Cell Transplant

BACKGROUND

Fatigue is a prominent quality of life concern among recipients of hematopoietic cell transplantation (HCT).

PURPOSE

The present study investigated whether objectively measured sleep efficiency and sedentary behavior are related to greater reports of fatigue.

METHODS

Eighty-two allogeneic HCT recipients who were 1-5 years post-transplant and returning for a follow-up visit participated (age M = 56, 52% female, 56% leukemia). They wore an actigraph assessing sleep efficiency and sedentary behavior for one week and completed an electronic log assessing fatigue each evening during the same period.

RESULTS

Twenty-six percent of patients reported clinically meaningful fatigue. On average, fatigue was mild (M = 2.5 on 0-10 scale, SD = 2.0), sleep was disturbed (sleep efficiency M = 78.9%, SD = 8.9), and patients spent the majority of time in sedentary (M = 55.4%, SD = 10.2) or light (M = 35.9%, SD = 8.6) activity. Multilevel model analysis of between-person differences indicated that patients who experienced less efficient sleep the previous evening provided greater evening reports of average fatigue, b = -0.06, 95% CI (-0.11, -0.01). Similarly, within-person analyses indicated that when patients experienced less efficient sleep the previous evening or were more sedentary as compared to their average, they provided greater evening reports of average fatigue, b = -0.02, 95% CI (-0.05, -0.004); b = 4.46, 95% CI (1.95, 6.97), respectively.

CONCLUSIONS

Findings demonstrate that poor sleep and daily sedentary behavior are related to evening reports of fatigue and should be considered modifiable targets for intervention.

Factors Influencing Physical Activity in Cancer Patients During Oncological Treatments: A Qualitative Study

Introduction:

Although the literature supports the importance of physical activity in the oncological context, in Italy a large number of patients are not sufficiently active.

Methods:

The present study aimed to explore factors influencing an active lifestyle in cancer patients during oncological treatments. Semi-structured focus groups, including 18 patients with different cancer types, were conducted at the Oncology Unit in the University Hospital Trust of Verona (Italy). The interviews were audio-recorded, transcribed verbatim, and analyzed with content analysis.

Results:

According to the Health Belief Model, transcripts were categorized into the following themes: benefits, barriers, and cues to action. Patients reported a series of physical, physiological, and psychological benefits deriving from an active lifestyle. The main barriers hampering the physical activity participation were represented by treatment-related side effects, advanced disease, and some medical procedures, for example, ileostomy. Several strategies that can trigger patients to exercise were identified. Medical advice, social support from family and friends, features such as enjoyment, setting goals, and owning an animal can motivate patients to perform physical activity. At the same time, an individualized program based on patients’ characteristics, an available physical activity specialist to consult, more detailed information regarding physical activity in the oncological setting, and having accessible structures were found important facilitators to implementing active behavior.

Conclusions:

Overall, patients have a positive view regarding physical activity, and a variety of obstacles and cues to action were recognized. Considering this information may help to improve adherence to a physical activity program over time, consequently increasing the expected benefits.

Prediction of evening fatigue severity in outpatients receiving chemotherapy: less may be more

Background

Fatigue is the most common and debilitating symptom experienced by oncology patients undergoing chemotherapy. Little is known about patient characteristics that predict changes in fatigue severity over time.

Purpose

To predict the severity of evening fatigue in the week following the administration of chemotherapy using machine learning approaches.

Methods

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (N=1217) completed questionnaires one week prior to and one week following administration of chemotherapy. Evening fatigue was measured with the Lee Fatigue Scale (LFS). Separate prediction models for evening fatigue severity were created using clinical, symptom, and psychosocial adjustment characteristics and either evening fatigue scores or individual fatigue item scores. Prediction models were created using two regression and three machine learning approaches.

Results

Random forest (RF) models provided the best fit across all models. For the RF model using individual LFS item scores, two of the 13 individual LFS items (i.e., "worn out", "exhausted") were the strongest predictors.

