A qualitative study to explore the experience of fatigue in cancer patients

The long-term course and relationship with survival of multidimensional fatigue in patients with brain metastases after Gamma Knife radiosurgery

PURPOSE

The aims of this study were to evaluate long-term multidimensional fatigue in patients with brain metastases (BM) up to 21 months after Gamma Knife radiosurgery (GKRS) and (change in) fatigue as predictor of survival.

METHODS

Patients with 1 to 10 BM, expected survival > 3 months, and Karnofsky Performance Status ≥ 70, and Dutch non-cancer controls were included. Fatigue was measured with the Multidimensional Fatigue Inventory. Levels of fatigue between patients and controls were compared using independent-samples t-tests. Linear mixed models were used to evaluate fatigue within the patient group up to 21 months after GKRS. Pre-GKRS fatigue and minimal clinically important (MCI) changes in fatigue in the first three months (defined as a 2-point difference) after GKRS were evaluated as predictors of survival time.

RESULTS

Prior to GKRS, patients with BM (n = 92) experienced significantly higher fatigue on all subscales than controls (n = 104). Over 21 months, physical fatigue increased, and mental fatigue decreased significantly. More specifically, general, and physical fatigue increased significantly between pre-GKRS and 3 months, followed by stable scores between 3 (n = 67) and 6 (n = 53), 6 and 12 (n = 34) and 12 and 21 (n = 21) months. An MCI increase in general or physical fatigue over the first 3 months after GKRS was a significant predictor of shorter survival time.

CONCLUSION

Except for mental fatigue, all aspects of fatigue remained elevated or further increased up to 21 months after treatment. Furthermore, an increase in general or physical fatigue within three months after GKRS may be a prognostic indicator for poorer survival.

CLINICALTRIALS

GOV IDENTIFIER

NCT02953756, November 3, 2016.

Multidimensional assessment of fatigue in patients with brain metastases before and after Gamma Knife radiosurgery

PURPOSE

Fatigue is a common and distressing symptom in cancer patients which negatively affects patients' daily functioning and health-related quality of life. The aim of this study was to assess multidimensional fatigue in patients with brain metastases (BM) before, and after Gamma Knife radiosurgery (GKRS).

METHODS

Patients with BM, an expected survival > 3 months, and a Karnofsky Performance Status ≥ 70 and 104 Dutch non-cancer controls were recruited. The Multidimensional Fatigue Inventory (MFI), measuring general fatigue, physical fatigue, mental fatigue, reduced activity and reduced motivation, was used. Baseline levels of fatigue between patients and controls were compared using independent-samples t-tests. The course of fatigue over time, and clinical and psychological predictors thereof, were analyzed using linear mixed models (within-group analyses).

RESULTS

Ninety-two, 67 and 53 patients completed the MFI at baseline, and 3 and 6 months after GKRS. Before GKRS, patients with BM experienced significantly higher levels of fatigue on all subscales compared to controls (medium to large effect sizes). Over 6 months, general and physical fatigue increased significantly (p = .009 and p < .001), and levels of mental fatigue decreased significantly (p = .027). No significant predictors of the course of fatigue over time could be identified.

CONCLUSIONS

Fatigue is a major problem for patients with BM. Different patterns over time were observed for the various aspects of fatigue in patients with BM. Information on the various aspects of fatigue is important because fatigue may negatively affect patients' functional independence, health-related quality of life, and adherence to therapy.

The Experience of Fatigue in Breast Cancer Patients 1-12 Month Post-Chemotherapy: A Qualitative Study

The study explored the experience of fatigue, its effects and ways of coping with fatigue and the role of family and social support among breast cancer patients. In-depth, semi-structured interviews were conducted with 13 breast cancer patients stages I-III, aged 34-67, who were up to one year after the termination of chemotherapy. Two main themes emerged: "Being imprisoned in the body of an 80-year-old," focuses the fatigue experienced by younger and older women, during and post treatment, including the different patterns of fatigue and the various means of coping with fatigue; The "Family's bear-hug" exemplifies the role of the environment in coping with the experience of fatigue and the complexities entailed in receiving support from family and friends. The study provides a comprehensive picture of fatigue in its various contexts during and post-treatment and its impact on family relations and quality of life among younger and older breast cancer patients.

'It's when you're not doing too much you feel tired': A qualitative exploration of fatigue in end-stage kidney disease

BACKGROUND

Fatigue is commonly experienced in end-stage kidney disease (ESKD) patients. In order to develop patient-centred psychosocial interventions to help patients manage fatigue symptoms, a more in-depth understanding regarding the experience of fatigue is needed.

OBJECTIVE

The objective of this study was to explore renal patients' experiences of fatigue, across renal replacement therapy (RRT) modalities.

METHODS

Twenty-five in-depth semi-structured interviews were conducted. Interviews were audio-taped, transcribed, and analysed using inductive thematic analysis.

RESULTS

Main themes included the strong role of the illness and treatment in the aetiology of fatigue. Two contrasting streams of illness-fatigue interpretations emerged: catastrophizing versus normalizing. Participants emphasized the importance of having a sense of purpose in facilitating active management of fatigue. Many participants described the consequences of fatigue on their functioning. Low mood, frustration, and anger were common emotional consequences of fatigue. Three dominant fatigue management strategies emerged: one related to accommodation of activities around fatigue, another on increasing activities to counteract fatigue, and the third one revolved around self-compassion. Social support emerged as an important aspect of the fatigue experience, serving as a source of motivation, yet participants were wary of becoming a burden to others.

CONCLUSION

Findings identify casual attributions, behavioural and emotional reactions, management strategies, and facilitators of active management of fatigue in ESKD. Untying fatigue from the illness and treatment may help patients to develop alternative less catastrophic perceptions of fatigue, increase their perception of control over fatigue, and facilitate active fatigue management. Statement of contribution What is already known on this subject? Fatigue is persistent and debilitating in end-stage kidney disease (ESKD), with no consistent treatment model. Promising evidence is available for psychological fatigue interventions in other chronic conditions. There is a gap in studies looking at the fatigue experiences of patients with ESKD across renal replacement therapies. What does this study add? Fatigue is not inherently negative, but shaped by patients' beliefs and behaviours. Findings provide novel insights, for example, on the important role social support seems to play in fatigue. An in-depth understanding of fatigue may help to inform a future patient-centred intervention in ESKD.

Blood transfusion practice in the UK and Ireland: a survey of palliative care physicians

OBJECTIVES

Red cell (blood) transfusions are used in palliative care to manage patients with symptomatic anaemia or when patients have lost blood. We aimed to understand current blood transfusion practice among palliative medicine doctors and compare this with National Institute for Health and Care Excellence (NICE) guidance. NICE guidance advocates more restrictive transfusion practice but is based on clinical trials in non-palliative care contexts; the extent to which these findings should be applied to palliative care remains unclear.

