Factors related to persistent fatigue following completion of breast cancer treatment

Multidimensional Predictors of Cancer-Related Fatigue Based on the Predisposing, Precipitating, and Perpetuating (3P) Model: A Systematic Review

Cancer-related fatigue (CRF) is a widespread symptom with high prevalence in cancer patients, seriously affecting their quality of life. In the context of precision care, constructing machine learning-based prediction models for early screening and assessment of CRF is beneficial to this situation. To further understand the predictors of CRF for model construction, we conducted a comprehensive search in PubMed, Web of Science, Embase, and Scopus databases, combining CRF with predictor-related terms. A total of 27 papers met the inclusion criteria. We evaluated the above studies into three subgroups following the predisposing, precipitating, and perpetuating (3P) factor model. (1) Predisposing factors-baseline fatigue, demographic characteristics, clinical characteristics, psychosocial traits and physical symptoms. (2) Precipitating factors-type and stage of chemotherapy, inflammatory factors, laboratory indicators and metabolic changes. (3) Perpetuating factors-a low level of physical activity and poorer nutritional status. Future research should prioritize large-scale prospective studies with emerging technologies to identify accurate predictors of CRF. The assessment and management of CRF should also focus on the above factors, especially the controllable precipitating factors, to improve the quality of life of cancer survivors.

Biological mechanisms of cancer-related fatigue in breast cancer survivors after treatment: a scoping review

PURPOSE

Cancer-related fatigue (CRF) is the most common symptom experienced by cancer survivors. It is a multidimensional symptom affecting physical, emotional, and/or cognitive spheres, different from other types of fatigue. Characteristically is not alleviated by sleep or rest. CRF could have specific features in breast cancer survivors (BCS), because of sex, hormones, and distinct treatments. On the other hand, more than 25% of BCS report persistent CRF for 10 years or more after the diagnosis. The present study aims to recapitulate the knowledge about the biological mechanisms that potentially drive CRF in BCS after treatment.

METHODS

To answer a broad question, a scoping review methodology was used. Data were collated from three bibliographic databases: PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies were selected if they had included more than 20 BCS, after finishing their treatment, fatigue was measured with a quantitative scale and biomarkers were analyzed.

RESULTS

The final database was composed of 1896 records. Sixty-four studies finally met the eligibility criteria. Inflammation (61%), hypothalamic-pituitary-adrenal (HPA) axis dysregulation (14%), autonomic nervous system (ANS) dysfunction (11%), and diet (9%) were the biological pathways most frequently studied. Unfortunately, results from studies about inflammation and HPA axis show many inconsistencies.

CONCLUSION

More research about the role of ANS dysfunction and diet on the pathogenesis of CRF would be warranted according to the results of the review. There are some fields such as endocannabinoid systems, mitochondrial dysfunction, gut microbiota, and oxidative stress that have been insufficiently explored.

IMPLICATIONS FOR CANCER SURVIVORS

To widen the scope of future research in the physiopathology of CRF, it is necessary to identify mechanisms that would be potentially involved and have been insufficiently explored. Because of the high prevalence of CRF in BCS and the tremendous impact that fatigue has in their quality of life, it is essential to improve the efficacy of the treatments through a good knowledge of the biological basis of CRF.

Global burden of female breast cancer and its association with socioeconomic development status, 1990-2044

BACKGROUND

Breast cancer is a widespread disease in women worldwide.

AIM

We aimed to explore the global epidemiological trends of female breast cancer (FBC) between 1990 and 2044.

METHODS AND RESULTS

Disease burden, population, and socio-demographic index (SDI) data were obtained from the Global Health Data Exchange (GHDx) database. We analyzed temporal trends, age differences, risk factors, and geographic patterns of FBC disease burden globally and explored the association between age-standardized incidence rate (ASIR) of FBC and SDI. Bayesian age-period-cohort model was also performed to predict the changes in FBC incidence worldwide from 2020 to 2044. First, the global ASIR of FBC increased by 14.31% from 1990 to 2019 (95% Uncertainty Interval 4.75% to 23.98%). The death rate presented a falling trend. Second, alcohol use is the most-highlighted risk factor for FBC in some high-income regions such as Europe. A high fasting plasma glucose levels is the most prominent risk factor for FBC in Latin America and Africa. Third, the ASIR of the FBC increases with the SDI. Fourth, the incidence is expected to increase faster among women aged 35-60 years and fastest for those aged 50-54 years from 2020 to 2044. Countries with a high incidence of FBC that is expected to increase significantly include Barbados, Burkina Faso, Senegal, Monaco, Lebanon, Togo, and Uganda.

CONCLUSION

The disease burden of FBC varies worldwide; the findings suggest attaching importance to the control of middle and low-middle SDI regions. Public health as well as cancer prevention experts should pay more attention to regions and populations at an increased risk of developing FBC, focusing on their prevention and rehabilitation while conducting further epidemiological studies to investigate the risk factors of their increase.

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

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

Effects of exercise interventions on cancer-related fatigue in breast cancer patients: an overview of systematic reviews

OBJECTIVE

This overview of systematic reviews aims to critically appraise and consolidate evidence from current systematic reviews (SRs)/meta-analyses on the effects of exercise interventions on cancer-related fatigue (CRF) in breast cancer patients.

METHODS

SRs/meta-analyses that explored the effects of exercise interventions on CRF in breast cancer patients compared with the routine methods of treatment and care were retrieved from nine databases. The methodological quality of the included SRs was appraised using A MeaSurement Tool to Assess systematic Reviews II (AMSTAR II). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to calculate the grading of outcomes in the included SRs. The exercise type, frequency, duration, and inclusion/absence of supervision were further evaluated with subgroup analyses. The Stata 16.0 software was utilized for data analysis.

RESULTS

Twenty-nine reviews were included. The overall methodological quality and level of evidence of the included reviews were unsatisfactory, with only three reviews rated as high methodological quality and no review identified as high-quality evidence. Moderate certainty evidence indicated that exercise could improve fatigue in breast cancer patients (SMD = - 0.40 [95%CI - 0.58, - 0.22]; P = 0.0001). Subgroup analysis based on the types of exercise showed that yoga (SMD = - 0.30 [95%CI - 0.56, - 0.05]; I2 = 28.7%) and aerobic exercise (SMD = - 0.29 [95%CI - 0.56, - 0.02]; I2 = 16%) had a significantly better effect on CRF in breast cancer patients; exercising for over 6 months (SMD = - 0.88 [95%CI - 1.59, - 0.17]; I2 = 42.7%; P = 0.0001), three times per week (SMD = - 0.77 [95%CI - 1.04, - 0.05]; I2 = 0%; P = 0.0001), and for 30 to 60 min per session (SMD = - 0.81 [95%CI - 1.15, - 0.47]; I2 = 42.3%; P = 0.0001) can contribute to a moderate improvement of CRF. Supervised exercise (SMD = - 0.48 [95%CI - 0.77, - 0.18]; I2 = 87%; P = 0.001) was shown to relieve CRF.