Conclusion

This study is the first to use machine learning techniques to predict evening fatigue severity in the week following chemotherapy from fatigue scores obtained in the week prior to chemotherapy. Our findings suggest that the language used to assess clinical fatigue in oncology patients is important and that two simple questions may be used to predict evening fatigue severity.

Factors associated with sleep quality during chemotherapy: An integrative review

Aim

To identify the most important factors associated with sleep pattern changes in patients with cancer during chemotherapy treatment.

Design

An integrative review of the literature was performed between December 2017-August 2018.

Methods

Two independent reviewers searching the National Library of Medicine (PubMed/MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature in Health Sciences (LILACS), Scopus and Scielo. The process followed the recommendations of the PRISMA tool. A total of 16 articles were selected for the final study sample, including 11 cohort studies and 5 cross-sectional studies.

Results

The predisposing factors for the most prevalent sleep disturbances were precipitants related to the disease and the treatment, such as fatigue, pain, depression, anxiety and distress. Predisposing factors related to lifestyle and demographic characteristics have a significant correlation with sleep disturbances.

Design considerations for the development of neuromuscular electrical stimulation (NMES) exercise in cancer rehabilitation

Aim: The aim of this narrative review is to explore design considerations for effective neuromuscular electrical stimulation exercise prescription in cancer rehabilitation, with simultaneous consideration for fundamental principles of exercise training and the current state of the art in neuromuscular electrical stimulation technologies and application methodologies.Method: Narrative review.Results: First, we consider the key neuromuscular electrical stimulation exercise design considerations, with a focus on training objectives and individual training requirements and constraints for individuals with cancer. Here, we contend that concurrent, low and high frequency neuromuscular electrical stimulation exercise, individually prescribed and progressed may be optimal for enhancing physical function. Second, we review the appropriate literature to identify the most appropriate stimulation parameters (pulse frequency, intensity, duration and duty cycle) to deliver effective neuromuscular electrical stimulation in cancer rehabilitation.Conclusions: We propose an informed and innovative neuromuscular electrical stimulation exercise intervention design and provide practical information for clinicians and practitioners who may work with and implement neuromuscular electrical stimulation exercise in cancer.Implications for rehabilitationNeuromuscular electrical stimulation is an emerging technology in cancer rehabilitation to help provide an aerobic and muscle strengthening exercise stimulus.Neuromuscular electrical stimulation may help improve aerobic exercise capacity, muscle strength and augment quality of life.Current prescription in cancer lacks adherence to the fundamental principles of exercise training, which may negatively affect adherence.

Feasibility and acceptability of intensive longitudinal data collection of activity and patient-reported outcomes during chemotherapy for breast cancer

PURPOSE

Ecological momentary assessment (EMA) may help us better understand biopsychosocial determinants and outcomes of physical activity during chemotherapy, but may be burdensome for patients. The purpose of this study was to determine the feasibility and acceptability of using EMA to assess activity, symptoms, and motivation among early-stage breast cancer patients undergoing chemotherapy.

METHODS

Women were instructed to wear an accelerometer 24/7 (hip during day and wrist overnight). Text message prompts were sent 4 times/day concerning patient-reported symptoms and motivational factors for 10 consecutive days (3 days pre-, day of, and 6 days post-chemotherapy dose). These measures occurred at the beginning, middle, and end of a full course of chemotherapy. At study conclusion, participants reported on perceived study acceptability, burden, and reactivity.

RESULTS

Of the 75 women who consented to participate, 63 (84%) completed all 3 assessment time points. Participants responded to 86% of total text prompts and had valid accelerometer data on 82% of study days. Compliance was similar across all time points. The majority (78%) rated their study experience as positive; 100% were confident in their ability to use study technology. Reactivity varied with 27% indicating answering symptom questions did not affect how they felt and 44% and 68% indicated answering questions and wearing the accelerometer, respectively, made them want to increase activity.

CONCLUSIONS

Findings indicate EMA methods are feasible for breast cancer patients undergoing chemotherapy. EMA may help us better understand the biopsychosocial processes underlying breast cancer patients' activity in the context of daily life.