METHODS

Four clinical vignettes of common clinical palliative care scenarios were developed. Members of the Association for Palliative Medicine were invited to complete the survey. Results were compared with acceptable responses based on current NICE recommendations and analysed to determine the influence of respondents' gender, experience or work setting.

RESULTS

27% of 1070 members responded. Overall, ideal or acceptable responses were selected by less than half of doctors to all four vignettes. Doctors were more liberal in prescribing blood transfusions than NICE guidance would advocate. Senior doctors were less likely to choose an acceptable response than junior colleagues.

CONCLUSION

Palliative care practice is varied and not consistent with a restrictive blood transfusion policy. More recently trained doctors follow less liberal practices than senior colleagues. More direct evidence of benefits and harms of blood transfusion is needed in palliative care to inform practice.

Fatigue in Type 2 Diabetes: Impact on Quality of Life and Predictors

Fatigue is a persistent symptom, impacting quality of life (QoL) and functional status in people with type 2 diabetes, yet the symptom of fatigue has not been fully explored. The purpose of this study was to explore the relationship between fatigue, QoL functional status and to investigate the predictors of fatigue. These possible predictors included body mass index (BMI), Hemoglobin A1C (HbA1C), sleep quality, pain, number of complications from diabetes, years since diagnosis and depression. Forty-eight individuals with type 2 diabetes (22 females, 26 males; 59.66±7.24 years of age; 10.45 ±7.38 years since diagnosis) participated in the study. Fatigue was assessed by using Multidimensional Fatigue Inventory (MFI-20). Other outcomes included: QoL (Audit of Diabetes Dependent QoL), and functional status (6 minute walk test), BMI, HbA1c, sleep (Pittsburg sleep quality index, PSQI), pain (Visual Analog Scale), number of complications, years since diagnosis, and depression (Beck's depression Inventory-2). The Pearson correlation analysis followed by multivariable linear regression model was used. Fatigue was negatively related to quality of life and functional status. Multivariable linear regression analysis revealed sleep, pain and BMI as the independent predictors of fatigue signaling the presence of physiological (sleep, pain, BMI) phenomenon that could undermine health outcomes.

The Experience of Fatigue Across Long-Term Conditions: A Qualitative Meta-Synthesis

CONTEXT

Fatigue is a common and debilitating symptom associated with many long-term conditions and is reported to cause significant levels of distress for those individuals. There is a substantial body of literature related to the nature of fatigue; however, this has not been drawn together and compared across conditions.

OBJECTIVES

The aim of this review was to synthesize data on the nature of fatigue across long-term conditions.

METHODS

The review was designed as a qualitative meta-synthesis and followed the Joanna Briggs Institute guidelines for synthesizing qualitative research. The following databases were searched for the period January 1980 to January 2016, Ovid (Medline, Embase, CINAHL, and PsycINFO) and manual searching from the reference lists from articles identified by electronic search. Fifty-seven studies were included in the review, and findings related to the nature of fatigue were extracted and findings meta-synthesized.

RESULTS

The perceived nature of fatigue across long-term conditions was encompassed in one synthesis; the fatigue experience is without precedent, with four categories: a different fatigue to any experienced before, the intensity of fatigue is overwhelming, the trajectory of fatigue, and impact on sleep and sleep disturbance. Just over half of the participants in the included studies were diagnosed with cancer. Patterns in the experience of fatigue by condition were found for cancer-related fatigue and post-stroke fatigue where data were able to be synthesized.

CONCLUSION

Although similarities in the nature of the fatigue experienced were found across conditions, differences were also evident and could be mapped for cancer-related fatigue and post-stroke fatigue. Further qualitative research on the experience of fatigue across a wide range of chronic conditions would further contribute to understanding similarities and differences across conditions and inform both research and practice in relation to assessment and management.

Identification of distinct fatigue trajectories in patients with breast cancer undergoing adjuvant chemotherapy

PURPOSE

The goal of this study was to characterize changes in daily fatigue in women undergoing chemotherapy for breast cancer. We examined whether there are subgroups of patients with distinct fatigue trajectories and explored potential psychosocial and biomedical predictors of these subgroups.

METHODS

Participants were 77 women with breast cancer receiving adjuvant chemotherapy with AC-T (2-week cycle) and TC or TCH (3-week cycle) regimens. They completed 28 daily ratings online using an adapted version of the Patient-Reported Outcomes Measurement Information System (PROMIS®) fatigue instrument.

RESULTS

Both regimens followed an "inverted-U-shaped" fatigue pattern over approximately 2 weeks. Growth mixture modeling identified three patient subgroups with distinct trajectories. Fatigue scores in the "low fatigue" group (23 %) increased following the infusion and quickly abated. The "transient fatigue" (27 %) group had a very pronounced increase. Patients in the "high fatigue" (50 %) group reported consistently elevated fatigue with a relatively small increase. Demographic and medical variables were not associated with fatigue trajectory. Patients in the "high fatigue" group reported significantly poorer physical, emotional, and social functioning, poorer general health, and more depressed mood than patients in the "low fatigue" group. The "transient fatigue" group reported significantly better physical and social functioning than the "high fatigue" group, but emotional distress and depression similar to the "high fatigue" group.

CONCLUSIONS

The identification of patient subgroups with distinct fatigue trajectories during chemotherapy is an essential step for developing preventative strategies and tailored interventions. Our results suggest that different trajectories are associated with patients' psychosocial and general health.

Living through pelvic radiotherapy:A mixed method study of self-care activities and distressful symptoms

PURPOSE

To explore patients' experience of their illness when undergoing pelvic radiotherapy by describing the presence and severity of distressful symptoms and to explore initiated self-care activities in response to illness and symptoms.

METHODS

A mixed-method study was performed which included a core qualitative dataset and a supplementary quantitative dataset. Twenty-nine women undergoing five weeks of radiotherapy were prospectively interviewed during five weeks of treatment in order to capture experiences, distressful symptoms and quality of life during treatment. Grounded theory formed collection and analysis of the qualitative dataset and statistics were used to analyze the quantitative dataset.

RESULTS

A maintained self-identity was concluded as being central during the trajectory of treatment. Initiated self-care activities served to alleviate physical, emotional, and social suffering; helping the respondents keep their integrity and sense of self. Previous life experiences influenced the process of being able to maintain self-identity. The gastrointestinal symptoms and pain caused most distress.

CONCLUSIONS

In order to be able to maintain self-identity patients endure treatment by focusing on symptoms, on getting cured and on their self-image. Several distressful symptoms implied social limitations and a sense that the body would not take the strain. The result of this study can help health care professionals to gain a better understanding of the struggle to endure pelvic radiotherapy. Further, health care professionals should be more proactive in alleviating their patients' distressful symptoms. The results imply that previous life experiences should precede initiated interventions because these life experiences affect the patients' self-care activities.

