Evolution of cancer-related symptoms over an 18-month period

Prevalence and risk factors for cancer-related fatigue in women with malignant gynecological tumors: a meta-analysis and systematic review

BACKGROUND

Cancer-related fatigue (CRF) is one of the most prevalent symptoms, but its prevalence and associated risk factors remain inconsistent across studies.

OBJECTIVE

To identify the prevalence and risk factors for CRF in women with malignant gynecological tumors.

METHODS

A comprehensive search of databases, including Web of Science, Cochrane Library, PubMed, Embase, CNKI, VIP, Wan Fang, and CBM, was conducted for relevant studies published from the inception of the database until September 7, 2023. Two reviewers used EndnoteX9 software to independently review, extract data, cross-check, and use the Newcastle-Ottawa quality assessment scale and the Agency for Healthcare Research and Quality tool for risk of bias assessment to evaluate bias risk. Stata 17.0 software was used to perform a traditional meta-analysis.

RESULTS

The meta-analysis included 33 studies, of which 29 reported the prevalence of CRF. The combined prevalence of CRF was 89% (95% confidence interval [CI]: 80-95%), and the combined prevalence of chronic CRF was 25% (95%CI: 22-28%). The combined prevalence of CRF in patients with ovarian cancer, cervical cancer, endometrial, and gynecological malignancies (including but not limited to cervical, ovarian, vaginal and other mixed types of gynecological cancers) was 77%, 94%, 90%, and 93%, respectively. The variability in CRF measurement is due to the different scales used across studies. Its prevalence varies by country, and developing countries, especially China, have a high prevalence of CRF. The following risk factors were associated with CRF: age (odds ratio [OR] = 1.43, 95%CI = 1.12-1.83), psychological factors (OR = 1.40, 95%CI = 1.14-1.72), disease stage (OR = 1.65, 95%CI 1.14-2.40), and social support (OR = 0.77, 95%CI 0.67-0.87).

CONCLUSION

The prevalence of CRF is significant in women with gynecological cancers, especially in developing countries. Age, psychological factors, and disease stage are risk factors for CRF, while social support serves as a protective factor. Healthcare professionals can obtain a clearer picture of CRF in women with gynecological malignant tumors and identify risk factors to support subsequent interventions in these patients.

PROSPERO ID

CRD42023489433.

Understanding mental health in breast cancer from screening to Survivorship: an integrative phasic Model and tool

Integrative models of mental illness and health in psycho-oncology are aimed at all types of cancer, although the patients' experiences and issues may vary. This review summarizes the different theories and models of mental illness and health pertaining to the breast cancer experience and proposes an integrative phasic model applicable to the breast cancer trajectory. Five databases were searched for studies related to breast cancer mental health and illness theories and models. The PRISMA checklist form was used to extract the essential information from the included studies. Eleven theories and models on the experience of breast cancer were found. The integrative model based on these theories and models illustrates that the breast cancer experience is conceptualized as a trajectory with seven landmark 'events', each associated with a pathogenic 'challenge' leading to six possible 'symptoms', 1) psychological distress with anxious features, 2) psychological distress with depressive features, 3) non-specific distress 4) psychological distress with trauma-related features 5) low health-related quality of life, and 6) fear of recurrence. The Breast Cancer Psychological Integrative Phasic Model is supported by a simple clinical tool (BreastCancerPsych - Integrative Clinical Tool) that serves as a valuable resource throughout the care trajectory. These integrative phasic model and clinical tool are designed to help mental health clinicians formulate treatments that are tailored to the needs of their patients, especially for trajectories that are not marked by resilience.

Brain-Derived Neurotrophic Factor rs6265 polymorphism is associated with severe cancer-related fatigue and neuropathic pain in female cancer survivors

PURPOSE

This study examined the relationships between a single-nucleotide polymorphism (SNP) of brain-derived neurotrophic factor (BDNF) rs6265 and psychoneurological (PN) symptoms in female cancer survivors.

METHODS

This secondary analysis examined 393 study participants. In addition to demographic variables, self-reported PN symptom scores (anxiety, bodily pain, depression, fatigue, neuropathic pain, and sleep disturbance) were collected using the Patient-Reported Outcomes Measurement Information System and 36-Item Short-Form Health Survey. Buccal swab samples were collected to obtain genotypes for BDNF rs6265 (Val/Val, Val/Met, or Met/Met). The PN symptom scores were compared across genotypes, and the relationships were examined using a regression model. We also explored correlations between different symptoms within each genotype.

RESULTS

Participants with the Met/Met genotype reported significantly worse cancer-related fatigue and neuropathic pain, which was confirmed by rank-based regression analysis. In addition, cancer-related fatigue was correlated with other PN symptoms, particularly depression. These correlations were stronger in study participants with the Met/Met genotype than those with other genotypes.

CONCLUSION

Our study suggests that female cancer survivors with the Met/Met genotype of BDNF rs6265 are likely to experience worse cancer-related fatigue and neuropathic pain and that cancer-related fatigue is a good predictor of co-occurring PN symptoms in this population.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings advance the scientific community's understanding of cancer-related PN symptoms experienced by female cancer survivors, especially the unique role of BDNF rs6265 polymorphism in these symptoms. Our findings offer valuable insights for clinical practice that the symptom experience among female cancer survivors may vary based on BDNF genotypes.