CONCLUSION

Exercise played a favorable role in alleviating CRF in breast cancer. Yoga was recommended as a promising exercise modality for CRF management in the majority of the included studies. Exercising for at least three times per week with 30 to 60 min per session could be recommended as a suitable dosage for achieving improvement in CRF. Supervised exercise was found to be more effective in alleviating CRF than unsupervised exercise. More rigorously designed clinical studies are needed to specify the exact exercise type, duration, frequency, and intensity to have an optimal effect on CRF in breast cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: CRD42020219866.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

Problems in living among breast cancer survivors

Purpose:

Breast cancer survivors may experience worse social, physical, and emotional function compared to the general population, although symptoms often improve over time. Data on problems in living can help to improve interventions and supportive care for breast cancer survivors. Symptoms such as fatigue, pain, difficulties with sleep, and sexual problems may have an adverse effect on the quality of life of breast cancer survivors.

Methods:

We examined problems in living using data from a survey of 164 breast cancer survivors who had completed primary therapy for the disease.

Results:

A total of 164 women completed the study questions (response rate 16.4%). The mean age of the women was 67 years. Among all participants, 66.7% were white, 29.5% were African-American, and the remainder were of other races. Almost all of the symptoms were more likely to be reported by participants who were < 55 years of age. Other important correlates of symptoms included non-white race, marital status, and having a household income of less than $50,000 per year.

Conclusion:

The results of this study highlight the need for caregivers to emphasize screening for and discussion of symptoms, including sleep difficulties, fatigue, loss of strength, aches and pains, and muscle or joint stiffness. Of particular concern are younger survivors and those who are African American or low-income.

Fatigue and resting-state functional brain networks in breast cancer patients treated with chemotherapy

PURPOSE

This longitudinal study aimed to disentangle the impact of chemotherapy on fatigue and hypothetically associated functional brain network alterations.

METHODS

In total, 34 breast cancer patients treated with chemotherapy (BCC +), 32 patients not treated with chemotherapy (BCC -), and 35 non-cancer controls (NC) were included. Fatigue was assessed using the EORTC QLQ-C30 fatigue subscale at two time points: baseline (T1) and six months after completion of chemotherapy or matched intervals (T2). Participants also underwent resting-state functional magnetic resonance imaging (rsfMRI). An atlas spanning 90 cortical and subcortical brain regions was used to extract time series, after which Pearson correlation coefficients were calculated to construct a brain network per participant per timepoint. Network measures of local segregation and global integration were compared between groups and timepoints and correlated with fatigue.

RESULTS

As expected, fatigue increased over time in the BCC + group (p = 0.025) leading to higher fatigue compared to NC at T2 (p = 0.023). Meanwhile, fatigue decreased from T1 to T2 in the BCC - group (p = 0.013). The BCC + group had significantly lower local efficiency than NC at T2 (p = 0.033), while a negative correlation was seen between fatigue and local efficiency across timepoints and all participants (T1 rho = - 0.274, p = 0.006; T2 rho = - 0.207, p = 0.039).

CONCLUSION

Although greater fatigue and lower local functional network segregation co-occur in breast cancer patients after chemotherapy, the relationship between the two generalized across participant subgroups, suggesting that local efficiency is a general neural correlate of fatigue.

Cancer-related Fatigue in Breast Cancer Survivors: A Review

Fatigue has been the most distressing and frequent symptom in breast cancer (BC) survivors after treatment. Although fatigue can occur in other cancer survivors, women with a history of BC might share some distinctive features. The present study aimed to recapitulate the knowledge about risk factors and correlates of cancer-related fatigue (CRF) in BC survivors after oncologic therapy. An electronic data search was conducted in PubMed using the terms "fatigue," "breast," "cancer," and "survivors." Records were included if they were original articles, available in English, had used a quantitative scale, had > 100 participants, and had excluded women with BC relapse. BC survivors were required to have finished their treatments ≥ 2 months before, except for hormonal therapy. The physiopathology and other interventions were considered beyond the scope of our review. The correlates were subsequently classified into 7 main categories: (1) sociodemographic data, (2) physical variables, (3) tumor- and treatment-related variables, (4) comorbidities, (5) other symptoms, (6) psychological issues, and (7) lifestyle factors. Fatigue was consistently greater in younger, obese, and diabetic women. Women reporting fatigue often communicated symptoms such as pain, depression, insomnia, and cognitive dysfunction. Coping strategies such as catastrophizing could play an important role in the persistence of fatigue. However, tumor characteristics, previous treatments received, and physical activity were not consistently reported. CRF was a strong predictor of the quality of life of BC survivors after treatment. In conclusion, we found CRF was a frequent and serious symptom that severely affects the quality of life of BC survivors after treatment. Health practitioners require more awareness and information about CRF.

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.

Breast Cancer Survivors

Women living with and beyond breast cancer have special health care needs. Persistent physical and psychological symptoms such as fatigue, pain, sleep disturbances, and fear of recurrence as well as quality-of-life outcomes have been described in women during and after breast cancer. Much less information exists on the experience of women completing treatment. This study describes the information and support needs of women following breast cancer treatment. A semistructured interview guide designed by the research team was used to gather data. Major findings indicate that women continue to experience a variety of physical and psychological symptoms and have concrete information and support needs following therapy, including the need for information on persistent treatment effects, emotional distress, and lifestyle changes. Findings illustrate that there is need to provide comprehensive information and support to help women transition from breast cancer therapy. Additional research is needed to optimize approaches to providing posttreatment care.

Preliminary differences in peripheral immune markers and brain metabolites between fatigued and non-fatigued breast cancer survivors: a pilot study

Persistent cancer-related fatigue (PCRF) is one of the most troubling side-effects of breast cancer (BC) treatment. One explanatory model for PCRF is sickness behavior, which is a set of adaptive responses including sleepiness and depressed mood in reaction to an inflammatory trigger. Prior research has investigated differences in inflammatory cytokines between fatigued and non-fatigued BC survivors, but no study has examined differences in brain metabolites. Differences in inflammatory markers, and brain metabolites using proton magnetic resonance spectroscopy were evaluated within 16 fatigued and 13 non-fatigued BC survivors. Fatigued BC survivors had significantly higher ratios of two markers derived from brain metabolites; namely (a) creatine, normalized to total creatine (creatine + phosphocreatine (Cr/tCr)) ratio (P = 0.03) and (b) glutamate + glutamine (Glx) to N-acetyl-aspartate (NAA) ratio (P = 0.01) in the posterior insula compared to non-fatigued breast cancer survivor. Further, serum IL-6 was increased in fatigued women compared to non-fatigued women (P = 0.03), Using receiver operator curves (ROC) we determined that the posterior insula Glx/NAA ratio was the best predictor of fatigue with an overall area under the receiver operating characteristic curve (AUROC) of 79%, with a sensitivity of 81% and a specificity of 69%. However, posterior insula Glx/NAA, Cr/tCr and serum IL-6 were not significantly correlated with one another implying the possibility of independent biological mechanisms for PCRF rather than an interrelated mechanism as represented by the sickness behavior model. This study provides novel preliminary evidence of several distinct neurobiological changes in the posterior insula associated with PCRF in BC survivors. Future, longitudinal studies are needed to explore these distinct biological phenomena where changes through time in peripheral immune markers and brain metabolites are examined to determine if they correlate with changes in fatigue.