Symptom clusters in patients with advanced cancer: a systematic review of observational studies

CONTEXT

Advanced cancer patients typically experience multiple symptoms, which may influence patient outcomes synergistically. The composition of these symptom clusters (SCs) differs depending on various clinical variables and the timing and method of their assessment.

OBJECTIVES

The objective of this systematic review was to examine the composition, longitudinal stability, and consistency across methodologies of common SCs, as well as their common predictors and outcomes.

METHODS

A search of MEDLINE, CINAHL, Embase, Web of Science, and PsycINFO was conducted using variants of symptom clusters, cancer, and palliative care.

RESULTS

Thirty-three articles were identified and reviewed. Many SCs were identified, with four common groupings being anxiety-depression, nausea-vomiting, nausea-appetite loss, and fatigue-dyspnea-drowsiness-pain. SCs in most cases were not stable longitudinally. The various statistical methods used (most commonly principal component analysis, exploratory factor analysis, and hierarchical cluster analysis) tended to reveal different SCs. Different measurement tools were used in different studies, each containing a different array of symptoms. The predictors and outcomes of SCs were also inconsistent across studies. No studies of patient experiences of SCs were identified.

CONCLUSION

Although the articles reviewed revealed four groups of symptoms that tended to cluster, there is limited consistency in the way in which SCs and variables associated with them are identified. This is largely due to a lack of agreement about a robust, clinically relevant definition of SCs. Future research should focus on patients' subjective experience of SCs to inform a clinically relevant definition of SCs and how they are managed over time.

The patient experience of fatigue in motor neurone disease

Aims: This paper is a qualitative investigation that aims to investigate the lived experience of fatigue in patients with motor neurone disease—a progressive and fatal neurological condition.

Background: Fatigue is a disabling symptom in motor neurone disease (MND) that affects a large number of patients. However, the term “fatigue” is in itself imprecise, as it remains a phenomenon without a widely accepted medical definition. This study sought to investigate the phenomenon of fatigue from the perspective of the MND patient.

Methods: Ten patients with MND participated in semi-structured recorded interviews at a regional neuroscience center in Liverpool, UK. Transcripts analysis was broadly informed by the principles of interpretative phenomenological analysis (IPA).

Findings: Fatigue was unanimously explained to be disabling and progressive phenomenon. Participants described two forms of fatigue: whole-body tiredness or use-dependent reversible muscle weakness related to exertion of limb and bulbar muscles. Both weakness and whole-body tiredness could be experienced simultaneously, and patients used the terms “fatigue” and “tiredness” interchangeably. Alongside descriptions of fatigue themes of Adaptation, Motivation, Avoidance, Frustration and Stress were revealed. Fatigue could be defined as “reversible motor weakness and whole-body tiredness that was predominantly brought on by muscular exertion and was partially relieved by rest.”

Conclusion: The results of this study support a multi-dimensional model of fatigue for patients with MND. Fatigue appears to be experienced and explained in two ways, both as an inability to sustain motor function and as a pervasive tiredness. Fatigue was only partially relieved by rest and tended to worsen throughout the day. It is crucial that MND care practitioners and researchers appreciate the semantic dichotomy within fatigue.

Fatigue and Related Factors in People With Type 2 Diabetes

Purpose

The purpose of this study was to examine the presence and severity of fatigue in people with type 2 diabetes.

Methods

The Fatigue Severity Scale (FSS), Fatigue Assessment Scale (FAS), and Visual Analog Fatigue Scale (VAFS) were administered by anonymous survey of 37 individuals with and 33 individuals without diabetes to assess the presence of fatigue. Data on age, gender, weight, height, year of diagnosis, and number/type of complications were also collected. Nonparametric tests tested for differences in fatigue measures between the groups, and distribution characteristics of the FAS, FSS, and VAFS scores were examined. Spearman rank correlation coefficients examined the relationships between the variables.

Results

People with diabetes scored higher on all 3 fatigue assessment scales as compared to controls (FAS: 25.11 vs 19.94, P = .001; FSS: 4.30 vs 2.59, P = .000; VAFS: 4.64 vs 1.75, P = .000). Data were normally distributed for FSS in the group with diabetes and the group without diabetes, and scores of FAS, FSS, and VAFS showed no ceiling effects. A positive correlation was noted between fatigue measures and number of complications ( r = .482; P = .003).

Conclusions

Higher levels of fatigue were noted in people with type 2 diabetes as compared to healthy age-matched control; however, the cause and impact of these changes remain unclear. FSS is a recommended tool for measuring fatigue in this population. Further studies are needed to explore the contributing factors to fatigue in those with diabetes.

Qualitative research into the symptom experiences of adult cancer patients after treatments: a systematic review and meta-synthesis

PURPOSE

This review paper aimed to draw together the findings of qualitative research into the symptom experience of adult cancer patients in order to develop a better understanding of symptom experiences following cancer treatment.

METHODS

Systematic review and meta-synthesis techniques were used to identify, appraise and synthesise the relevant literature.

RESULTS

A thematic account of shared symptom experiences reported across papers is presented. Four main themes are discussed: interaction with health services, changing relationships, changing self and coping. In addition the range of symptoms reported across qualitative cancer research is highlighted.

CONCLUSIONS

Unexpected symptoms can have negative effects on patients who need to be better prepared for long-term symptom experiences. In addition, it is important to acknowledge that patients' symptom experiences do not happen in isolation and should be addressed holistically within the context of patients' lives.

The experience of fatigue in people with inflammatory bowel disease: an exploratory study

AIMS

To explore fatigue, the impact it has on daily life and the strategies used to ameliorate the symptom, as described by people with inflammatory bowel disease.

BACKGROUND

Fatigue is the most troublesome symptom during remission of inflammatory bowel disease. Fatigue affects people's daily functioning, impacting on quality of life. There is limited understanding of the nature of and the ways fatigue in inflammatory bowel disease is experienced and managed in everyday adult life.

DESIGN

An epistemological interpretive approach to understand participants' self-reported experiences of disease-related fatigue.

METHODS

A convenience sample of 46 participants was recruited from the Crohn's and Colitis UK member database. Five focus group interviews (November 2008-February 2009) were conducted, audio-recorded, transcribed, and analysed using an inductive thematic framework.

FINDINGS

Five themes were identified: the experience of fatigue, causes of fatigue, managing fatigue, consequences of fatigue, and seeking support. Fatigue had a debilitating effect on the social and emotional well-being of participants and limited their employment opportunities. People used a range of strategies to cope and reported that fatigue-related issues seemed to be poorly understood by clinicians and were not addressed in medical consultations.

CONCLUSION

Fatigue was an inextricable part of daily life for some people with inflammatory bowel disease. Specialist nurses and medical colleagues need to address the personal, social, and economic consequences of fatigue, whilst further nursing research would improve understanding of the impact of fatigue and help develop appropriate intervention strategies for people with inflammatory bowel disease.