Relationship of cancer-related fatigue with psychoneurophysiological (PNP) symptoms in breast cancer survivors

PURPOSE

Cancer-related fatigue (CRF) is a highly prevalent and debilitating symptom reported by breast cancer survivors (BCS). CRF has been associated with the co-occurrence of anxiety, depression, poor sleep quality, cognitive impairment, which are collectively termed as psychoneurophysiological (PNP) symptoms. CRF and these PNP symptoms are often reported during and after treatment with long-lasting distress. It is unclear how CRF and these PNP symptoms influence each other. This study aimed to explore predictive factors (i.e., PNP symptoms and social-demographic factors) of CRF, and test exploratory path models of the relationships of CRF with PNP symptoms (depression, anxiety, sleep disturbance, pain, and cognitive function) in BCS.

METHODS

This paper is part of a larger descriptive, correlational, and cross-sectional study. Validated and reliable instruments assessed CRF, depression, anxiety, sleep disturbance, pain, and cognitive function. Descriptive statistics, Pearson correlation, multiple linear regression models, and path analysis were employed.

RESULTS

Patients (N = 373) who reported less bodily pain had worst CRF (r = -0.45, p < .01). Significant predictors of CRF included depression, sleep disorder, bodily pain, perceived cognitive ability, and dispositional (state) optimism. Depression alone accounted for 31% of the variance in CRF. An integrative path model with bodily pain, neuropathic pain, CRF, and depression showed a good fit across different indices (CFI = 0.993, RMSEA = 0.047, 90% CI 0-0.12, SRMR = 0.027).

CONCLUSIONS

This study identified significant predictors of CRF and revealed a good fit mediation model with significant pathways for CRF, suggesting that a common etiology may underpin the co-occurrence of CRF with PNP symptoms (pain and depression). However, further investigation with longitudinal design is necessary to explore the causal relationships of these symptoms. Evidence-based strategies/interventions are needed to reduce or eliminate the burden of these symptoms on the lives of BCS.

Prevalence of Psychoneurological Symptoms and Symptom Clusters in Women with Breast Cancer Undergoing Treatment: Influence on Quality of Life

OBJECTIVES

To identify subgroups of psychoneurological symptoms (PNS) and their relationship to different clinical variables in a sample of women with breast cáncer (BC) with different type of treatment, and the possible influence of these on quality of life (QoL), using a factorial principal components analysis.

DATA SOURCES

Observational, cross-sectional, non-probability study (2017-2021) at Badajoz University Hospital (Spain). A total of 239 women with BC receiving treatment were included.

RESULTS

68% of women presented fatigue, 30% depressive symptoms, 37.5% anxiety, 45% insomnia, and 36% cognitive impairment. The average score obtained for pain was 28.9. All the symptoms were related between themselves, and within the cluster of PNS. The factorial analysis showed three subgroups of symptoms, which accounted for 73% of variance: state and trait anxiety (PNS-1), cognitive impairment, pain and fatigue (PNS-2), and sleep disorders (PNS-3). The depressive symptoms were explained equally by PNS-1 and PNS-2. Additionally, two dimensions of QoL were found (functional-physical and cognitive-emotional. These dimensions correlated with the three PNS subgroups found. A relationship was found between chemotherapy treatment and PNS-3, and its negative impact on QoL.

CONCLUSIONS

A specific pattern of grouped symptoms in a psychoneurological cluster with different underlying dimensions has been identified which negatively influences QoL of survivors of BC.

IMPLICATION FOR NURSING PRACTICE

It is important to raise awareness among professionals and patients about the existence of a cluster of PNS, the patient's profile, as well as the factors that exacerbate them. This will allow them to be treated more effectively and comprehensively.

Systematic review of sleep and sleep disorders among prostate cancer patients and caregivers: a call to action for using validated sleep assessments during prostate cancer care

OBJECTIVE/BACKGROUND

To examine the impact of prostate cancer (PCa) on sleep health for patients and caregivers. We hypothesized that sleep disturbances and poor sleep quality would be prevalent among patients with PCa and their caregivers.

PATIENTS/METHODS

A systematic literature search was conducted according to the Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines. To be eligible for this systematic review, studies had to include: (1) patients diagnosed with PCa and/or their caregivers; and (2) objective or subjective data on sleep. 2431 articles were identified from the search. After duplicates were removed, 1577 abstracts were screened for eligibility, and 315 underwent full-text review.

RESULTS AND CONCLUSIONS

Overall, 83 articles met inclusion criteria and were included in the qualitative synthesis. The majority of papers included patients with PCa (98%), who varied widely in their treatment stage. Only 3 studies reported on sleep among caregivers of patients with PCa. Most studies were designed to address a different issue and examined sleep as a secondary endpoint. Commonly used instruments included the Insomnia Severity Index and European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaires (EORTC-QLQ). Overall, patients with PCa reported a variety of sleep issues, including insomnia and general sleep difficulties. Both physical and psychological barriers to sleep are reported in this population. There was common use of hypnotic medications, yet few studies of behavioral interventions to improve sleep for patients with PCa or their caregivers. Many different sleep issues are reported by patients with PCa and caregivers with diverse sleep measurement methods and surveys. Future research may develop consensus on validated sleep assessment tools for use in PCa clinical care and research to promote facilitate comparison of sleep across PCa treatment stages. Also, future research is needed on behavioral interventions to improve sleep among this population.