Home-Based e-Health Platform for Multidimensional Telemonitoring of Symptoms, Body Weight, Sleep, and Circadian Activity: Relevance for Chronomodulated Administration of Irinotecan, Fluorouracil-Leucovorin, and Oxaliplatin at Home-Results From a Pilot Study

PURPOSE

To assess the impact of chronomodulated irinotecan fluorouracil-leucovorin and oxaliplatin (chronoIFLO4) delivered at home on the daily life of patients with cancer in real time using a home-based e-Health multifunction and multiuser platform. This involved multidimensional telemonitoring of circadian rest-activity rhythm (CircAct), sleep, patient-reported outcome measures, and body weight changes (BWCs).

PATIENTS AND METHODS

Patients received chronoIFLO4 fortnightly at home. Patients completed the 19-item MD Anderson Symptom Inventory on an interactive electronic screen, weighed themselves on a dedicated scale, and continuously wore a wrist accelerometer for CircAct and sleep monitoring. Daily data were securely teletransmitted to a specific server accessible by the hospital team. The clinically relevant CircAct parameter dichotomy index I < O and sleep efficiency (SE) were calculated. The dynamic patterns over time of patient-reported outcome measures, BWC, I < O, and SE informed the oncology team on tolerance in real time.

RESULTS

The platform was installed in the home of 11 patients (48 to 72 years of age; 45% men; 27% with performance status = 0), who were instructed on its use on site. They received 26 cycles and provided 5,891 data points of 8,736 expected (67.4%). The most severe MD Anderson Symptom Inventory scores were: interference with work (mean: 5.1 of 10) or general activity (4.9), fatigue (4.9), distress (4.2), and appetite loss (3.6). Mean BWC was -0.9%, and mean SE remained > 82%. CircAct disruption (I < O ≤ 97.5%) was observed in four (15%) cycles before chronoIFLO4 start and in five (19%) cycles at day 14.

CONCLUSION

The patient-centered multidimensional telemonitoring solution implemented here was well accepted by patients receiving multidrug chemotherapy at home. Moreover, it demonstrated that chronoIFLO4 was a safe therapeutic option. Such integrated technology allows the design of innovative management approaches, ultimately improving patients' experience with chemotherapy, wellbeing, and outcomes.

Hope-related goal cognitions and daily experiences of fatigue, pain, and functional concern among lung cancer patients

PURPOSE

Cross-sectional research suggests that thinking about multiple ways to reach goals (hope pathways) and the belief that one can reach them (hope agency) may be adaptive for lung cancer patients. We examined the between-person and within-person associations among aspects of hope agency and pathways thinking, daily fatigue, pain, and functional concerns (e.g., sense of independence, usefulness) among lung cancer patients during active treatment.

METHODS

Data from a daily diary study were used to examine relations among hope agency, hope pathways, fatigue, pain, and functional concern in 50 patients with advanced lung cancer. Participants were accrued from one outpatient cancer center and completed the study between 2014 and 2015.

RESULTS

Adjusting for covariates and the previous day's symptoms or concern, patients who engaged in higher pathways thinking reported lower daily symptoms, whereas those who engaged in higher agency thinking reported less functional concern. Within-person increases in pathways thinking were associated with less daily fatigue, pain, and functional concern; within-person increases in agency thinking were associated with less daily fatigue and pain. Models examining symptoms and concerns as predictors of hope suggested within-person increases in functional concern and fatigue and pain were related to lower agency and pathways thinking the same day. Patients with higher fatigue and pain did not report lower agency or pathways thinking, but patients with more functional concern did.

CONCLUSIONS

Increases in hope pathways thinking may be associated with lower symptoms and better functioning in lung cancer patients. This suggests that it is important to determine the efficacy of interventions that emphasize the pathways the component of hope.