Prospective evaluation of a 12-week walking exercise program and its effect on fatigue in prostate cancer patients undergoing radical external beam radiotherapy

OBJECTIVE

To evaluate tolerability and compliance to a walking exercise program and its effect on fatigue during and after radical external beam radiation therapy (EBRT) for prostate cancer.

METHODS

A total of 50 subjects with prostate cancer undergoing EBRT over 6 to 8 weeks were prospectively accrued to an exercise intervention group, matched for age and clinical characteristics to 30 subjects in a historical control group who underwent EBRT with no specific exercise intervention. Starting 1 week before EBRT, exercise participants performed moderate-intensity walking targeting 60% to 70% age-predicted maximum heart rate, at least 20 min/d, 3 d/wk over 12 weeks. The Brief Fatigue Inventory was administered at baseline, mid-EBRT (week 3-4), end-EBRT (week 6-8), and 6 months post-EBRT.

RESULTS

Of 50, 42 (84%) of exercise participants completed the walking program. There were no cardiovascular complications, musculoskeletal injuries, or other adverse events. A total of 89% subjects reported "Good-Excellent" satisfaction during and up to 6 months post-EBRT. Fatigue in control subjects escalated from baseline to end-EBRT, remaining high at 6 months post-EBRT (P[r] = 0.03). In contrast, mean total fatigue scores in exercise subjects were stable from baseline up to 6 months post-EBRT (P = 0.52). Trends for higher fatigue interference with quality of life were observed in the control group as compared with the exercise group.

CONCLUSIONS

Moderate-intensity walking exercise during radical EBRT is safe and feasible. The high convenience and satisfaction ratings, in conjunction with the observed fatigue trends, indicate that this activity has the potential to attenuate fatigue and improve quality of life for patients with localized prostate cancer undergoing curative therapy.

Perceptions and experiences of post-irradiation swallowing difficulties in nasopharyngeal cancer survivors

This study aimed to explore the perceptions and experiences of swallowing difficulties in irradiated survivors of nasopharyngeal carcinoma (NPC). Qualitative semi-structured interviews were conducted with 60 post-irradiation NPC patients after they had answered a set of self-report questions. The interviews were transcribed verbatim for analysis. Results of the self-report data showed that in response to a global question 'Do you have any swallowing difficulties?' eight-five per cent of the respondents reported a certain degree of difficulty. The qualitative interview findings, however, suggested that this figure might have been underestimated. Patient interpretations of swallowing difficulties had excluded part of the symptoms. Some respondents who claimed to have no difficulty swallowing, in fact, were suffering from oral retention of food bolus, regurgitation of food or liquids through the nose, and/or even choking. The risk of aspiration was generally neglected. Informants' concerns focused more on the threat of cancer recurrence, thus paid less attention to the radiation-induced swallowing complication. Respondents did not possess sufficient knowledge to judge their swallowing abilities at a general level. This study suggests ways to enhance patient-provider communication and health education to improve patient knowledge.

Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study

INTRODUCTION

About one-third of cancer survivors suffer from severe chronic fatigue. Aim of this study was to evaluate the efficacy of mindfulness-based cognitive group therapy in reducing severe chronic fatigue in cancer survivors with mixed diagnoses.

PATIENTS AND METHODS

Participants (n = 100) were randomly selected from a cohort and allocated to an intervention and a waiting list condition. Analyses were based on 59 participants in the intervention condition and 24 in the waiting-list condition. Fatigue severity (Checklist Individual Strength), functional impairment (Sickness Impact Profile) and well being (Health and Disease-Inventory) were assessed before and after the 9-week intervention. The intervention group had a follow-up 6 months following the intervention.

RESULTS

At post-treatment measurement the proportion of clinically improved participants was 30%, versus 4% in the waiting list condition (χ(2) (1) = 6.71; p = 0.007). The mean fatigue score at post-measurement was significantly lower in the intervention group than in the waiting list group corrected for pre-treatment level of fatigue. The mean well-being score at post-measurement was significantly higher in the intervention group than in the waiting list group corrected for pre-treatment level of well-being. The treatment effect was maintained at 6-month follow-up. No difference between the two conditions was found in functional impairment.

DISCUSSION

Mindfulness-based cognitive therapy is an effective treatment for chronic cancer-related fatigue.

Fatigue in patients with diabetes: a review

OBJECTIVE

Fatigue is a common and distressing complaint among people with diabetes and likely to hinder the ability to perform daily diabetes self-management tasks. A review of the literature about diabetes-related fatigue was conducted with an eye toward creating a framework for beginning to conduct more focused studies on this subject.

METHODS

A literature search containing the terms diabetes, fatigue, tiredness, and symptoms was conducted to search for literature that addressed diabetes-related fatigue.

RESULTS

Diabetes presents many potential pathways for fatigue, but focused studies on this symptom are rare. Furthermore, research on diabetes-related fatigue is limited by fatigue's nonspecific symptoms and because fatigue researchers have yet to agree on standardized definition, measurement, or diagnostic criteria. Additionally, few diabetes randomized clinical trials included measurement of patient-reported outcomes, such as symptoms or health-related quality of life in their study designs, although one that did provided some meaningful finding that symptom-focused education improved self-management practices, Hb(A1c) levels, quality of life, and symptom distress.

CONCLUSION

There is a need to standardize the definition, measurement, and diagnostic criteria of fatigue in diabetes. We present a model that can guide focused studies on fatigue in diabetes. The model capitalizes on the multidimensional phenomena (physiological, psychological, and lifestyle) associated with fatigue in diabetes.

Life impact of urologic pain syndromes

In order to explore the personal experience of chronic urologic pain we asked patients to journal in their own words their daily symptoms and the effects of those symptoms on home/family life, working life and social life. Journal responses were independently reviewed by three researchers and major themes summarized following an inductive approach. Three major themes were identified concerning symptoms, personal and interpersonal effects of symptoms and related role limitations. Fatigue emerged as a newly recognized symptom that may benefit from treatment. Role limitations are mediated by potentially modifiable personal and interpersonal effects currently not addressed in urologic pain treatment paradigms.

Exploratory analysis of the relationships between aerobic capacity and self-reported fatigue in patients with rheumatoid arthritis, polymyositis, and chronic fatigue syndrome

OBJECTIVE

To determine if self-reported levels of physical activity and fatigue are related to peak oxygen uptake (VO(2peak)) and whether these relationships differ among the patient groups (rheumatoid arthritis [RA], polymyositis [PM], and chronic fatigue syndrome [CFS]).

DESIGN

Correlational investigation.

SETTING

Two ambulatory research clinics at the National Institutes of Health, Clinical Center, Bethesda, MD.

PARTICIPANTS

There were 9 patients with PM, 10 with RA, and 10 with CFS. All patients met case criteria for their respective diagnoses. METHODS/MAIN OUTCOME MEASUREMENTS: VO(2peak) during bicycle ergometry and self-reported fatigability, fatigue, and physical activity. VO(2peak) was used as the criterion measurement of physiological fatigue with which the self-reported variables were compared.