Randomized, Controlled Trial of an Intervention Combining Self-Care and Self-Hypnosis on Fatigue, Sleep, and Emotional Distress in Posttreatment Cancer Patients: 1-Year Follow-Up

Cancer can provoke fatigue, sleep disturbances, and emotional distress. Hypnosis interventions have shown positive short-term effects on these symptoms. However, less is known about their long-term effects. This study assessed the short- and long-term effects of a group intervention combining self-care and self-hypnosis on these symptoms in posttreatment cancer patients. Ninety-five female cancer survivors were randomized to either a hypnosis group intervention or wait-list control. Results showed significant decreases in fatigue, sleep difficulties and emotional distress after intervention for the hypnosis group intervention in comparison to the wait-list control. Most of these positive effects were maintained at 1-year follow-up. Most participants received the hypnosis group intervention approximately 10.65 months after diagnosis, and it is possible that delivering the intervention earlier after diagnosis could have achieved a more robust impact. Further studies are needed to replicate these results in comparison to an active control condition and investigate the best time postdiagnosis for initiating the intervention.

The characteristics and related factors of insomnia among postoperative patients with gastric cancer: a cross-sectional survey

Purpose

This study aims to explore the characteristics and related factors of insomnia of patients after operation for gastric cancer.

Methods

A cross-sectional survey was carried out and finally 115 patients with insomnia after operation for gastric cancer were included. The general information, gastric cancer-related information, sleep quality, and other symptoms were investigated.

Results

① The Pittsburgh sleep quality index score of most insomnia patients after gastric cancer surgery was 11-15 points, and the sleep quality rating was “poor”. ② The sleep quality of patients with insomnia after surgery for gastric cancer is related to the number of chemotherapy cycles, fatigue, and depression. ③ The probability of reduced sleep quality with the number of chemotherapy cycles >6 is 3.640 times that of ≤6. The probability of reduced sleep quality during moderate to severe fatigue was 4.390 times that of patients with no or mild fatigue.

Conclusion

Attention to related factors may be associated with improvement of sleep quality in patients with gastric cancer after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06295-6.

A novel approach to management of sleep-associated problems in patients with breast cancer (MOSAIC) during chemotherapy : A pilot study

STUDY OBJECTIVES

This pilot randomized controlled trial (RCT) was conducted to assess the preliminary effects of Brief Behavioral Therapy for Cancer-Related Insomnia (BBT-CI) delivered by trained research staff in comparison to a sleep hygiene pamphlet control and to assess moderators of treatment effect in patients with breast cancer undergoing chemotherapy.

METHODS

Of 74 participants recruited, 37 were randomized to BBT-CI and 37 were randomized to the control condition. Trained staff members delivered the intervention during chemotherapy treatments to reduce patients' burden. Insomnia was assessed with the Insomnia Severity Index (ISI), anxiety was assessed with the Spielberger State-Trait Anxiety Inventory, symptom burden was assessed with the Symptom Inventory (SI), and study staff recorded previous treatments and surgeries received by patients.

RESULTS

Patients randomized to BBT-CI showed significantly greater improvements in their ISI scores compared to the sleep hygiene group. Additionally, several treatment moderators were identified. The effect of BBT-CI was greater among individuals with lower baseline state-trait anxiety, with previous surgery for cancer, and with higher baseline somatic symptom severity.

CONCLUSIONS

BBT-CI shows preliminary efficacy compared to the sleep hygiene handout on insomnia in cancer patients undergoing chemotherapy. A large-phase III RCT needs to be conducted to replicate the preliminary findings.

Neoadjuvant and adjuvant end-points in health technology assessment in oncology

Health technology assessment (HTA) of clinical and economic value of a new intervention is an integral step in providing the access of patients to innovative cancer care and treatment. Overall survival (OS) is the preferred criterion for demonstrating the therapeutic efficacy in HTA given its direct clinical and patient relevance. However, with often long life expectancy of patients with early cancer, analysis of OS becomes less practical. Partially due to this reason, pathological complete response (pCR) and time-to-event end-points like disease-free survival are frequently incorporated into the pivotal clinical trials in the neoadjuvant and adjuvant settings. However, there exists a discrepancy between different national HTA bodies regarding the acknowledgement of patient relevance of these end-points. In this article, we analysed the perspectives of patients on different aspects of end-points used in clinical trials in early cancer. Gathered evidence strongly suggests that complete tumour eradication and reduced risk of recurrence provide important psychological benefits thus signifying that pCR and time-to-event end-points are directly relevant to patients. Additionally, we reviewed opinions on patient relevance of neoadjuvant and adjuvant therapy end-points adopted by HTA bodies during the recent evaluations. We found that improvements in end-points used in the adjuvant setting were commonly considered as valuable to patients. In contrast, opinions on patient relevance of neoadjuvant therapy end-points varied between the national HTA bodies. Universal acknowledgement of patient relevance of therapeutic end-points for early cancer by HTA bodies is necessary to balance the inequality in uptake of innovative therapies into national healthcare systems.