Insomnia in breast cancer: a prospective observational study

STUDY OBJECTIVES

Insomnia in cancer patients is prevalent, persistent, and confers risk for physical and psychological disorder. We must better understand how insomnia develops in cancer patients and explore the main contributors to its chronicity so that insomnia management protocols can be integrated more effectively within cancer care. This study monitors the etiology of insomnia in breast cancer patients and identifies risk factors for its persistence.

METHODS

One hundred seventy-three females with newly diagnosed, non-metastatic breast cancer were tracked from diagnosis for 12 months. Participants completed monthly sleep assessments using the Insomnia Severity Index (ISI) and 3 monthly health-related quality-of-life assessments using the European Organisation for Research and Treatment of Cancer - Breast (EORTC QLQ-C30-BR23) scale. Clinical data on disease status and treatment regimens were also assessed.

RESULTS

Prior to diagnosis, 25% of participants reported sleep disturbance, including 8% with insomnia syndrome (IS). Prevalence increased at cancer diagnosis to 46% (18% IS) and remained stable thereafter at around 50% (21% IS). We also explored sleep status transitions. The most common pattern was to remain a good sleeper (34%-49%) or to persist with insomnia (23%-46%). Seventy-seven percent of good sleepers developed insomnia during the 12-month period and 54% went into insomnia remission. Chemotherapy (odds ratio = 0.08, 95% confidence interval [CI] 0.02-0.29, p < .001) and pre-diagnosis ISI scores (odds ratio = 1.13/unit increase in pre-diagnosis sleep score, 95% CI 1.05-1.21, p = .001) were identified as the main risk factors for persistent insomnia.

CONCLUSIONS

These data advance our understanding of insomnia etiology in cancer patients and help identify those who should be prioritized for insomnia management protocols.

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.

A Scientific Rationale to Improve Resistance Training Prescription in Exercise Oncology

To date, the prevailing evidence in the field of exercise oncology supports the safety and efficacy of resistance training to attenuate many oncology treatment-related adverse effects, such as risk for cardiovascular disease, increased fatigue, and diminished physical functioning and quality of life. Moreover, findings in the extant literature supporting the benefits of exercise for survivors of and patients with cancer have resulted in the release of exercise guidelines from several international agencies. However, despite research progression and international recognition, current exercise oncology-based exercise prescriptions remain relatively basic and underdeveloped, particularly in regards to resistance training. Recent publications have called for a more precise manipulation of training variables such as volume, intensity, and frequency (i.e., periodization), given the large heterogeneity of a cancer population, to truly optimize clinically relevant patient-reported outcomes. Indeed, increased attention to integrating fundamental principles of exercise physiology into the exercise prescription process could optimize the safety and efficacy of resistance training during cancer care. The purpose of this article is to give an overview of the current state of resistance training prescription and discuss novel methods that can contribute to improving approaches to exercise prescription. We hope this article may facilitate further evaluation of best practice regarding resistance training prescription, monitoring, and modification to ultimately optimize the efficacy of integrating resistance training as a supportive care intervention for survivors or and patients with cancer.

High-intensity interval training and hyperoxia during chemotherapy: A case report about the feasibility, safety and physical functioning in a colorectal cancer patient

INTRODUCTION

We conducted a case study to examine the feasibility and safety of high-intensity interval training (HIIT) with increased inspired oxygen content in a colon cancer patient undergoing chemotherapy. A secondary purpose was to investigate the effects of such training regimen on physical functioning.

CASE PRESENTATION

A female patient (51 years; 49.1 kg; 1.65 m; tumor stage: pT3, pN2a (5/29), pM1a (HEP), L0, V0, R0) performed 8 sessions of HIIT (5 × 3 minutes at 90% of Wmax, separated by 2 minutes at 45% Wmax) with an increased inspired oxygen fraction of 30%. Patient safety, training adherence, cardiorespiratory fitness (peak oxygen uptake and maximal power output during an incremental cycle ergometer test), autonomous nervous function (i.e., heart rate variability during an orthostatic test) as well as questionnaire-assessed quality of life (EORTC QLQ-C30) were evaluated before and after the intervention.No adverse events were reported throughout the training intervention and a 3 months follow-up. While the patient attended all sessions, adherence to total training time was only 51% (102 of 200 minutes; mean training time per session 12:44 min:sec). VO2peak and Wmax increased by 13% (from 23.0 to 26.1 mL min kg) and 21% (from 83 to 100 W), respectively. Heart rate variability represented by the root mean squares of successive differences both in supine and upright positions were increased after the training by 143 and 100%, respectively. The EORTC QLQ-C30 score for physical functioning (7.5%) as well as the global health score (10.7%) improved, while social function decreased (17%).