RESULTS

The Pearson r revealed that self-reported physical activity correlated with VO(2peak) (r = 61, P = .01). However, fatigability and fatigue did not correlate with VO(2peak). Linear regression analysis was performed to assess the effects of diagnosis group, self-reported activity level or fatigue, and their interaction. A trend in the data showed a distinctive relationship between fatigue/fatigability within the 3 groups. In addition, when controlling for group status, self-reported activity predicted aerobic capacity as measured by VO(2peak).

CONCLUSIONS

This study confirms that patients with chronic, but stable RA, PM, or CFS are fatigued and have significantly decreased aerobic capacity. Self-reports of physical activity predicted VO(2peak), and may be used as an indicator of activity-based aerobic capacity. Self-reports of fatigue, however, did not correlate with VO(2peak) and hence are assessing something other than an index of aerobic capacity, and provide additional information about patients' perceptions, which will require further investigation.

Fatigue as experienced by patients with rheumatoid arthritis (RA): A qualitative study

OBJECTIVE

Interest in fatigue research has grown since the finding that fatigue is, besides pain, the symptom most frequently reported by patients with rheumatoid arthritis (RA). The aim of this study was to explore the experience of fatigue from the patients' perspective.

METHODS

Twenty-nine patients with RA filled-out written questionnaires on fatigue severity, disability, quality of life and sleep disturbance, and disease activity was calculated using the Disease Activity Score (DAS28). All patients were individually interviewed and asked about fatigue. Qualitative analyses were completed using software program "The Observer". Basic codes, a code plan and coding rules were developed by two researchers through a consensus-based review process. Frequencies of the central codes were calculated by the program SPSS.

RESULTS

RA fatigue is verbalised as a physical everyday experience with a variety in duration and intensity. Its sudden onset and exhausting nature is experienced as frustrating and causing anger. Patients mentioned having RA as the main cause of their fatigue. The consequences of fatigue are overwhelming and influence patients' everyday tasks, attitudes and leisure time. Patients described how they have to find their own management strategies by trial and error and described pacing and rest, relaxation and planning activities as the most appropriate interventions. Downward comparison and acceptance as part of the disease are also reported as successful coping strategies for fatigue. Most patients did not discuss fatigue with clinicians explicitly, accepting that they were told that fatigue is part of the disease and believing that they have to manage it alone.

CONCLUSION

The results show that RA fatigue is experienced as being different from "normal" fatigue. Patients do not expect much support from health care professionals, assuming that they have to manage fatigue alone as it is part of the disease. These results will help professionals caring for RA patients to communicate about fatigue, to explore the nature of fatigue individually and to develop tailored interventions.

Methodological issues related to assessing and measuring quality of life in patients with cancer: implications for patient care

Consideration of quality-of-life issues by all members of the healthcare team is essential in caring for people with cancer. In cancer research, quality of life is generally classified as health-related quality of life or individual quality of life. This paper discusses the instruments used to measure quality-of-life outcomes, and the relevance of such findings for healthcare staff in planning and providing effective and patient-centred care. Visual analogue scales (VASs) and questionnaires are commonly used to measure quality of life; however, both types of instruments are criticized because the content may not be relevant to individual patients, and do not distinguish differences between statistical and clinical significances in the findings. Using a combination of questionnaires and VASs may overcome some of these criticisms. In order to interpret the difference between statistical and clinical significance of findings and the associated implications for patient care, a mixed-methods approach to data collection is recommended in quality-of-life studies. This provides meaning and understanding to the quantitative data and individual perspectives on patients' experiences of having cancer. Information from such studies may also be more effective in helping healthcare staff identify relevant issues when planning cancer care services at individual, local and national level.

Fatigue experience and coping strategies in Taiwanese lung cancer patients receiving chemotherapy

AIMS

The aim of this cross-sectional study was to explore fatigue levels and fatigue-coping strategies in Taiwanese lung cancer patients receiving chemotherapy.

BACKGROUND

Lung cancer is now recognized as one of the most common cancers in Taiwan, with a high prevalence of mortality. As chemotherapy progresses, fatigue is a common cause of symptom distress.

METHODS

Data on demographic and disease-related characteristics were gathered from the medical record, and data on fatigue and coping strategies were gathered by questionnaires administered to 101 lung cancer patients receiving chemotherapy.

RESULTS

The mean fatigue score for the total sample was 8.0 (SD = 5.0, range = 0-20), indicating light-to-moderate fatigue. The majority of patients (n = 76, 75.2%) had a baseline haemoglobin level of <or=12 g/dl and a significantly greater (t = 2.7, p < 0.01) mean fatigue score (8.5 SD 4.6) than patients with haemoglobin >12 g/dl (6.2 SD 5.7). Fatigue levels were significantly higher in patients receiving a third course of chemotherapy than in those receiving a first course (F = 3.7, p = 0.03). The most commonly used management category was energy conservation (n = 659), and the most commonly used strategy was sitting (n = 101) and lying down (n = 98). However, participants rated exercise (mean = 3.9), sleep (mean = 3.8) and walking (mean = 3.6) as the most effective.

CONCLUSION

This study highlighted the management of fatigue problems in lung cancer patients receiving chemotherapy, especially in respecting patients' self-report of fatigue-management strategies. Relevance to clinical practice. Health care providers should carefully assess patients for fatigue while they are receiving chemotherapy. These patients and their caregivers should be taught to notice fatigue and encouraged to choose coping strategies that reduce fatigue level, thus improving their quality of life.

Being given a cancer diagnosis in old age: A phenomenological study

OBJECTIVES

The aim of the study was to illuminate the lived experience of being given a cancer diagnosis in old age.

BACKGROUND

Little research has been done on the experience of elderly people developing cancer and the impact of the illness on their lives. Such knowledge is needed to support elderly people in dealing with issues arising after cancer is diagnosed.

DESIGN

A descriptive phenomenological method was used to investigate the phenomenon "the lived experience of being given a cancer diagnosis in old age".

PARTICIPANTS

In total, 16 persons (aged 65+, mean age 76, range 68-83) with cancer were interviewed, all referred to the same oncology outpatient clinic in Copenhagen County.

METHOD

Open-ended interviews were used to get a clear understanding of the experience of a cancer diagnosis in old age. Giorgi's phenomenological analysis was used.

FINDINGS

The findings showed that the essential meaning of the lived experience was "Illness as a turning point marking old age". This main essence was represented overall by three essences: "Illness means losing control", "Disturbing the family balance" and "Life and death suddenly apparent". These three essences were manifested through seven constituents: growing old in the context of illness, becoming a patient with cancer, everyday life being controlled by bodily limitations, managing family reactions, becoming conscious about dying and death through illness experience and retaining hope, and enjoying life.