Changes in Fatigue, Psychological Distress, and Quality of Life After Chemotherapy in Women with Breast Cancer: A Prospective Study

BACKGROUND

Chemotherapy leads to various symptoms and psychological distress, which contribute to a significant decrease in the quality of life of the patients.

OBJECTIVES

The aim of this study was to identify changes and interrelationships in the fatigue-depression-anxiety symptom cluster and quality of life during the cancer care trajectory in women with breast cancer.

METHODS

Fifty women participated in the study and completed questionnaires at 3 different times: prechemotherapy, postchemotherapy, and 6 months after the completion of chemotherapy. The assessment tools were the Functional Assessment of Cancer Therapy-Fatigue Scale, Hospital Anxiety and Depression Scale, and Functional Assessment of Cancer Therapy-Breast Cancer version 4 Scale. Data were analyzed using descriptive and repeated-measures analysis of variance statistics.

RESULTS

A significant increase in fatigue (F = 41.95, P < .001) and psychological distress (F = 26.55, P < .001) from prechemotherapy to postchemotherapy was noted. Improvement was observed 6 months after the completion of chemotherapy. A positive or negative change in fatigue was associated with the same in psychological distress. Quality of life (F = 65.22, P < .001) also showed similar change patterns as observed with fatigue and psychological distress. Fatigue had a greater impact on quality of life at postchemotherapy, but psychological distress had a greater impact at prechemotherapy and at the 6-month follow-up.

CONCLUSION

These results suggest that chemotherapy is highly associated with the fatigue-depression-anxiety symptom cluster and quality of life in women with breast cancer.

IMPLICATIONS FOR PRACTICE

Nursing intervention is needed to relieve the intensity of the fatigue-depression-anxiety symptom cluster and thus improve the quality of life of patients undergoing chemotherapy from before treatment to follow-up.

Anxiety, Depression, and Colorectal Cancer Survival: Results from Two Prospective Cohorts

Given the unalterable nature of most risk factors for colorectal cancer (CRC) survival (e.g., disease stage), identifying modifiable determinants is critical. We investigated whether anxiety and depression were related to CRC survival using data from the Nurses' Health Study (NHS) and Health Professional Follow-up Study (HPFS). Participants who received a CRC diagnosis and provided information about anxiety (nNHS = 335; nHPFS = 232) and depression (nNHS = 893; nHPFS = 272) within 4 years of diagnosis were included. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) of overall mortality, while controlling for covariates (sociodemographics, cancer characteristics, and lifestyle factors). Pooled risk estimates were derived from fixed effects meta-analyses of the cohorts. Among 1732 CRC patients, 814 deaths occurred during the 28-year follow-up. Each 1 standard deviation increase in anxiety or depression symptoms was associated with a similar 16% higher mortality risk (anxiety: 95% CI = 1.05-1.29; depression: 95% CI = 1.07-1.26). Comparable results were observed across all sensitivity analyses (introducing a 1-year lag, restricting to CRC-related mortality, considering potential behavioral pathways) and stratified models (cancer stage, sex). Our findings suggest greater anxiety and depression symptoms can not only impede adherence to healthy habits and reduce quality of life in cancer patients but could also be a marker for accelerated CRC progression.

Predicting Anxiety in Hospitalized Cancer Patients

CONTEXT

Anxiety in patients with cancer is highly prevalent; yet it remains underestimated and inadequately assessed. Little is known about predictors for anxiety in hospitalized patients with cancer. Insight in predictors should improve recognition and enable a targeted approach.

OBJECTIVES

To determine the prevalence of anxiety and predictors for anxiety in hospitalized patients with cancer at different stages of disease.

METHODS

A cross-sectional analysis of patients with cancer admitted to the Utrecht University Medical Center in 2015-2018 was conducted. The Utrecht Symptom Diary, an adapted Dutch version of the Edmonton Symptom Assessment System, was used to assess symptom burden on a numeric rating scale (0 = no symptom and 10 = worst possible symptom). Scores ≥4 were considered clinically relevant. All patients completed the Utrecht Symptom Diary as part of routine care. The first questionnaire after admission was selected. Using multivariable linear regression, the predictive value of potential predictors on anxiety was analyzed.

RESULTS

In total, 2144 patients were included, of which 22% reported clinically relevant anxiety. The prevalence of anxiety was highest (36%) in patients receiving symptom-directed palliation only. In the total group, female gender, younger age, depressed mood, sleeping problems, dyspnea, and cancer of the head and neck were predictive of anxiety. Throughout all stages of disease, depressed mood was consistently the strongest predictor.

CONCLUSION

We found a high prevalence of anxiety in hospitalized patients with cancer. It is recommended to explore anxiety in hospitalized patients with cancer, in particular when they experience depressed mood. Structural use of a symptom diary during hospitalization facilitates the recognition of anxiety and concurrent symptoms.