Effectiveness, Mediators, and Effect Predictors of Internet Interventions for Chronic Cancer-Related Fatigue: The Design and an Analysis Plan of a 3-Armed Randomized Controlled Trial

Background

Internet interventions offer advantages that especially cancer survivors who suffer from fatigue could benefit from. Given the growing number of such patients, Internet interventions could supplement and strengthen currently available health care.

Objective

This paper describes the design and analysis plan that will be used to study 2 Internet interventions aimed at reducing severe fatigue in cancer survivors: a mobile ambulant activity feedback therapy supported through a weekly email by a physiotherapist and a weekly Web- and mindfulness-based cognitive therapy supported online by a psychologist. The data resulting from this trial will be used to (1) investigate the effectiveness, (2) investigate potential mediators of these interventions, and (3) explore participant characteristics that can predict the effect of these interventions.

Methods

A 3-armed randomized controlled trial is proposed that compares both Internet interventions with an active control condition that solely consists of receiving psycho-educational emails. The intervention period is 9 weeks for all 3 conditions. Six months after baseline, participants in the control condition can choose to follow 1 of the 2 experimental Internet interventions. Outcomes are measured in terms of fatigue severity, mental health, and self-perceived work ability. All are Web-assessed at baseline, 2 weeks after the intervention period, and at 6 and 12 months after baseline. Fatigue severity, mindfulness, physical activity, expectations and credibility of the intervention, therapeutic working alliance, sleep quality, and sense of control over fatigue are assessed 3 times during the intervention period for identifying mediators of the interventions. Recruitment is performed nationally throughout the Netherlands through patient organizations and their websites, newspapers, and by informing various types of health professionals. All participants register at an open-access website. We aim at including 330 cancer survivors who have finished curative-intent cancer treatment at least 3 months previously, and have been suffering from severe fatigue ever since. All cancer types are included. A detailed analysis plan is described to address the research questions, which allows for individual variation, and fully exploits the longitudinal design.

Results

Recruitment started in April 2013 and will proceed until April 2015.

Conclusions

This paper describes a systematic trial design for studying 2 different interventions for chronic cancer-related fatigue in order to gain insight into the effectiveness and mediators of the interventions. This design will also be used to identify predictors for the interventions’ effect on fatigue. By publishing our hypotheses and analysis plan before completion of data collection, this paper is a first step in reporting on this trial comprehensively.

Trial Registration

The Netherlands National Trial Register (NTR3483). (Archived by WebCite at http://www.webcitation.org/6NWZqon3o).

A Qualitative Description of a Family Intervention for Breast Cancer Survivors Experiencing Fatigue

Breast cancer survivors commonly experience fatigue, but family-focused interventions as a means to reduce fatigue are understudied. This qualitative study explored the experience of adding a family component to a multimodal group intervention for fatigue. Data were collected from group observations, in-depth interviews, and debriefing sessions with the program social worker. Fourteen survivors completed the family intervention (mean age 57 years) with a family member or close friend. Four themes associated with the family intervention were identified: (a) importance of family inclusion, (b) education of family members about fatigue,

The biology of cancer-related fatigue: a review of the literature

PURPOSE

Understanding the etiology of cancer-related fatigue (CRF) is critical to identify targets to develop therapies to reduce CRF burden. The goal of this systematic review was to expand on the initial work by the National Cancer Institute CRF Working Group to understand the state of the science related to the biology of CRF and, specifically, to evaluate studies that examined the relationships between biomarkers and CRF and to develop an etiologic model of CRF to guide researchers on pathways to explore or therapeutic targets to investigate.

METHODS

This review was completed by the Multinational Association of Supportive Care in Cancer Fatigue Study Group-Biomarker Working Group. The initial search used three terms (biomarkers, fatigue, cancer), which yielded 11,129 articles. After removing duplicates, 9145 articles remained. Titles were assessed for the keywords "cancer" and "fatigue" resulting in 3811 articles. Articles published before 2010 and those with samples <50 were excluded, leaving 75 articles for full-text review. Of the 75 articles, 28 were further excluded for not investigating the associations of biomarkers and CRF.

RESULTS

Of the 47 articles reviewed, 25 were cross-sectional and 22 were longitudinal studies. More than half (about 70 %) were published recently (2010-2013). Almost half (45 %) enrolled breast cancer participants. The majority of studies assessed fatigue using self-report questionnaires, and only two studies used clinical parameters to measure fatigue.

CONCLUSIONS

The findings from this review suggest that CRF is linked to immune/inflammatory, metabolic, neuroendocrine, and genetic biomarkers. We also identified gaps in knowledge and made recommendations for future research.

Prospective analysis of the risk factors for falls in lymphoma patients

PURPOSE

To explore the risk factors for falls in lymphoma patients receiving chemotherapy.

METHODS

Lymphoma patients (203) who received chemotherapy were prospectively recruited and analyzed. Eligible participants were followed up by weekly telephone contact for 6 months or until the time of a fall or death. Risk factors for falling in lymphoma patients were identified using univariate regression analysis and multivariate binary logistic regression analysis.

RESULTS

Of the 203 cases, 13.3% (27 cases) had a fall during follow-up. Univariate regression analysis showed the following risk factors for falls in lymphoma patients: gender (P = 0.023), Eastern Cooperative Oncology Group (ECOG) performance status score (P < 0.0001), cancer stage (P < 0.0001), extranodal involvement (P = 0.041), serum lactate dehydrogenase (LDH) level (P < 0.0001), revised International Prognostic Index (R-IPI) (P < 0.0001), history of falls (P < 0.0001), gait (P < 0.0001), cognitive condition (P = 0.029) and intravenous catheter placement (P < 0.0001). Multivariate binary logistic regression analysis found four independent factors significantly associated with the risk of falling in lymphoma patients: female gender (P = 0.042), later stage (P = 0.021), R-IPI (P = 0.030), and intravenous catheter placement (P = 0.001).

CONCLUSIONS

Gender, stage, R-IPI, and intravenous catheter placement were independent risk factors for falls in patients with lymphoma. Lymphoma patients with these four risk factors should receive particular attention and fall prevention education to reduce the incidence of falls. The R-IPI may be a new predictor of falling in lymphoma patients and may aid in the management of falls.

Cancer-related fatigue in patients before and after radical prostatectomy. Results of a prospective multi-centre study

PURPOSE

A multi-centre, longitudinal study was conducted to assess the prevalence of fatigue amongst men with localized prostate cancer, to describe several dimensions of fatigue and to explore the predictability of fatigue by psychological distress and physical function.