CONCLUSION

It is important in clinical practice, to identify the specific meaning the turning point has for an elderly person with cancer, and to understand the particular approach he or she uses to handle the awareness of being old.

Chemotherapy-Related Fatigue in Childhood Cancer: Correlates, Consequences, and Coping Strategies

The aim of this research is to examine the experience and impact of chemotherapy-related fatigue in recently diagnosed pediatric oncology patients. A repeated-measures, within-subjects, mixed (quantitative plus qualitative) design was used to prospectively assess fatigue during early chemotherapy cycles and to compare fatigue to depressive symptoms. Parental interviews collected concurrently were analyzed for descriptions of the child's fatigue and mood states and for strategies to cope with fatigue. Results indicated a significant correlation between fatigue and depression, but qualitative analyses suggested that the 2 phenomena may be unique and distinguishable. Qualitative analyses of parent interviews also identified specific strategies that were frequently used in response to high levels of fatigue. The findings illustrate the significant impact of chemotherapy-related fatigue in children being treated for cancer. The study also provides guidance for the assessment of fatigue and related symptoms and identifies specific strategies for coping with fatigue.

The experience of cancer-related fatigue and chronic fatigue syndrome: a qualitative and comparative study

Cancer-related fatigue (CRF) is a common and disabling symptom complex reported by survivors. This study aimed to better understand the manifestations of CRF in women treated for breast cancer, and to compare them with those of women diagnosed with chronic fatigue syndrome (CFS). Women with CRF persisting 6 months after treatment for early stage breast cancer, and women with CFS participated in separate, audiotaped focus groups. Transcripts of the sessions were analyzed using the NUD*IST software, and interpreted using grounded theory. Twenty-eight women participated, 16 with CRF and 12 with CFS. Analysis of transcripts from both groups revealed a similar core set of symptoms, featuring fatigue, neurocognitive difficulties, and mood disturbances. Women with CFS reported additional symptoms including musculoskeletal pain and influenza-like manifestations. Both groups suffered disabling behavioral consequences of the symptom complex. Qualitatively, CRF appears closely related to CFS. These findings raise the emergent hypothesis of a conserved neurobehavioral symptom complex, which results from diverse triggering insults.

The social and emotional toll of chemotherapy - patients' perspectives

The aim of this paper is to briefly describe the unique methodology employed by nine nurse researchers who conducted research into the social and emotional effects of chemotherapy from the patient's perspective, and to present four dominant themes. The research developed from discussions at a local UK Nurses Oncology Forum, during which nurses voiced their concern about the social and emotional implications for people receiving chemotherapy. It was anticipated that understanding the issues from the patient's perspective would assist nurses to reconsider and reshape the care provided, particularly in the chemotherapy clinic. Using principles of phenomenology, the nurse researchers collected data from participants using conversational-style interviews. Some participants kept diaries of chemotherapy experiences. These data were subsequently analysed using a modified phenomenological analysis framework. Nineteen people were recruited to the study, resulting in 98 interviews and seven diaries. Eight major themes emerged from the data: striving for normality, the role of significant others, feeling up - feeling down, flagging, being sociable, anxiety, the chemotherapy process, and participating in the research. Relationship dynamics, the perceived role of significant others and the frustrations associated with lack of concentration and memory loss are important findings that should influence nursing care and management.

Assessing Cultural Appropriateness of Three Translated Cancer-Related Fatigue Instruments

The purpose of this study was to evaluate the cultural appropriateness (ie, semantic equivalence, content equivalence, and conceptual equivalence) of 3 translated fatigue instruments (the Cancer Fatigue Scale, the Fatigue Symptom Inventory, and the Schwartz Cancer Fatigue Scale-revised) by using 2 phases: (a) establishment of semantic and content equivalencies by the rigorous process of translation and back-translation, and (b) evaluation of content equivalence and conceptual equivalence by testing on monolingual subjects with the translated fatigue scales and a questionnaire with fatigue terms list and open-ended questions. Convenience sampling was used to recruit subjects at a chemotherapy treatment center for outpatients in Taiwan. The results indicated that the content in the 3 scales were relevant to the experience of fatigue among Taiwanese from the view of patients, but only the fatigue domains in the Cancer Fatigue Scale-Chinese version was similar to the original construct based on the exploratory factor analysis. However, the results for examining the content equivalencies by the fatigue terms list showed that only 4 items in the list were used to describe fatigue by more than 50% of the patients. Therefore, the contents of the chosen scales might not represent the whole concept of fatigue in Taiwan. Exploration of the content and construct of fatigue in Taiwan and further testing of the translated scales are recommended. In addition, the result in this study is helpful for clinical nurses to understand expressions of fatigue in cancer patients within the Chinese culture but the meaning of fatigue still needs to be further explored.

Meeting information needs on cancer-related fatigue: an exploration of views held by Italian patients and nurses

BACKGROUND

Interest in cancer-related fatigue has been growing over the last two decades and efforts have been dedicated to investigate this topic. However, research addressing the adequacy of educational resources for patients with this distressing and common symptom is lacking. Only one study has been undertaken and this explored Swiss and British patients' views.

MATERIALS AND METHODS

The current study replicated and extended the study previously undertaken in the United Kingdom (UK) and Switzerland. It sought views on the adequacy of materials on cancer-related fatigue available to patients with cancer living in Italy, and to determine the educational preferences and needs of Italian patients with cancer-related fatigue. These were attained through conduct of two focus groups. One was undertaken with Italian patients and the other with a group of Italian nurses.

MAIN RESULTS

Findings from this study supported patients' desire for timely, accurate and individualised information. Barriers to effective fatigue education included the limited dialogue regarding fatigue initiated in clinical settings. It appeared that nurses and patients held different priorities in symptom management. Further, it was acknowledged that there was often insufficient time to inform patients adequately about fatigue. Participants considered written materials as helpful complements to oral information, thus supporting the provision of information in both forms. However, it was clear that fewer written resources concerning cancer-related fatigue were available in Italy compared to either in Switzerland or in the UK.

CONCLUSION

The study supported the view within the current literature that whilst cancer-related fatigue is recognised as a frequent and disruptive symptom, patient education about this symptom and its management still needs to be enhanced. The resources available to educate patients about cancer-related fatigue should be improved and made more accessible to patients who experience it.

A phenomenological study of fatigue in patients with primary biliary cirrhosis

AIM

This paper reports the findings of research on the lived experience of fatigue in patients with primary biliary cirrhosis - a type of chronic liver disease.

BACKGROUND

Fatigue is a universal phenomenon, commonly associated with both acute and chronic illness, but also seen in healthy individuals. However, it is not often addressed in healthcare encounters despite its disabling nature, perhaps because of the multitude of contributing factors and the lack of effective treatments. It is a common and debilitating symptom in patients with primary biliary cirrhosis. Despite the prevalence of fatigue in this condition, patients' experiences of this symptom have not been researched.