Comparison of Sleep Quality before and after Chemotherapy in Locally Advanced Nonsmall Cell Lung Cancer Patients: A Prospective Study

BACKGROUND

Preservation of sleep quality is a modifiable and treatable factor, which may enhance the patient's adherence to other supportive and palliative care procedures. The outcome of sleep disturbances in lung cancer patients before and after treatment aren't reported. The aim of this study was to investigate changes in sleep quality before and after chemotherapy in locally advanced or metastatic NSCLC patients.

METHODS

It was a prospective study including 64 patients with stage III or IV nonsmall-cell lung cancer. Patients answered the Tunisian dialectal version of the following questionnaires: PSQI and QLQ-C30 in order to evaluate, respectively, the sleep quality and the quality of life. The assessments took place before chemotherapy and then repeated after the chemotherapy course was over.

RESULTS

The mean age was 62.9 years. All patients were active smokers. Before chemotherapy, there were 10 patients (15%) with poor sleep quality. The most frequent complaints were daytime sleepiness (70%) and nocturnal arousals (100%). After chemotherapy, the mean PSQI score increased from 2.9 to 5.4, and 45% of all patients had poor sleep quality. Most frequent complaints were the extension of sleep latency (69%), daytime sleepiness (98%), and nocturnal arousals (100%). Predicting factors of sleep disturbance according to statistical univariate analysis were delayed diagnosis confirmation (p = 0.05), delayed treatment onset (p < 10-3), depressive mood (p = 0.001), and anxious mood (p = 0.001). Multivariate analysis had shown a significant and independent correlation between sleep quality and shortened diagnosis and treatment delays. Sociodemographic parameters, clinical parameters, and factors related to treatment procedure had no correlation with sleep quality.

CONCLUSIONS

Our study demonstrates the persistence and potential intensity worsening of sleep disturbances in advanced stage nonsmall-cell lung cancer patients. We, hereby, reported a statistical correlation between sleep quality and quality of life in our patients.

Unmet information needs predict anxiety in early survivorship in young women with breast cancer

PURPOSE

To examine variations in anxiety and longitudinal associations between unmet supportive care needs and elevated anxiety in young women (< 50 years) within 13 months of their breast cancer diagnosis.

METHODS

Two hundred and nine women recruited through Victorian Cancer Registry completed questionnaires at study entry (T1) (average 7 months post-diagnosis) then 3 (T2) and 6 months later (T3). Women completed the Hospital Anxiety and Depression Scale (HADS) and Supportive Care Needs Survey-Breast Cancer (SCNS-Breast) at each time point. Primary outcome was anxiety with six domains of SCNS-Breast (physical daily living, information, psychological, health system information, peer support, patient care and miscellaneous needs) the key predictors. Generalised estimating equations examined longitudinal associations.

RESULTS

Over the 6 months, the proportion of young women with elevated anxiety decreased (T1, 41% to T3, 35%; p = .06) as did the proportion with any moderate or high unmet needs (T1, 88%; T3, 74%; p < .01). While psychological needs and peer needs were positively associated with anxiety levels in multivariable cross-sectional analyses, in multivariable longitudinal analysis, only informational needs were associated with higher levels of anxiety (p < .001) with this association holding after adjusting for baseline anxiety levels.

CONCLUSIONS

While reducing over time, a third of young women treated for breast cancer enter early survivorship with elevated anxiety and unmet supportive care needs.

IMPLICATIONS FOR CANCER SURVIVORS

As informational needs were positively associated with future levels of anxiety, addressing needs in this domain may decrease the risk of anxiety in younger women with breast cancer.

Adult cancer patients' perception of social support in non-profit electronic counselling services: a descriptive qualitative study

Background: Cancer patients may need to seek support from electronic sources because their needs are not fulfilled in the hospital settings.Objectives: The explore cancer patients' perception of social support in non-profit electronic counselling services.Design: A qualitative descriptive cross-sectional design.Methods: The data were collected from adult cancer patients who had utilized non-profit electronic counselling services. The interviews were conducted face-to-face or over the phone and analysed with inductive content analysis.Findings: Two patterns were identified: (1) a contact person that will ensure a personalized matching type of support to enhance patients' ability to cope with cancer if necessary and (2) deficient resources of the electronic counselling services to provide the matching type of support to enhance patients' coping with cancer.Conclusions: For patients to be able to successfully cope with their disease, it is essential that the electronic social support type matches each patient's specific needs.

Predictors of Smoking Cessation and Relapse in Cancer Patients and Effect on Psychological Variables: an 18-Month Observational Study

BACKGROUND

Although cancer patients are generally strongly advised to quit smoking in order to improve treatment efficacy and survival, up to 68 % of patients who were smokers at the time of cancer diagnosis continue smoking. Psychological factors such as depression and anxiety are likely to be associated with smoking behavior following a cancer diagnosis, but the empirical evidence is scarce.

PURPOSE

This observational study aimed at estimating smoking cessation rates and assessing the effect of smoking cessation on psychological symptoms, as well as the predictive role of the same psychological variables on smoking cessation and smoking relapse following cancer surgery.

METHODS

As part of a larger prospective, epidemiological study, smokers (n = 175) with a first diagnosis of nonmetastatic cancer completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, and the Fear of Cancer Recurrence Inventory. Quitters (n = 55) and pair-matched nonquitters (n = 55) were compared on each symptom at pre-quitting, post-quitting, and at a 4-month follow-up. Predictors of smoking cessation and smoking relapse, including psychological variables, were also investigated.