METHODS

The prevalence of fatigue was evaluated using the Multidimensional Fatigue Inventory in 329 prostate cancer patients before, 3, 6 and 12 months after surgery. Psychological distress was assessed using the Hospital Anxiety and Depression Scale. Physical function was measured using the EORTC QLQ-C30.

RESULTS

After surgery, about 14 % of the patients were screened with chronic fatigue. For all dimensions of fatigue, only small longitudinal changes could be observed. Psychological distress could be identified as a good predictor of fatigue after but not before surgery.

CONCLUSIONS

Radical prostatectomy has no or little impact on the prevalence of fatigue. However, about 14 % of patients with chronic fatigue could possibly benefit from psychosomatic interventions. Interventions should consider the simultaneous appearance of fatigue and psychological distress and a reduced physical function.

Symptom clusters of pain, depressed mood, and fatigue in lung cancer: assessing the role of cytokine genes

PURPOSE

Symptom clusters, the multiple, co-occurring symptoms experienced by cancer patients, are debilitating and affects quality of life. We assessed if a panel of immune-response genes may underlie the co-occurrence of severe pain, depressed mood, and fatigue and help identify patients with severe versus non-severe symptom clusters.

METHODS

Symptoms were assessed at presentation, prior to cancer treatment in 599 newly diagnosed lung cancer patients. We applied cluster analyses to determine the patients with severe versus non-severe symptom clusters of pain, depressed mood, and fatigue.

RESULTS

Two homogenous clusters were identified. One hundred sixteen patients (19 %) comprised the severe symptom cluster, reporting high intensity of pain, depressed mood, and fatigue and 183 (30 %) patients reported low intensity of these symptoms. Using Bayesian model averaging methodology, we found that of the 55 single nucleotide polymorphisms assessed, an additive effect of mutant alleles in endothelial nitric oxide synthase (-1474 T/A) (posterior probability of inclusion (PPI) = 0.78, odds ratio (OR) = 0.54, 95 % credible interval (CI) = (0.31, 0.93)); IL1B T-31C (PPI = 0.72, OR = 0.55, 95 % CI = (0.31, 0.97)); TNFR2 Met(196)Arg (PPI = 0.70, OR = 1.85, 95 % CI = (1.03, 3.36)); PTGS2 exon 10+837T > C (PPI = 0.69, OR = 0.54, 95 % CI = (0.28, 0.99)); and IL10RB Lys(47)Glu (PPI = 0.68; OR = 1.74; 95 % CI = (1.04, 2.92)) were predictive for symptom clusters.

CONCLUSIONS

Genetic polymorphisms may facilitate identification of high-risk patients and development of individualized symptom therapies.

[Structural equation modeling on health-related quality of life in patients with obstructive sleep apnea]

PURPOSE

This study was done to test structural equation modeling of health-related quality of life (QOL) of men with obstructive sleep apnea in order to identify parameters affecting QOL and provide guidelines for interventions and strategies to improve QOL in these patients.

METHODS

Model construction was based on 'The conceptual model of patient outcome in health-related QOL' by Wilson and Cleary, using the variables; age, physiological factors, social support, cognitive appraisal, symptoms and QOL. Participants were 201 adult male patients recruited at a tertiary university hospital in Seoul. Data were collected via questionnaires, polysomnography, and clinical records.

RESULTS

Age and symptoms directly influenced QOL. Social support and cognitive appraisal about sleep did not have a direct influence on QOL, but indirectly affected it via symptoms. QOL was lower in patients who were younger and had more severe symptoms. Symptoms were more severe for patients with lower social support and more dysfunctional cognitive appraisal. When social support was lower, cognitive appraisal was more dysfunctional.

CONCLUSION

These results suggest it is necessary to not only manage symptoms, but also apply interventions to increase social support and cognitive appraisal about sleep in order to increase QOL in patients with obstructive sleep apnea.

Living with side effects from cancer treatment--a challenge to target information

BACKGROUND

Patients with cancer experience side effects related to their antineoplastic treatment. Demands for efficiency limit the time patients spend with health professionals. This requires that professionals are able to offer adequate support to patients in coping with side effects of treatment in everyday life. However, it appears that the level of information about and support in living with side effects may be insufficient.

OBJECTIVE

To explore patients' experiences of how side effects from chemotherapy and radiotherapy impact everyday life as well as the information needs in coping with these side effects.

METHODS

Nine patients' experiences were analysed and interpreted using a phenomenological-hermeneutical approach. Data were collected through semi-structured interviews.

FINDINGS

The patients are deeply impacted by side effects in their everyday life. They struggle to take power but experience loss of control. They feel inexperienced without knowledge in an 'ongoing system', and because of lack of continuity, they do not come up with their real needs. To avoid pitfalls in the information, the patients need individualized support from the professionals.

CONCLUSION

If the patients have to be supported during everyday life with side effects from cancer treatment in an individualized way, the professional must be aware that the patients risk adapting to the busy healthcare system. To empower the patient, the professional must be able to sense the patients' appeal for help and enter into caring relationships.

IMPLICATIONS FOR PRACTICE

To ensure targeted information, the relationship between nurse and patient must build on nursing values including the patients' illness - perspective. However, the professionals must take a critical look at how they provide information and how they act to empower the patients.

Fatigue after treatment in breast cancer survivors: prevalence, determinants and impact on health-related quality of life

PURPOSE

Fatigue is a phenomenon that may persist for years after completion of adjuvant therapy, and is one of the most frequent symptoms associated with breast cancer survivors. The purposes of this study were to investigate the occurrence of fatigue in disease-free breast cancer survivors after treatment, to identify variables associated with fatigue, and to evaluate the impact of fatigue on health-related quality of life.

METHODS

A cross-sectional study was conducted on 202 consecutive women diagnosed with in-situ to Stage III breast cancer attending in outpatient facilities of two large hospitals, one year or more after diagnosis. They completed the Piper Fatigue Scale-Revised and the European Organization for Research and Treatment of Cancer QLQ-C30. Multiple logistic regression models were used to identify predictive factors associated with fatigue. EORTC QLQC-30 scores for fatigued survivors were compared to non-fatigued survivors.

RESULTS

The prevalence of fatigue reported by the breast cancer survivors was 37.6%. Multiple logistic regression analysis revealed that predictive factors for fatigue included younger age (odds ratio [OR]=2.23, 95% confidence interval [CI]=1.11-4.45, p = 0.024); presence of pain (OR = 3.87, 95% CI = 1.88-7.98, p = 0.000); dyspnea (OR = 3.72, 95% CI = 1.46-9.50, p = 0.006); insomnia (OR = 2.40, 95% CI = 1.19-4.86, p = 0.015); and nausea and vomiting (OR = 12.25, 95% CI = 1.18-126.75, p = 0.036). Fatigued women had poorer health-related quality of life than non-fatigued women in all domains.

CONCLUSION

Our results suggest that many disease-free breast cancer survivors after treatment experienced fatigue that compromises their health-related quality of life.