CONCLUSIONS

Our results show that a already short period of HIIT with concomitant hyperoxia was safe and feasible for a patient undergoing chemotherapy for colon cancer. Furthermore, the low overall training adherence of only 51% and an overall low training time per session (∼13 minutes) was sufficient to induce clinically meaningful improvements in physical functioning. However, this case also underlines that intensity and/or length of the HIIT-bouts might need further adjustments to increase training compliance.

Psychometric evaluation and adaptation of the Spine Oncology Study Group Outcomes Questionnaire to evaluate health-related quality of life in patients with spinal metastases

BACKGROUND

The Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ) was developed as the first spine oncology‐specific health‐related quality of life (HRQOL) measure. This study evaluated the psychometric properties and clinical validity of the SOSGOQ in a diverse cohort of patients with spinal metastases.

METHODS

An international, multicenter, prospective observational cohort study including patients with spinal metastases who underwent surgery and/or radiotherapy was conducted by the AOSpine Knowledge Forum Tumor. Demographic, tumor, and treatment data were collected. HRQOL was evaluated using the SOSGOQ and Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF‐36) at baseline and fixed follow‐up times. Construct validity was assessed using multitrait scaling analyses, confirmatory factor analyses, and correlation with the SF‐36 and NRS pain score. Test‐retest reliability was assessed in a subgroup of patients between 12 weeks after treatment and the retest 4 to 9 days later.

RESULTS

A total of 238 patients were enrolled at 9 centers across North America; 153 of these patients had HRQOL data available at 12 weeks after treatment. Multitrait scaling analyses and confirmatory factor analyses resulted in a refined version of the SOSGOQ with 4 domains and 4 single items. The revised SOSGOQ (SOSGOQ2.0) demonstrated strong correlations with SF‐36 and the ability to discriminate between clinically distinct patient groups. Reliability of the SOSGOQ2.0 was demonstrated to be good, with an intraclass correlation coefficient ranging from 0.58 to 0.92 for the different domains.

CONCLUSIONS

The SOSGOQ2.0 is a reliable and valid measure with which to evaluate HRQOL in patients with spinal metastases. It is recommended to use the SOSGOQ2.0 together with a generic HRQOL outcome measure to comprehensively assess HRQOL and increase sensitivity and specificity. Cancer 2018;124:1828‐38. © 2018 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

The revised Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0) is a reliable and valid measure with which to evaluate health‐related quality of life (HRQOL) in patients with spinal metastases. It is recommended to use the SOSGOQ2.0 together with a generic HRQOL outcome measure to comprehensively assess HRQOL and increase sensitivity and specificity.

Sleep disruption among cancer patients following autologous hematopoietic cell transplantation

Despite a high prevalence of sleep disruption among hematopoietic cell transplant (HCT) recipients, relatively little research has investigated its relationships with modifiable cognitive or behavioral factors or used actigraphy to characterize sleep disruption in this population. Autologous HCT recipients who were 6 to 18 months post-transplant completed self-report measures of cancer-related distress, fear of cancer recurrence, dysfunctional sleep cognitions, and inhibitory sleep behaviors upon enrollment. Patients then wore an actigraph for seven days and completed a self-report measure of sleep disruption on day seven of the study. Among the 84 participants (age M=60, 45% female), 41% reported clinically-relevant sleep disruption. Examination of actigraph data confirmed that, on average, sleep was disrupted (wake after sleep onset M=66 minutes) and sleep efficiency was less than recommended (sleep efficiency M=78%). Cancer-related distress, fear of recurrence, dysfunctional sleep cognitions, and inhibitory sleep behaviors were related to self-reported sleep disruption (p’s < .05) but not objective sleep indices. Results suggest that many HCT recipients experience sleep disruption after transplant. Cancer-related distress, fear of recurrence, dysfunctional sleep cognitions, and maladaptive sleep behaviors are related to self-reported sleep disruption and should be considered targets for cognitive behavioral intervention in this population.