RESULTS

Fifty-five patients (31.4 %) stopped smoking at least on one occasion during the study. Of the 55 quitters, 27 (49.1 %) experienced a relapse. At pre-quitting, quitters had significantly higher levels of anxiety (p = .03) and fear of cancer recurrence (p = .01) than nonquitters, symptoms that significantly diminished at post-quitting and 4 months later in this subgroup of patients. Having breast cancer significantly predicted smoking cessation (relative risk [RR] = 3.08), while depressive symptoms were a significant predictor of smoking relapse (RR = 1.07).

CONCLUSIONS

This study highlights the importance of psychological symptoms in predicting tobacco cessation and relapse among individuals with cancer. Our findings suggest that breast cancer patients are more inclined to stop smoking than patients with other cancers, but future studies should attempt to delineate the effect on smoking cessation of gender and other demographics that characterize this subgroup. This study also suggests that a particular attention should be paid to the early management of depressive symptoms in order to prevent smoking relapse.

Psychological symptoms and subsequent healthy lifestyle after a colorectal cancer diagnosis

OBJECTIVE

Although medical professionals recommend lifestyle changes following a colorectal cancer (CRC) diagnosis to improve outcomes, such changes are not consistently implemented. This study examines whether higher distress is associated with lower likelihood of engaging in favorable behaviors after CRC diagnosis.

METHOD

Women from the Nurses' Health Study prospective cohort who completed anxiety (n = 145) and depression (n = 227) symptom scales within 4 years after receiving a CRC diagnosis were included. Measures of lifestyle (diet, physical activity, alcohol, smoking, body mass index [BMI]) were queried prediagnosis, when psychological symptoms were assessed (1988 and 1992, respectively), and then every 4 years thereafter until 2010. Women were categorized according to initial psychological symptoms levels and followed through 2010 or until last follow-up completed.

RESULTS

Higher versus lower anxiety symptoms were significantly related to unhealthier lifestyle scores throughout follow-up (β = -0.25, CI [-0.44, -0.05]); however, the rate of change over time was similar across groups (pinteraction effect = 0.41). Stratified analyses hinted that higher anxiety and depression symptoms were related to increased odds of reporting a future unhealthy lifestyle within 10-years postdiagnosis. Beyond 10 years, anxiety became statistically unrelated with future lifestyle, and higher depressive symptoms were associated with lower odds of subsequently having an unhealthy lifestyle, albeit nonstatistically significant (OR = 0.35, 95% CI [0.10, 1.24], p = 0.10).

CONCLUSIONS

Among women with CRC, higher anxiety and depression symptoms were associated with subsequent unhealthier lifestyle in the 10 years following diagnosis. With replication, such findings may suggest that treating psychological symptoms early in the cancer trajectory may not solely reduce psychological distress but also promote healthier lifestyle. (PsycINFO Database Record

Surgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity

BACKGROUND

Fatigue has been reported by many patients undergoing surgery and is associated with a negative prognosis. The factors associated with postoperative fatigue and its evolution during the postoperative period are unclear. Adequate fatigue measurement instruments are necessary to obtain reliable evaluations and to direct effective care to control fatigue in this patient population.

OBJECTIVES

This article describes the evolution of postoperative fatigue in patients with cancer as well as related factors.

METHODS

A review of the literature using the CINAHL® and PubMed databases was undertaken.

FINDINGS

The prevalence of moderate and severe fatigue varies during the postoperative period, with a reduction in the 12 months after surgery. Various factors (e.g., stress, anxiety, depression, pain, changes in sleep patterns) seem to influence the severity of fatigue. More evidence is needed to explore the relationship between immediate postoperative fatigue and the evolution of fatigue during the period following surgical treatment for cancer.

Inflammatory pathway genes associated with inter-individual variability in the trajectories of morning and evening fatigue in patients receiving chemotherapy

Fatigue, a highly prevalent and distressing symptom during chemotherapy (CTX), demonstrates diurnal and interindividual variability in severity. Little is known about the associations between variations in genes involved in inflammatory processes and morning and evening fatigue severity during CTX. The purposes of this study, in a sample of oncology patients (N=543) with breast, gastrointestinal (GI), gynecological (GYN), or lung cancer who received two cycles of CTX, were to determine whether variations in genes involved in inflammatory processes were associated with inter-individual variability in initial levels as well as in the trajectories of morning and evening fatigue. Patients completed the Lee Fatigue Scale to determine morning and evening fatigue severity a total of six times over two cycles of CTX. Using a whole exome array, 309 single nucleotide polymorphisms SNPs among the 64 candidate genes that passed all quality control filters were evaluated using hierarchical linear modeling (HLM). Based on the results of the HLM analyses, the final SNPs were evaluated for their potential impact on protein function using two bioinformational tools. The following inflammatory pathways were represented: chemokines (3 genes); cytokines (12 genes); inflammasome (11 genes); Janus kinase/signal transducers and activators of transcription (JAK/STAT, 10 genes); mitogen-activated protein kinase/jun amino-terminal kinases (MAPK/JNK, 3 genes); nuclear factor-kappa beta (NFkB, 18 genes); and NFkB and MAP/JNK (7 genes). After controlling for self-reported and genomic estimates of race and ethnicity, polymorphisms in six genes from the cytokine (2 genes); inflammasome (2 genes); and NFkB (2 genes) pathways were associated with both morning and evening fatigue. Polymorphisms in six genes from the inflammasome (1 gene); JAK/STAT (1 gene); and NFkB (4 genes) pathways were associated with only morning fatigue. Polymorphisms in three genes from the inflammasome (2 genes) and the NFkB (1 gene) pathways were associated with only evening fatigue. Taken together, these findings add to the growing body of evidence that suggests that morning and evening fatigue are distinct symptoms.