Differences in sleep disturbance and fatigue between patients with breast and prostate cancer at the initiation of radiation therapy

CONTEXT

Little is known about the occurrence and severity of sleep disturbance and fatigue between patients with common cancer diagnoses.

OBJECTIVES

Study purposes were to evaluate for differences in the occurrence rates of sleep disturbances and fatigue; evaluate for differences in the severity of sleep disturbance using both subjective and objective measures; and evaluate for differences in the severity of self-reported fatigue in patients with breast and prostate cancer at the initiation of radiation therapy (RT).

METHODS

Patients with breast (n=78) and prostate (n=82) cancer were evaluated before the initiation of RT using the Pittsburgh Sleep Quality Index, General Sleep Disturbance Scale, Lee Fatigue Scale, and wrist actigraphy. Differences in sleep disturbance and fatigue between groups were evaluated using independent sample t-tests and Chi-square analyses.

RESULTS

Occurrence rates for sleep disturbance (P<0.0001) and fatigue (P=0.03) were significantly higher in patients with breast compared with prostate cancer. Patients with breast cancer self-reported significantly higher levels of sleep disturbance (P=0.008) and fatigue (P=0.005) than patients with prostate cancer. However, using actigraphy, patients with prostate cancer had poorer sleep efficiency (P=0.02) than patients with breast cancer.

CONCLUSION

Based on self-report, patients with breast cancer experience sleep disturbance more frequently and with greater severity than patients with prostate cancer. Objective measures of sleep disturbance suggest that prostate cancer patients have more severe sleep disturbance than breast cancer patients. All the patients experienced poor sleep quality and fatigue, which suggests that oncology patients need to be assessed for these symptoms.

Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters

To investigate prevalence and severity of symptoms and symptom clustering in breast cancer survivors who attended MBSR(BC). Women were randomly assigned into MBSR(BC) or Usual Care (UC). Eligible women were ≥ 21 years, had been diagnosed with breast cancer and completed treatment within 18 months of enrollment. Symptoms and interference with daily living were measured pre- and post-MBSR(BC) using the M.D. Anderson Symptom Inventory. Symptoms were reported as highly prevalent but severity was low. Fatigue was the most frequently reported and severe symptom among groups. Symptoms clustered into 3 groups and improved in both groups. At baseline, both MBSR(BC) and the control groups showed similar mean symptom severity and interference; however, after the 6-week post-intervention, the MBSR(BC) group showed statistically-significant reduction for fatigue and disturbed sleep (P < 0.01) and improved symptom interference items, compared to the control group. For the between-group comparisons, 11 of 13 symptoms and 5 of 6 interference items had lower means in the MBSR(BC) condition than the control condition. These results suggest that MBSR(BC) modestly decreases fatigue and sleep disturbances, but has a greater effect on the degree to which symptoms interfere with many facets of life. Although these results are preliminary, MBSR intervention post-treatment may effectively reduce fatigue and related interference in QOL of breast cancer survivors.

Prevalência e comorbidade de dor e fadiga em mulheres com câncer de mama

O estudo analisou a prevalência e a comorbidade de dor e fadiga em mulheres com câncer de mama. Trata-se de estudo transversal, com amostra, não probabilística de 182 mulheres em tratamento ambulatorial para câncer de mama, entrevistadas no período de julho 2006 a março de 2007. Fadiga, avaliada pela Escala de Fadiga de Piper, foi dividida em duas categorias (escore 0,1-4,9 e >5-10). Dor, avaliada pela escala de 0-10, foi categorizada do mesmo modo que fadiga. Fadiga ocorreu em 94 mulheres (51,6%), sendo >5 em 44 (46,8%) delas. Dor ocorreu em 86 mulheres (47,2%), sendo >5 em 50 (58,1%). Fadiga e dor correlacionaram-se (r=0,38, p=0,003) e a comorbidade fadiga e dor foi de 38,3%. Dor intensa acentuou a fadiga (p=0,089) e fadiga intensa acentuou a dor (p=0,016). Tais dados são inéditos em nosso meio, confirmam a existência de um cluster de sintoma e dos prejuízos decorrentes dessa comorbidade.

Systematic review and meta-analysis of the correlates of cancer-related fatigue

BACKGROUND

Fatigue is one of the most common problems experienced by cancer patients. The factors most frequently reported to correlate with cancer-related fatigue are symptom distress (pain, nausea/vomiting, dyspnea, and lack of appetite) and psychological distress (depression and anxiety).

AIMS

This study was performed to examine the overall association of symptom and psychological distress with cancer-related fatigue using systematic literature review and meta-analysis. This study also aimed to determine which factors have a higher correlation with fatigue, and therefore should receive nursing priority.

METHODS

A meta-analysis of 30 primary studies identified by searching computer databases, which included MEDLINE, PubMed, and CINAHL.

RESULTS

Results showed that all symptoms (pain, dyspnea, nausea/vomiting, and lack of appetite) and psychological distress (depression and anxiety) included had a significant association with cancer-related fatigue with medium-to-large effect sizes, which were estimated using correlation coefficients. The overall correlations of psychological distress with cancer-related fatigue were found to be higher than those of symptom distress. The correlation of nausea/vomiting with cancer-related fatigue was higher than those of pain and dyspnea.

CONCLUSIONS AND IMPLICATIONS

Our findings highlight the importance of psychological distress in dealing with cancer-related fatigue in addition to the need to be attentive to a patient's symptom distress. Of the symptom distress, nausea/vomiting should be prioritized by nurses when managing cancer-related fatigue. This study provides sound empirical evidence that can be used to draft guidelines for the management of cancer-related fatigue.

Factors associated with cancer-related fatigue in breast cancer patients undergoing endocrine therapy in an urban setting: a cross-sectional study

BACKGROUND

Fatigue is prevalent in breast cancer survivors and has profound effects on daily life. The interference of fatigue with endocrine therapy may be difficult to separate. This study investigates the prevalence and severity of fatigue and identifies the demographic, clinical, and lifestyle factors associated with cancer-related fatigue (CRF) in breast cancer patients undergoing endocrine therapy in an urban area.

METHODS

Women with stage I-IIIA breast cancer were recruited and asked to participate (n = 371) in the study. The 315 women who responded to the questionnaire (84.9%), 54 (17.1%) had completed endocrine therapy and 261 (82.9%) were still undergoing endocrine therapy. The patients had been diagnosed at an average of 31 months prior to recruitment (range, 7 to 60 months); the average age was 48 (range, 33 to 72) years. The 11-point scale and Visual Analog Scale (VAS) were employed to quantify the level of fatigue experienced by the patients. Logistic regression analyses and a trend test method were performed to evaluate factors associated with CRF.