METHOD

An interpretive-phenomenological approach developed by van Manen was chosen and this combines features of descriptive and interpretive phenomenology. Eight participants were interviewed during 2005 about their fatigue experience. Thematic analysis was conducted.

FINDINGS

Five themes were identified: an unreliable body, fatigue as always present yet insidious, planning a life to conserve energy, struggling to maintain normality and emotional consequences. These themes reflected the unrelenting, intrusive nature of fatigue into the lives of those affected.

CONCLUSION

This research will provide empathic insight into the fatigue experience in this condition and generate communication about coping strategies. It will add to the body of research on fatigue in chronic conditions and may generate ideas for intervention research.

Course of Fatigue Between Two Cycles of Adjuvant Chemotherapy in Breast Cancer Patients

The purpose of this study was to determine the course of fatigue in patients with breast cancer between 2 cycles of adjuvant chemotherapy, from the day of administration until the day of the next infusion. In a prospective cohort study, a sample of 151 patients with breast cancer receiving adjuvant chemotherapy was recruited from 6 hospitals in mainly the south of the Netherlands. Patients reported their experience of fatigue in a diary, the Shortened Fatigue Questionnaire, on a daily basis between the third and fourth treatment with adjuvant chemotherapy. Patients were treated with either a doxorubicin containing schedule or with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF, 28 days). In the 28-day regimens, infusions were given on day 1 and day 8. The days after completion of the third and the start of the fourth treatment with chemotherapy were statistically analyzed. We tested the hypothesis that the maximum fatigue score occurs in the first 4 days after treatment. The mean age of the sample was 47.2 years (SD = 8.8). Most women (84%) were married or lived together with a partner. The majority (80%) of all patients had been diagnosed with stage II breast cancer. The division between mastectomies (47%) and lumpectomies (52%) was approximately equal. Sixty percent of the patients received radiotherapy before the third treatment with chemotherapy and/or in the period they kept the diary. A chaotic pattern of fatigue between the 2 cycles of chemotherapy emerged. Smooth (splines) curves showed an average highest level of fatigue on day 3 from the start. For the 28-day regimens, another distinct peak was seen around day 11. A relatively larger number of patients experienced peak fatigue levels before day 5. The course of fatigue in the CMF group was significantly different compared with the doxorubicin regimens. The fatigue peak in the CMF group was lower. Women taking cyclophosphamide orally experienced the peak level of fatigue significantly later. Influences of other variables were not observed in any chemotherapy group. Cancer-related fatigue has a chaotic nature. The first days after treatment with chemotherapy are the worst. The type of chemotherapy has a significant impact on the course of fatigue. Improved understanding of the nature and course of fatigue could equip healthcare providers better for informing patients about what they may expect. Future research should include interventions aimed at reducing or coping with fatigue.

Patients’ subjective symptoms, quality of life and intake of food during the recovery period 3 and 12 months after upper gastrointestinal surgery

Few studies describe patients' quality of life and their experienced symptoms during the recovery period after having undergone upper gastrointestinal surgery at 3 and 12 months. The aims of this study were to explore patients' quality of life and symptoms preoperatively and at 3 and 12 months following upper gastrointestinal surgery and to describe and compare patients' experiences of appetite, food intake, weight changes, tiredness and sleeping patterns. A descriptive and comparative quantitative design was used. Three instruments were used: the Gastrointestinal Symptom Rating Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and the Eating Dysfunction Scale. A questionnaire was used to investigate symptoms such as mood, appetite, sleep, activities and well-being. Twenty-four patients were included in the study. The major results were that anxiety levels and global health status decreased and that patients felt more disappointed after 12 months compared with after 3 months. Four patients at 3 months after surgery and eight patients at 12 months regained their weight compared with the situation before surgery. The contribution of nursing care activities focusing on the importance of food intake and the patients' current and historical medical records in relation to their health status should continue to be examined and researched over a longer period of time.

Cancer-Related Fatigue

PURPOSE

Cancer-related fatigue contributes to negative outcomes relative to psychosocial and symptom distress, functional status, and quality of life, and yet it is often underdiagnosed and management is frequently suboptimal.

DESIGN

Systematic database searches were conducted, and primary research reports and meta-analyses of quantitative studies of interventions for fatigue published in English were identified and critically examined.

RESULTS

This paper reviews the etiology and evaluation of cancer-related fatigue and analyzes current empirical evidence supporting pharmacologic and nonpharmacologic techniques for its management.

DISCUSSION

A variety of pharmacologic and nonpharmacologic techniques to manage cancer-related fatigue have been studied, although most of the evidence is from single-arm pilot studies with small sample sizes, rather than from adequately powered, multicenter, randomized controlled trials. Continued research in ethnically and racially diverse samples is needed to identify the interventions that are most effective in specific cancer subpopulations and to develop and test interventions for fatigue at each phase in the illness trajectory.

Fatigue in frail elderly people

Many frail older people are likely to suffer from fatigue, but tools to measure fatigue in this population are lacking. Stage one of this study explored and described the experiences of fatigue of 12 older people from Australian residential aged care facilities. Themes identified were pacing yourself, battling on, hitting rock bottom, feeling safe, and moving on. Findings indicated that, with support, frail elders may be able to manage fatigue effects themselves. A measure of fatigue was developed from stage one findings, with reference to the literature. In stage two of the study, the Frail Elder Fatigue Assessment Tool was subjected to panel review, piloting, and refinement. The refined tool comprises 20 items in three subscales: fatigue effects; fatigue resources; and adaptation to fatigue. Further work is required to establish the tool's psychometric properties, but it should then be useful for both research and clinical assessment purposes.

Predictors of fatigue after treatment for prostate cancer

OBJECTIVES

To investigate whether post-treatment fatigue among men treated for prostate cancer varies by treatment, demographics, or pretreatment general and disease-specific health-related quality of life. We also sought to describe the baseline characteristics of men who were fatigued at follow-up to allow for interventions in those at greatest risk.

METHODS

We conducted a secondary analysis on data gathered from men with prostate cancer at biopsy and after treatment by examining factors that predicted for post-treatment fatigue.

RESULTS

Univariate and multivariate analysis results demonstrated that post-treatment fatigue was associated with baseline fatigue, role limitations due to emotional problems, treatment type, and treatment location.

RESULTS

Univariate analysis showed that those who were fatigued at follow-up were more likely to have been treated at a public facility (P = 0.0017), be nonwhite (Latino, African American, or Asian Pacific-Islander; P = 0.0362), be married (P = 0.0413), be not employed at least part-time (P = 0.0327), to have one or more comorbidities (P = 0.0005), and to have scored lower in all domains of the RAND 36-Item Health Survey and UCLA Prostate Cancer Index at baseline (all P < or = 0.05) than those not fatigued at follow-up. Those who declined from baseline energy levels were more likely to have had lower baseline energy scores (P < 0.0001), to have been treated in a public facility (P = 0.0578), and to have had a baseline prostate-specific antigen level of 10 ng/mL or greater (P = 0.059) than those who remained at their baseline energy level. Lower baseline role-emotional scores were associated with both fatigue at follow-up and a decline from baseline at follow-up.