Trajectories of Stress, Depressive Symptoms, and Immunity in Cancer Survivors: Diagnosis to 5 Years

PURPOSE

Five-year disease endpoint trajectories are available for every cancer site. In contrast, there are few longitudinal, biobehavioral studies of survivors extending beyond the first or second year following diagnosis. This gap is addressed with stress, depressive symptom, and immunity data from breast cancer patients followed continuously for 5 years.

EXPERIMENTAL DESIGN

Women (N = 113) diagnosed and surgically treated for breast cancer and awaiting adjuvant therapy completed self-report measures of stress and depressive symptoms and provided blood for immune assays [natural killer cell cytotoxicity (NKCC) and T-cell blastogenesis]. Assessments (N = 12) were repeated every 4 to 6 months for 5 years.

RESULTS

Multiphase linear mixed models show phases of change and identified specific time points of change. Cancer stress shows two distinct phases of decline, with the change point being 12 months. In contrast, a steep decline in depressive symptoms occurs by 7 months, with stable, low levels thereafter. NKCC shows a steady upward trajectory through 18 months and upper limit stability thereafter, whereas there was no reliable trajectory for T-cell blastogenesis.

CONCLUSIONS

For the first time, trajectories and specific time points of change in biobehavioral data for breast cancer survivors are provided, traced through 5 years. Following diagnosis, the breast survivor experience is one of a co-occurrence of change (recovery) in psychologic and innate immunity markers from diagnosis to18 months, and a pattern of stability (depression, NKCC) or continued improvement (stress) through year 5. These data provide new directions for survivorship care and detail of the biobehavioral trajectory. Clin Cancer Res; 23(1); 52-61. ©2016 AACR.

Burden of symptoms associated with development of metastatic bone disease in patients with breast cancer

Purpose

Women with breast cancer frequently develop painful bone metastases. This retrospective study was designed to longitudinally characterize patterns of patient-reported symptoms among patients with breast cancer relative to the diagnosis of bone metastases.

Methods

Patient records were identified from the Oncology Services Comprehensive Electronic Records (OSCER) database which includes outpatient oncology practices across the USA. Symptom burden was assessed by Patient Care Monitor (PCM) assessments, which are administered as part of routine care in a subset of these practices. Eligible patients were women diagnosed with breast cancer (ICD-9-CM 174.xx) who developed bone metastases (ICD-9-CM 198.5) and had ≥1 PCM assessment between January 2007 and December 2012. The pre-specified endpoint was the occurrence of moderate to severe symptom burden, defined as PCM score ≥4 (0–10 scale).

Results

One thousand one hundred five women (median age, 61) met the eligibility criteria. Worsening of symptoms, particularly fatigue and pain, occurred in the months leading up to the diagnosis of bone metastases. After bone metastases diagnosis, the rate of increase in the proportion of patients experiencing moderate/severe symptoms slowed, but continued to climb during follow-up. Median time to moderate/severe symptoms was 0.9 month for fatigue, 1 month for pain, 2.9 months for trouble sleeping, and 7.7 months for numbness/tingling. Half of the patients received bone-targeted agents after diagnosis of bone metastases.

Conclusions

Symptom burden, especially pain and fatigue, increased both before and after the diagnosis of bone metastases, highlighting the need for proactive monitoring and management of symptoms in breast cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-016-3154-x) contains supplementary material, which is available to authorized users.

The symptom phenotype of oncology outpatients remains relatively stable from prior to through 1 week following chemotherapy

Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low-Low, 44.1% as Moderate-Moderate and 30.9% as High-High. Compared to the Low-Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.

Predictors and Trajectories of Morning Fatigue Are Distinct From Evening Fatigue

CONTEXT

Fatigue is the most common symptom in oncology patients during chemotherapy. Little is known about the predictors of interindividual variability in initial levels and trajectories of morning fatigue severity in these patients.

OBJECTIVES

An evaluation was done to determine which demographic, clinical, and symptom characteristics were associated with initial levels as well as the trajectories of morning fatigue and to compare findings with our companion paper on evening fatigue.

METHODS

A sample of outpatients with breast, gastrointestinal, gynecological, and lung cancer (n = 586) completed demographic and symptom questionnaires a total of six times over two cycles of chemotherapy. Fatigue severity was evaluated using the Lee Fatigue Scale. Hierarchical linear modeling was used to answer the study objectives.