RESULTS

Among the 315 patients, 189 (60%) had experienced or were experiencing CRF during endocrine therapy. Logistic regression analysis was performed to identify factors associated with CRF, including BMI (body mass index), clinical stage, menopausal status, duration of endocrine therapy, physical activity, and diet. Factors unrelated to CRF were age, marital status, treatment, endocrine therapy drugs, alcohol intake, and smoking. The trend test method revealed an association between physical activity and dietary level and the intensity of CRF.

CONCLUSIONS

The present findings suggest that fatigue is an important problem in the majority of breast cancer patients during endocrine therapy. We found that BMI, clinical stage, menopausal status, duration of endocrine therapy, physical activity, and diet are associated with fatigue. Future research should focus on the impact factors of CRF and lifestyle in the management of breast cancer patients.

Fatigue in gynecological cancer patients during and after anticancer treatment

CONTEXT

Research has indicated that individuals with gynecological cancer experience severe fatigue.

OBJECTIVES

This longitudinal survey aimed to analyze the fatigue experienced over the course of one year by a gynecological cancer population, to determine if the fatigue was more severe than that reported by females without cancer, and to identify variables associated with cancer-related fatigue (CRF).

METHODS

Data were collected over a 12-month period before, during, and after anticancer treatment. Fatigue was assessed using the Multidimensional Fatigue Symptom Inventory-Short Form. Participants with cancer also completed the Rotterdam Symptom Checklist.

RESULTS

Sixty-five cancer patients (mean age = 57.4 years, standard deviation [SD] = 13.9) and 60 control subjects (mean age = 55.4 years, SD = 13.6) participated. Descriptive analysis and repeated measurements modeling indicated that the cancer participants reported worse fatigue than the noncancer individuals before, during, and after anticancer treatment (P < 0.001) and that the level of fatigue in persons with cancer changed with time (P = 0.02). A forward stepwise regression demonstrated that psychological distress level was the only independent predictor of CRF during anticancer treatment (P < 0.00), explaining 44% of the variance in fatigue. After treatment, both psychological distress level (P < 0.00) and physical symptom distress (P = 0.03) were independent predictors of fatigue, accounting for 81% of the variance.

CONCLUSION

Psychological distress level is an important indicator of CRF in gynecological cancer. Interventions focused on the reduction of psychological distress may help alleviate CRF.

Causal relationships among factors associated with cancer-related fatigue

PURPOSE

This study was conducted to develop and verify a comprehensive model, which illustrates the dynamic causal relationships between fatigue and its associated factors in cancer patients.

METHOD

The subjects were 110 in- or out-patients with various types of cancer being treated at a University Hospital, Incheon, South Korea. The comprehensive model consists of physical distress, sleep-related, physiologic, psychological distress, physical performance, and exercise factors.

RESULTS

Psychological distress had a significant direct effect on physical distress, and 81% of the variance in physical distress was explained by psychological distress. While psychological distress showed to have a significant total effect (the sum of direct effects of psychological distress and indirect effects through its relationship with physical distress) on fatigue, it was not found to have a significant direct effect on fatigue. Only exercise had a significant direct effect on fatigue and 70% of fatigue variance was explained by exercise alone. All remaining factors were not found to have significant direct effects on fatigue.

CONCLUSIONS

The hypothetical model was well suited to explain cancer-related fatigue. Our result indicates that psychological distress should be relieved in combination with a strategy to reduce physical distress in order to obtain better outcomes with respect to cancer-related fatigue. Only exercise had a significant direct effect on fatigue. In terms of the nursing implications, the proposed model can help oncology nurses better understand cancer-related fatigue and assess presence of correctable correlates. This model can be a future framework when developing intervention strategies for cancer-related fatigue.

Relationships among optimism, well-being, self-transcendence, coping, and social support in women during treatment for breast cancer

OBJECTIVE

The impact of diagnosis and treatment for breast cancer, stressors that affect emotional well-being, is influenced by several psychosocial factors and the relationships among them. The purpose of this study was to investigate the relationship between optimism and emotional well-being (EWB) and the individual and combined mediation of this relationship by perceived social support (SS), problem focused coping (PFC), and self-transcendence in women with breast cancer during radiation therapy.

METHODS

Ninety-three women receiving radiation treatment for breast cancer completed questionnaires that measured EWB, optimism, SS, PFC, and self-transcendence.

RESULTS

Correlational and multiple regression analysis revealed that optimism was positively related to EWB. Of the three mediators, self-transcendence alone was found to partially mediate the relationship between optimism and EWB. The relationship between optimism and PFC was not significant. Optimism was related to SS, but its indirect effect on EWB through SS did not reach significance.

CONCLUSIONS AND IMPLICATIONS

During breast cancer treatment, the positive effects of optimism on EWB are partially mediated by a woman's level of self-transcendence. Brief screening of women's optimism may help identify women at risk for psychological distress. Early detection and interventions to promote psychological adjustment throughout the cancer trajectory (e.g. enhancing self-transcendence) should receive attention in future research.

Fatigue in cancer: a review of literature

Fatigue is a common symptom of advanced cancer limiting one's activity and affecting the quality of life. It is a multidimensional symptom complex with subjective and objective components. Hence, its definition and assessment seems arbitrary, incomplete, and elusive. Components of fatigue often merge with other 'disease states' as anemia, depression and so on, compounding difficulty to assess it separately. Fatigue has a high prevalence rate, and lasts longer in chronic diseases like cancer. Its association with treatment modalities like chemotherapy, radiotherapy alongside the primary disease process makes it seemingly ubiquitous in many cases. Systemic manifestation of cancer causes excess demand on body resources on cell repair, uncontrolled growth with metabolite accumulation causing fatigue. Co-morbid conditions of organic and psychological nature causes fatigue. There are many assessment tools for fatigue with different uses and objectives, simple and reproducible tools like Brief Fatigue Inventory, Edmonton Symptom assessment scale seem feasible in everyday practice. Management of fatigue is not straightforward and rewarding. Although treatment of cause appears to be an attractive option, it is not possible in all cases. Therapeutic agents targeting cytokine load is in early stages of study and available results are not favorable. Specific measures aimed at pain relief, prevention/treatment of sepsis, management of depression, avoidance of drugs causing fatigue, restoring the metabolic profile are important. Methyl phenidate, megestrol, and modafinil are some drugs with promising effect to treat fatigue, though confirmatory studies are yet to be established. Non-pharmacological methods are also helpful. Forewarning patients on upcoming fatigue, active regular exercise, and stress management are some of them. Fatigue being a multidimensional entity, single mode of therapy is insufficient. Combined modality tailored to individual patient need and understanding may be the right way to battle this ill-understood symptom. This review article examines the etiopathogenesis and management strategies of fatigue in cancer.