Estimation of Symptom Severity During Chemotherapy From Passively Sensed Data: Exploratory Study

BACKGROUND

Physical and psychological symptoms are common during chemotherapy in cancer patients, and real-time monitoring of these symptoms can improve patient outcomes. Sensors embedded in mobile phones and wearable activity trackers could be potentially useful in monitoring symptoms passively, with minimal patient burden.

OBJECTIVE

The aim of this study was to explore whether passively sensed mobile phone and Fitbit data could be used to estimate daily symptom burden during chemotherapy.

METHODS

A total of 14 patients undergoing chemotherapy for gastrointestinal cancer participated in the 4-week study. Participants carried an Android phone and wore a Fitbit device for the duration of the study and also completed daily severity ratings of 12 common symptoms. Symptom severity ratings were summed to create a total symptom burden score for each day, and ratings were centered on individual patient means and categorized into low, average, and high symptom burden days. Day-level features were extracted from raw mobile phone sensor and Fitbit data and included features reflecting mobility and activity, sleep, phone usage (eg, duration of interaction with phone and apps), and communication (eg, number of incoming and outgoing calls and messages). We used a rotation random forests classifier with cross-validation and resampling with replacement to evaluate population and individual model performance and correlation-based feature subset selection to select nonredundant features with the best predictive ability.

RESULTS

Across 295 days of data with both symptom and sensor data, a number of mobile phone and Fitbit features were correlated with patient-reported symptom burden scores. We achieved an accuracy of 88.1% for our population model. The subset of features with the best accuracy included sedentary behavior as the most frequent activity, fewer minutes in light physical activity, less variable and average acceleration of the phone, and longer screen-on time and interactions with apps on the phone. Mobile phone features had better predictive ability than Fitbit features. Accuracy of individual models ranged from 78.1% to 100% (mean 88.4%), and subsets of relevant features varied across participants.

CONCLUSIONS

Passive sensor data, including mobile phone accelerometer and usage and Fitbit-assessed activity and sleep, were related to daily symptom burden during chemotherapy. These findings highlight opportunities for long-term monitoring of cancer patients during chemotherapy with minimal patient burden as well as real-time adaptive interventions aimed at early management of worsening or severe symptoms.

Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial

BACKGROUND

High levels of fatigue have been documented in ovarian cancer patients. However, increased levels of fatigue are positively associated with a high risk of sleep disturbance and depression.

OBJECTIVE

To investigate the feasibility of a nurse-led home-based exercise and cognitive behavioral therapy (E&CBT) for ovarian cancer adults with cancer-related fatigue on outcomes of fatigue, plus other secondary outcomes (sleep disturbance and depression), either during or after completion of primary cancer treatment.

DESIGN

Randomized, single-blind control trial.

SETTINGS

Gynaecologic oncology department of the First Hospital of Jilin University in China.

PARTICIPANTS

72 eligible women who recently had surgery and completed their first cycle of adjuvant chemotherapy were randomly assigned to two groups.

INTERVENTION

The experimental group received exercise and cognitive behavioral therapy. Five nurses with nursing master degree were trained to deliver this intervention. Patients received online interventions each week in the patient's place of residence or in the nurse-led clinic, as requested. Home visits, coupled with telephone-based motivational interviews twice a week were available with the permission of the participants. comparison group participants received services as usual.

MEASUREMENTS

The primary outcome was measured by the Chinese version of the Piper Fatigue Scale that has 4 subscales (Behavior, Affect, Sensory, and Cognition). Secondary outcomes were measured using the Self-Rating Depression Scale and the Pittsburgh Sleep Quality Index questionnaire. Repeated-measure ANOVA was used to examine the effectiveness of this intervention in reducing fatigue, depression, and improving sleep quality.