RESULTS

A large amount of interindividual variability was found in the morning fatigue trajectories. A piecewise model fit the data best. Patients with higher body mass index, who did not exercise regularly, with a lower functional status, and who had higher levels of state anxiety, sleep disturbance, and depressive symptoms reported higher levels of morning fatigue at enrollment. Variations in the trajectories of morning fatigue were predicted by the patients' ethnicity and younger age.

CONCLUSION

The modifiable risk factors that were associated with only morning fatigue were body mass index, exercise, and state anxiety. Modifiable risk factors that were associated with both morning and evening fatigue included functional status, depressive symptoms, and sleep disturbance. Using this information, clinicians can identify patients at higher risk for more severe morning fatigue and evening fatigue, provide individualized patient education, and tailor interventions to address the modifiable risk factors.

Grasping the 'teachable moment': time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors

BACKGROUND

A cancer diagnosis may provide a 'teachable moment' in cancer recovery. To better understand factors influencing lifestyle choices following diagnosis, we examined associations between time since diagnosis and symptom burden with recommended dietary (e.g., five or more fruit/vegetable servings/day), physical activity (e.g., >150 active min, 3-5 times/week), and smoking behaviors (i.e., eliminate tobacco use) in cancer survivors.

METHODS

We analyzed cross-sectional survey data collected from breast (n = 528), colorectal (n = 106), and prostate (n = 419) cancer survivors following active treatment at The University of Texas MD Anderson Cancer Center. Four regression models were tested for behaviors of interest. Additionally, we assessed symptom burden as a potential moderator and/or mediator between time since diagnosis and behaviors.

RESULTS

Respondents were mostly female (55%) and non-Hispanic White (68%) with a mean age of 62.8 ± 11.4 years and mean time since diagnosis of 4.6 ± 3.1 years. In regression models, greater time since diagnosis predicted lower fruit and vegetable consumption (B = -0.05, p = 0.02) and more cigarette smoking (B = 0.06, p = 0.105). Greater symptom burden was a significant negative predictor for physical activity (B = -0.08, p < .001). We did not find evidence that symptom burden moderated or mediated the association between time since diagnosis and health behaviors.

CONCLUSION

We assessed the prevalence of recommended behaviors in the context of other challenges that survivors face, including time since diagnosis and symptom burden. Our results provide indirect evidence that proximity to a cancer diagnosis may provide a teachable moment to improve dietary and smoking behaviors and that symptom burden may impede physical activity following diagnosis. Copyright © 2015 John Wiley & Sons, Ltd.

Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial

PURPOSE/OBJECTIVES

To examine the effect of cognitive-behavioral therapy for insomnia (CBTI) on sleep improvement, daytime symptoms, and quality of life (QOL) in breast cancer survivors (BCSs) after cancer treatment.

DESIGN

A prospective, longitudinal, randomized, controlled trial.

SETTING

Oncology clinics, breast cancer support groups, and communities in Colorado.

SAMPLE

56 middle-aged BCSs with chronic insomnia.

METHODS

Women were randomly assigned to CBTI or behavioral placebo treatment (BPT) and completed measures of sleep, QOL, functioning, fatigue, and mood at baseline, postintervention, and at three- and six-month follow-ups.

MAIN RESEARCH VARIABLES

Sleep outcomes (e.g., sleep efficiency, sleep latency, total sleep time, wake after sleep onset, number of nightly awakenings); secondary variables included sleep medication use, insomnia severity, QOL, physical function, cognitive function, fatigue, depression, anxiety, and sleep attitudes or knowledge.

FINDINGS

Sleep efficiency and latency improved more in the CBTI group than the BPT group; this difference was maintained during follow-up. Women in the CBTI group had less subjective insomnia, greater improvements in physical and cognitive functioning, positive sleep attitudes, and increased sleep hygiene knowledge. No group differences in improvement were noted relative to QOL, fatigue, or mood.

CONCLUSIONS

Nurse-delivered CBTI appears to be beneficial for BCSs' sleep latency/efficiency, insomnia severity, functioning, sleep knowledge, and attitudes more than active placebo, with sustained benefit over time.

IMPLICATIONS FOR NURSING

Oncology nurses are in a unique position to identify insomnia in cancer survivors. When sleep disturbances become chronic, nurses need to make recommendations and referrals.

Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period

BACKGROUND

Anxiety, depression, insomnia, fatigue, and pain are frequently reported by cancer patients. These symptoms are highly interrelated. However, few prospective studies have documented the sequence with which symptoms occur during cancer care.

PURPOSE

This longitudinal study explored the temporal relationships between anxiety, depression, insomnia, fatigue, and pain over an 18-month period in a large population-based sample of nonmetastatic cancer patients (N = 828), using structural equation modeling.

METHODS

The patients completed a battery of self-report scales at baseline and 2, 6, 10, 14, and 18 months later.

RESULTS

The relationships between the same symptom at two consecutive assessments showed the highest coefficients (β = 0.29 to 0.78; all ps ≤ 0.05). Cross-loading parameters (β = 0.06 to 0.19; ps ≤ 0.05) revealed that fatigue frequently predicted subsequent depression, insomnia, and pain, whereas anxiety predicted insomnia.

CONCLUSIONS

Fatigue and anxiety appear to constitute important risk factors of other cancer-related symptoms and should be managed appropriately early during the cancer care trajectory.