A biobehavioral model for the study of exercise interventions in cancer-related fatigue

Cancer-related fatigue (CRF) is a multifactorial, biobehavioral phenomenon experienced by the majority of persons with cancer. It has negative consequences on the individual's physical functioning and quality of life. An array of biological, psychobehavioral, and functional mechanisms contributes to its occurrence. A relatively large number of studies have examined the effect of physical exercise on CRF over the past few decades. Most of these studies did not specifically examine the effect of physical exercise on the biobehavioral mechanisms underlying CRF. For the most part, these studies have not been guided by a consistent theoretical model. Consequently, the mechanisms by which exercise may ameliorate CRF are not fully elucidated. A theoretical model incorporating fatigue-related biobehavioral variables that could be affected by physical exercise will allow for effective knowledge development in this area and could lead to the development and refinement of exercise protocols that specifically target these mechanisms. Thus, the purpose of this paper is to present a comprehensive theoretical model to guide future research on the effectiveness of exercise interventions in CRF. The proposed model incorporates the biological, psychobehavioral, and functional variables implicated in the induction of CRF.

A brief intervention for fatigue management in breast cancer survivors

The purpose of this randomized control trial was to verify the effectiveness of a brief group intervention that combines stress management psycho-education and physical activity (ie, independent variable) intervention in reducing fatigue and improving energy level, quality of life (mental and physical), fitness (VO 2submax), and emotional distress (ie, dependent variables) in breast cancer survivors. This study applied Lazarus and Folkman stress-coping theoretical framework, as well as Salmon's unifying theory of physical activity. Eighty-seven French-speaking women who had completed their treatments for nonmetastatic breast cancer at a university hospital in Quebec City, Canada, were randomly assigned to either the group intervention (experimental) or the usual-care (control) condition. Data were collected at baseline, postintervention, and at 3-month follow-up. The 4-week group intervention was cofacilitated by 2 nurses. Results showed that participants in the intervention group showed greater improvement in fatigue, energy level, and emotional distress at 3-month follow-up, and physical quality of life at postintervention, compared with the participants in the control group. These results suggest that a brief psycho-educational group intervention focusing on active coping strategies and physical activity is beneficial to cancer survivors after breast cancer treatments.

Cancer fatigue: a review for psychiatrists

OBJECTIVE

Cancer-related fatigue (CRF) is a ubiquitous and debilitating phenomenon for patients both during and after treatment for cancer of all types. This review will outline the complex neurobiological mechanisms underlying CRF and their relevance to various treatment routes. It will cover aspects of screening, diagnosis and treatment, including both pharmacological and behavioral interventions for CRF. The goal of the article was not to perform a comprehensive literature review or meta-analysis, but rather to integrate clinically relevant information from different areas of research related to cancer fatigue, including etiology, diagnosis and management for a nonspecialist audience.

METHOD

The methodology used involved broadly surveying the literature available on Medline using such search terms as "cancer," "fatigue," "cytokine" and "depression," exploring relevant articles over the past 15 years and relevant citations from these articles and focusing on recent advances in the study of CRF.

RESULTS

CRF occurs at high prevalence rates during and subsequent to cancer treatment. Multidisciplinary approaches are available for the assessment and management of fatigue including underlying contributory factors.

CONCLUSIONS

An increasing base for evidence is present to guide the management of CRF. Additional research is warranted to understand the neurobiological mechanisms, etiology and risk factors for fatigue.

Breast Cancer and Fatigue

Fatigue is a common and disabling symptom in breast cancer patients and survivors. A rather nebulous concept, fatigue overlaps with sleepiness and depressed mood. In this chapter, we cover methods for assessing fatigue; describe the occurrence of fatigue before, during and after initial treatment; present possible underlying mechanisms of fatigue; and, enumerate approaches to its treatment.

Neuroendocrine-immune mechanisms of behavioral comorbidities in patients with cancer

Patients with cancer experience a host of behavioral alterations that include depression, fatigue, sleep disturbances, and cognitive dysfunction. These behavioral comorbidities are apparent throughout the process of diagnosis and treatment for cancer and can persist well into the survivorship period. There is a rich literature describing potential consequences of behavioral comorbidities in patients with cancer including impaired quality of life, reduced treatment adherence, and increased disease-related morbidity and mortality. Medical complications of cancer and its treatment such as anemia, thyroid dysfunction, and the neurotoxicity of cancer chemotherapeutic agents account in part for these behavioral changes. Nevertheless, recent advances in the neurosciences and immunology/oncology have revealed novel insights into additional pathophysiologic mechanisms that may significantly contribute to the development of cancer-related behavioral changes. Special attention has been focused on immunologic processes, specifically activation of innate immune inflammatory responses and their regulation by neuroendocrine pathways, which, in turn, influence CNS functions including neurotransmitter metabolism, neuropeptide function, sleep-wake cycles, regional brain activity, and, ultimately, behavior. Further understanding of these immunologic influences on the brain provides a novel conceptual framework for integrating the wide spectrum of behavioral alterations that occur in cancer patients and may reveal a more focused array of translational targets for therapeutic interventions and future research. Such developments warrant complementary advances in identification of cancer patients at risk as well as those currently suffering, including an increased emphasis on the status of behavior as a "sixth vital sign" to be assessed in all cancer patients throughout their disease encounter.

Cancer-related fatigue: links with inflammation in cancer patients and survivors

Fatigue is one of the most common and distressing side effects of cancer and its treatment and may persist long after successful treatment completion. Emerging evidence suggests that inflammatory processes may be involved in cancer-related fatigue both during and after treatment. In this review, we consider the evidence for an association between inflammation and fatigue in cancer patients and survivors. Further, we identify potential mechanisms for persistent inflammation, focusing on the HPA axis. Risk factors and treatments for cancer-related fatigue are also discussed.

Social Support and Psychological and Physical States Among Japanese Women With Breast Cancer Before and After Breast Surgery

PURPOSE/OBJECTIVES

To investigate the relationship of social support and psychological and physical states among Japanese women with breast cancer and to compare the variables before and one year after breast surgery.

DESIGN

A prospective longitudinal study.

SETTING

A general hospital in northern Japan.

SAMPLE

61 Japanese women with breast cancer.

METHODS

Measures were the Japanese versions of the Interpersonal Relationship Inventory, the General Health Questionnaire, and the Physical States Interview Form. Data were collected at four time points: before (time 1), three months after (time 2), six months after (time 3), and one year after (time 4) breast surgery.

MAIN RESEARCH VARIABLES

Social support (support, reciprocity, and conflict), social support network, and psychological and physical states.

FINDINGS

Psychological and physical states correlated significantly at all four time points. Significant correlations also were found between psychological states and support at times 2 and 4 and between psychological states and reciprocity at time 4. Repeated measures analysis of variance showed significant differences in support, reciprocity, conflict, and physical states but no significant differences in social support network or psychological states.

CONCLUSIONS

The results of the study suggest that healthcare professionals need to consider social support as an important factor when helping Japanese women adjust to the diagnosis and treatment of breast cancer.

IMPLICATIONS FOR NURSING

Healthcare professionals need to provide appropriate social support for Japanese women with breast cancer not only at the time of diagnosis of breast cancer but also after breast surgery.

The Relationship of Fatigue and Meaning in Life in Breast Cancer Survivors

PURPOSE/OBJECTIVES

To determine relationships among (a) cancer-related fatigue and meaning in life, (b) overall symptom distress and meaning in life, (c) fatigue and performance, and (d) overall symptom distress and performance in breast cancer survivors.