CONCLUSIONS

Men with lower pretreatment quality-of-life measures may be at increased risk of fatigue after prostate cancer treatment.

Heavy to carry: a survey of parents' and healthcare professionals' perceptions of cancer-related fatigue in children and young people

Cancer-related fatigue is a prevalent, but often under-recognized, symptom with the potential to impact the lives of both the child and the family. There is little known about the biological and the behavioral dimensions of fatigue, and not about the patterns of this symptom. The aim of this study was to investigate cancer-related fatigue from the perspective of parents of children and young people with cancer and from the perspective of healthcare professionals (HCPs) and to examine its impact on quality of life. A cross-sectional, questionnaire-based survey was undertaken with parents of patients attending 4 of the 22 United Kingdom Childhood Cancer Study Group centers; HCPs from 20 of these centers were also surveyed. Response rates were 42% for parents and caregivers (95/224) and 35% for HCPs (235/679). Results showed that fatigue was prevalent. Fifty-six percent of HCPs thought "most" or "all" patients experienced moderate fatigue; 57% of parents said that the patient experienced fatigue at least once a week. Data demonstrate that fatigue was perceived to be a significant problem by parents and HCPs. Healthcare professionals indicated that the mean percentage of patients who experience fatigue, to whom they recommended a treatment, was 29%. Rest and relaxation were recommended by the majority (59%; 138). The overall impression is that both HCPs and parents acknowledge that children and young people are likely to experience fatigue. Recognition of the significance of this symptom is a crucial first step in improving future management and offering strategies that can help both child and family.

Patients' perceptions of fatigue in rheumatoid arthritis: Overwhelming, uncontrollable, ignored

OBJECTIVE

Fatigue is commonly reported by patients with rheumatoid arthritis (RA) but is rarely a treatment target. The aim of this study was to explore the concept of fatigue as experienced by patients with RA.

METHODS

Fifteen patients with RA and fatigue (> or =7 on a 10-cm visual analog scale) were individually interviewed and asked about the description, cause, consequence, and management of fatigue. Transcripts were systematically analyzed by 2 researchers independently, relevant phrases were coded, and earlier transcripts were checked for the emerging codes. A random sample of analyses were independently reviewed. A total of 191 codes arising from the data were grouped into 46 categories and overarching themes.

RESULTS

Vivid descriptions reflect 2 types of fatigue: severe weariness and dramatic overwhelming fatigue. RA fatigue is different from normal tiredness because it is extreme, often not earned, and unresolving. Participants described physical, cognitive, and emotional components and attributed fatigue to inflammation, working the joints harder, and unrefreshing sleep. Participants described far-reaching effects on physical activities, emotions, relationships, and social and family roles. Participants used self-management strategies but with limited success. Most did not discuss fatigue with clinicians but when they did, they felt it was dismissed. Participants held negative views on the management of fatigue.

CONCLUSION

The data show that RA fatigue is important, intrusive, and overwhelming, and patients struggle to manage it alone. These data on the complexity of fatigue experiences will help clinicians design measures, interventions, and self-managment guidance.

The meaning of having to live with cancer in old age

Little is known about how older people with cancer experience their life situation. To increase the understanding of how illness is experienced in older people with cancer, the aim of this study was to investigate the meaning of living with cancer in old age. The hermeneutic phenomenological method as described by van Manen and referred to as 'phenomenology of praxis' was used. Ten persons (seven women and three men) aged 75 and over, who had a diagnosis of cancer and who had just completed cancer treatment, were interviewed in their own homes. The analysis revealed a life world affected to varying degrees by the cancer disease. The lived experiences across the interviews were revealed in four overarching essential themes: transition into a more or less disintegrated existence, sudden awareness of the finiteness of life, redefinition of one's role in life for good and for bad, meeting disease and illness. To provide individual support and appropriate care to older people with cancer it is important for health care professionals to identify and take care of disabilities and to support the reorientation in the disintegrated life situation. It is also important to have preparedness to meet the old person's thoughts about death. Thus, it is important to encourage the old person to describe her/his illness experience to increase understanding about what is meaningful for her/him.

Meanings of the phenomenon of fatigue as narrated by 4 patients with cancer in palliative care

The disabling experience of fatigue suffered in connection with incurable cancer is an area within nursing that has generated only limited research interest. The need for a change in focus is presented in the literature: from treating the symptom itself to facilitating living with the fatigue caused by a life-threatening disease. This implies that helping to alleviate fatigue must start from the patients' own understanding and interpretation of this experience. Our study attempts to achieve this understanding through illuminating the meanings of fatigue as experienced by 4 patients with cancer in palliative care. The research interviews were analyzed using a phenomenological-hermeneutic approach inspired by the philosophy of Ricoeur. Our findings indicate a world in which one meaning of fatigue connected with incurable cancer is a lived bodily experience of approaching death. Comprehending fatigue in this way allows us to understand the paradoxes we found in the text, such as struggling in vain against fatigue, and hoping to overcome fatigue but expecting failure. The paradoxes represent a struggle between body and mind, between bodily experiences and intellectual understanding, and have important implications for how we communicate with patients about fatigue.

A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer

Depression is a common symptom in patients with advanced cancer and patients who are depressed may also have physical symptoms which are difficult to palliate and which improve as their depression is appropriately treated. This study was carried out to determine if there was an association between depression and physical symptoms in patients with advanced cancer and to establish whether a seven-item verbal rating scale asking patients to verbally rate the severity of physical symptoms together with low mood could be used to screen for depression. The scale was validated against a semi-structured clinical interview according to DSM IV criteria. Seventy-four patients participated with an age range of 28-92 years. All patients had an ECOG performance status of two or three. The prevalence of major depression in this study was found to be 27% (95% C.I. 17-37%). The mean score on the verbal rating scale was 28.77 (median score 29.5) (95% C.I., 26.23 - 31.31; range 0-65). A cut-off of > or = 30 gave a sensitivity of 65% and specificity of 59%, with positive and negative predictive values of 37% and 82% respectively. The verbal mood item alone had an optimal cut-off point of 3, with a sensitivity of 80% and specificity of 43%. Patients diagnosed as being depressed according to psychiatric interview rated each symptom higher than nondepressed patients. The verbal mood item and total verbal rating score correlated with a high significance (rs = 0.607, P < 0.01), implying a relationship between a patient's subjective mood state and other symptoms. Both using the verbal scale and asking patients to verbally rate their mood alone had poor efficacy as a screening tool. However, there is a close association between physical symptoms and the presence of depression in palliative care patients.