RESULTS

For baseline comparisons, no significant differences were found between the two groups. After the interventions, total fatigue scores were significantly reduced from T1 to T2, to T3 in the experimental group (4.37, 4.24, 3.90), respectively. The comparison group showed almost no change in total fatigue score over time. In the repeated measures ANOVA, the differences of behavioral fatigue score (F=11.647, p=0.001) and cognitive fatigue score (F=5.741, p=0.019) were statistically significant for the group by time interaction. After the interventions, the experimental group participants demonstrated significantly lower symptoms of depression compared with the comparison group (T2: p=0.001 and T3: p<0.001). Sleep duration, sleep dysfunction, daytime dysfunction as well as total sleep quality significantly improved.

CONCLUSION

Nurse-delivered home-based E&CBT have measurable benefits in helping women with ovarian cancer to decrease cancer-related fatigue, depressive symptoms, and improving their quality of sleep.

Distinct Evening Fatigue Profiles in Oncology Outpatients Receiving Chemotherapy

Background

Fatigue is the most common and debilitating symptom experienced by oncology patients during chemotherapy (CTX). Fatigue severity demonstrates a large amount of inter-individual and diurnal variability.

Purpose

Study purposes were to evaluate for subgroups of patients with distinct evening fatigue profiles and evaluate how these subgroups differed on demographic, clinical, and symptom characteristics.

Methods

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (n=1332) completed questionnaires six times over two cycles of CTX. Lee Fatigue Scale (LFS) evaluated evening fatigue severity. Latent profile analysis was used to identify distinct evening fatigue profiles.

Results

Four distinct evening fatigue classes (i.e., Low (14.0%), Moderate (17.2%), High (36.0%), Very High (32.8%)) were identified. Compared to the Low class, patients in the Very High evening fatigue class were: younger, female, had childcare responsibilities, had more years of education, had a lower functional status, had a higher comorbidity burden, and were diagnosed with breast cancer. Patients in the Very High class reported higher levels of depressive symptoms, sleep disturbance, and evening fatigue at enrollment.

Conclusions

Findings provide new insights into modifiable risk factors for higher levels of evening fatigue. Clinicians can use this information to identify higher risk patients and plan appropriate interventions.

Effects of exercise on sleep problems in breast cancer patients receiving radiotherapy: a randomized clinical trial

PURPOSE

Sleep problems frequently affect breast cancer patients during and after treatment and reduce their quality of life. Treatment strategies are mostly unknown. Thus, we assessed within a randomized controlled trial whether a 12-week exercise program starting with the radiotherapy influences sleep trajectories.

METHODS

Sleep quality and problems were assessed via self-report in 160 breast cancer patients before, during, and 2, 6, and 12 months after participation in a trial investigating resistance exercise versus a relaxation control group concomitant with radiotherapy. As additional comparison group, 25 age-matched healthy women exercised and followed identical study procedures. Ordinal logistic regression analyses were used.

RESULTS

The exercise intervention significantly decreased sleep problems compared to the relaxation control group (scale: 0-100, with between-group mean differences of -10.2 (p = 0.03) from baseline to the end of radiotherapy and -10.9 (p = 0.005) to the end of the intervention), with sleep problems decreasing in the exercise group and increasing in the control group. At 12 months, differences were still observed but statistically non-significant (mean difference = -5.9, p = 0.20). Further adjustment for potential confounders did not change the results. Several determinants of sleep problems at baseline were identified, e.g., previous chemotherapy and higher body mass index.

CONCLUSIONS

Our randomized exercise intervention trial confirmed results from earlier but mostly smaller studies that radiotherapy aggravates sleep problems in breast cancer patients and that exercise can ameliorate these effects. Considering that sleep quality can be a major predictor of quality of life, our findings are of substantial importance to many breast cancer patients.