DESIGN

Cross-sectional and correlational.

SETTING

Community-based setting in eastern Pennsylvania.

SAMPLE

34 women who had completed their last treatment for breast cancer within the prior 16 months.

METHODS

Data were collected using the Piper Fatigue Scale (PFS), Life Attitude Profile-Revised (LAP-R), Memorial Symptom Assessment Scale-Short Form (MSAS-SF), and Medical Outcomes Study-Short Form 36 (SF-36).

MAIN RESEARCH VARIABLES

Fatigue and meaning in life.

FINDINGS

One moderate negative correlation was found between the PFS sensory subscale and the choice or responsibleness dimension of the LAP-R. Significant moderate to strong negative correlations were found between the MSAS-SF total score and two subscale scores and the existential transcendence dimension of the LAP-R. Significant moderate to strong negative correlations were found between four subscales of the SF-36 representing performance and the MSAS-SF total score.

CONCLUSIONS

Meaning in life may influence fatigue and overall symptoms in breast cancer survivors.

IMPLICATIONS FOR NURSING

Assessment of meaning in life may be important in the management of fatigue and overall symptoms in women after treatment for breast cancer.

The association between fatigue and inflammatory marker levels in cancer patients: a quantitative review

Increased cytokine and neopterin levels may be responsible for cancer-related fatigue, the most common complaint among cancer patients. We quantitatively reviewed empirical findings on this topic, focusing on studies not using immunotherapy. PubMed, PsychINFO and BIOSIS were searched for articles published until July 2006. Studies remained unweighted or were weighted according to study quality and sample size. The correlation coefficient r was used for statistical analyses. Heterogeneity among the studies was examined using the I(2) index. Eighteen studies (1037 participants) of moderately high methodological quality were located and statistically analyzed. Most studies measured more than one inflammatory marker, resulting in a total of 58 correlation estimates. In 31 of these, we had to input a null correlation because results had been simply reported as nonsignificant and no further statistical information was available. General analyses based on weighting according to sample size showed a significantly positive correlation between fatigue and circulating levels of inflammatory markers (r=0.11, p<0.0001). Analyses of individual inflammatory markers revealed significantly positive correlations between fatigue and IL-6 (r=0.12, p=0.004), fatigue and IL-1 ra (r=0.24, p=0.0005), and fatigue and neopterin (r=0.22, p=0.0001). Fatigue did not correlate significantly with IL-1 beta (r=0.05, p=0.42) or TNF-alpha (r=0.04, p=0.34). Given its preliminary nature due to the limited available data, this quantitative review showed a positive association between cancer-related fatigue and circulating levels of IL-6, IL-1 ra and neopterin. Future studies examining the relationship between cancer related fatigue and inflammation would benefit from multiple rather than single blood sampling and from repeated daily ratings of the multidimensional nature of fatigue.

Fatigue in breast cancer survivors two to five years post diagnosis: a HEAL Study report

PURPOSE

The purpose of this study was to estimate prevalence of fatigue, identify correlates of fatigue and evaluate the relationship between fatigue and health-related quality of life (HRQOL) in a large cohort of disease-free breast cancer survivors.

METHODS

Participants are enrolled in the HEAL Study, a multi-center prospective study of women diagnosed with in-situ to Stage IIIA breast cancer. HEAL participants (n = 1183) completed a baseline and a 24-month follow-up interview. Women in this report (n = 800) also completed a quality of life questionnaire that included the Piper Fatigue Scale and the RAND SF-36 two to five years after diagnosis. Multivariate regression methods were used to identify significant factors associated with fatigue. SF-36 scores for fatigued survivors were compared to non-fatigued survivor scores and population norms.

RESULTS

Forty-one percent of the breast cancer survivors were fatigued. Significant correlates of fatigue included pain, cognitive problems, physical inactivity, weight gain/personal appearance and antidepressant use. Fatigue was associated with poorer HRQOL, most notably in areas of role and social functioning.

CONCLUSION

This study provides further support for the conclusion that a significant proportion of breast cancer survivors experience fatigue that compromises HRQOL two to five years post-diagnosis.

Psychosocial Responses in Breast Cancer Survivors

OBJECTIVES

To review the evidence on psychosocial responses in breast cancer survivors (BCS); identify factors that influence those responses; and propose patterns of psychosocial functioning that may provide a framework for assessment and intervention.

DATA SOURCES

Research articles/abstracts; literature reviews.

CONCLUSION

The majority of breast cancer survivors demonstrate a pattern of recovery. Age, information, communication, social and emotional support, family, and degree of symptom distress are known factors influencing QOL outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Assessment of psychosocial functioning is essential to identify needs and risk factors. Interventions should be targeted to meet informational needs, promote effective communication, manage uncertainty, control symptoms, enhance social and emotional support, and address cultural differences.

The implementation of an oncologist referred, exercise self-management program for older breast cancer survivors

BACKGROUND

With increased breast cancer survivor rates among older women, the negative outcomes of breast cancer treatment may linger for years.

METHOD

We designed and implemented an oncologist referred, exercise self-management program to increase physical activity and health-related quality of life using a pretest-posttest, single group design. We recruited 34 breast cancer survivors seen for a follow-up oncology visit at two university cancer treatment centers. Women with a mean age of 59.6 years (S.D.=66) comprised the sample. Average time since diagnosed was 3.1 years; 45% had stage I breast cancer and 55% had stage II; 62% received chemotherapy and 59% received a mastectomy. Following a baseline assessment on exercise support, self-efficacy, barriers and benefits; quality of life; and a functional performance test, subjects participated in self-management classes and received telephone support. Participants (n=30) repeated the assessment at 6-months. We compared scores between time periods using t-tests.

RESULTS

Older women increased frequency of weekly, moderate physical activities (p<or=0.04), and weekly caloric expenditure (p<or=0.02). Perceived exercise barriers (p<or=0.02), aerobic endurance (p<0.04) and lower body strength (p<0.03) approached significance, and health-related quality of life (p<or=0.001) significantly improved.

CONCLUSION

An exercise self-management format referred by an oncologist is efficacious for implementing a lifestyle modification change among older breast cancer survivors.

Examining the influence of coping with pain on depression, anxiety, and fatigue among women with breast cancer

Breast cancer treatment can have a profound influence on a woman's physical, psychological, social, and spiritual well-being. Anxiety, depression, anger, fatigue, and fear of recurrence are common responses to a diagnosis of breast cancer and undergoing breast cancer treatment. Women develop their own coping strategies for the pain and other effects of treatment. However, it is unclear whether there is a relationship between adaptation to pain and psychological distress during breast cancer treatment. Findings from the present study reveal that breast cancer patients who have better pain coping strategies also have lower levels of anxiety, fatigue and depression. These results suggest that pain coping interventions may reduce fatigue and psychological distress among women with breast cancer.