A brief yoga intervention implemented during chemotherapy: A randomized controlled pilot study

OBJECTIVES

Fatigue and other treatment-related symptoms (e.g., sleep disturbance) are critical targets for improving quality of life in patients undergoing chemotherapy. Yoga may reduce the burden of such symptoms. This study investigated the feasibility of conducting a randomized controlled study of a brief yoga intervention during chemotherapy for colorectal cancer.

DESIGN

We randomized adults with colorectal cancer to a brief Yoga Skills Training (YST) or an attention control (AC; empathic attention and recorded education).

SETTING

The interventions and assessments were implemented individually in the clinic while patients were in the chair receiving chemotherapy.

INTERVENTIONS

Both interventions consisted of three sessions and recommended home practice.

MAIN OUTCOME MEASURES

The primary outcome was feasibility (accrual, retention, adherence, data collection). Self-reported outcomes (i.e., fatigue, sleep disturbance, quality of life) and inflammatory biomarkers were also described to inform future studies.

RESULTS

Of 52 patients initially identified, 28 were approached, and 15 enrolled (age Mean = 57.5 years; 80% White; 60% Male). Reasons for declining participation were: not interested (n = 6), did not perceive a need (n = 2), and other (n = 5). Two participants were lost to follow-up in each group due to treatment changes. Thus, 75% of participants were retained in the YST and 71% in the AC arm. Participants retained in the study adhered to 97% of the in-person intervention sessions and completed all questionnaires.

CONCLUSIONS

This study demonstrated the feasibility of conducting a larger randomized controlled trial to assess YST among patients receiving chemotherapy for colorectal cancer. Data collected and challenges encountered will inform future research.

Polymorphisms in Cytokine Genes Are Associated With Higher Levels of Fatigue and Lower Levels of Energy in Women After Breast Cancer Surgery

CONTEXT

Little is known about the phenotypic and molecular characteristics associated with changes over time in fatigue and lack of energy in patients with breast cancer.

OBJECTIVES

The aim of this study was to identify subgroups (i.e., latent classes) of women with distinct fatigue and energy trajectories; evaluate for differences in phenotypic characteristics between the latent classes for fatigue and energy; and evaluate for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators and latent class membership.

METHODS

Patients were enrolled before and followed for six months after breast cancer surgery. Latent class analyses were done to identify subgroups of patients with distinct fatigue and energy trajectories. Candidate gene analyses were done to identify cytokine genes associated with these two symptoms.

RESULTS

For both fatigue and lack of energy, two distinct latent classes were identified. Phenotypic characteristics associated with the higher fatigue class were younger age, higher education, lower Karnofsky Performance Status score, higher comorbidity, higher number of lymph nodes removed, and receipt of chemotherapy (CTX). Polymorphisms in interleukin (IL) 1β and IL10 were associated with membership in the higher fatigue class. Phenotypic characteristics associated with the lower energy class included: a lower Karnofsky Performance Status score and a higher comorbidity score. A polymorphism in IL1R1 was associated with membership in the lower energy class.

CONCLUSION

Within each latent class, the severity of fatigue and decrements in energy were relatively stable over the first six months after breast cancer surgery. Distinct phenotypic characteristics and genetic polymorphisms were associated with membership in the higher fatigue and lower energy classes.

Fatigue in lung cancer patients: symptom burden and management of challenges

Lung cancer (LC) remains the most common cause of cancer death in several countries across the world. Fatigue is the most frequently reported symptom in LC patients throughout the entire course of disease, and all international guidelines recommend early screening for cancer-related fatigue (CRF) and symptoms that can affect patients' quality of life. In patients with LC, fatigue belongs to the symptom cluster of pain, depression, and insomnia, which are commonly observed simultaneously, but are typically treated as separate although they may have common biological mechanisms. The treatment of CRF remains one of the difficult areas in the oncology field: scarce evidence supports pharmacological therapies, while some interesting data arising indicates alternative remedies and physical exercise seem to be one of the most effective approaches for CRF at any stage of LC.