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

A score prediction model for predicting the heterogeneity symptom trajectories among lung cancer patients during perioperative period: a longitudinal observational study

INTRODUCTION

Patients undergoing video-assisted thoracoscopic surgery (VATs) for lung cancer (LC) frequently experience prolonged symptoms that can significantly affect their quality of life (QoL).

PATIENTS AND METHODS

This study employed a longitudinal observational design. The MDASI and QLQ-C30 were utilized to evaluate symptoms and QoL one day before surgery, as well as at 1 day, 2 weeks, and 1, 2, and 3 months post-surgery. Latent class growth modeling (LCGM) was employed to identify heterogeneous trajectories. By Logistic regression analysis, a score prediction model was developed based on predictive factors, which was internally validated utilizing 1000 bootstrap samples. The SHaply Additive Explanations (SHAP) was used to calculating the contribution of each factor.

RESULTS

205 participants participated in this study. The predominant postoperative complaints included fatigue, shortness of breath, pain, and coughing. Two distinct classes of symptom trajectories were identified: 'severe group' and 'mild group'. Four independent predictors of heterogeneous symptom trajectories were used to develop a scoring model. The area under the receiver operating characteristic curve for this model was 0.742 (95% CI: 0.651-0.832). And the calibration curves demonstrated strong concordance between anticipated probability and actual data (mean absolute error: 0.033). Furthermore, the decision curve analysis (DCA) indicated higher net benefit than other four single factors. SHAP highlighted WBC and surgical duration time as the most influential features.

CONCLUSIONS

We established a score model to predict the occurrence of severe symptom trajectories 3 months postoperatively, promoting recovery by advancing rehabilitation plan based on preoperative and surgical situation.

REGISTRATION

ClinicalTrials.gov (ChiCTR2100044776).

Quality of life and symptom burden among hematologic malignancy patients undergoing CAR-T therapy: a cross-sectional study

Few studies have thoroughly evaluated the symptom burden and quality of life (QOL) among patients diagnosed with hematologic malignancies who underwent chimeric antigen receptor T-cell (CAR-T) therapy. In total, 97 eligible patients completed the Functional Assessment of Cancer Therapy generic scale (FACT-G) at week 4 after CAR-T cell infusion. We used the Common Terminology Criteria Adverse Events (CTCAE) to measure symptom burden of CAR-T patients during the same period. We studied factors associated with QOL using liner regression analysis. During the period of hospitalization after CAR-T treatment, the prevalence of self-reported symptoms among CAR-T patients was highest for fatigue (89.7%), followed by sleep disorders (79.4%) and decreased appetite (66.0%). And the mean score of FACT-G was 69.06 (SD = 13.88). Liner regression analysis showed that decreased appetite (β = -0.30, 95% CI = -7.48 to -1.83, P = 0.002), fatigue (β = -0.28, 95% CI = -7.23- -1.69, P = 0.002), nausea (β = -0.26, 95% CI = -10.50 to -2.16, P = 0.003) and a history of hematopoietic stem cell transplantation (HSCT) (β = -0.21, 95% CI = -13.38- -1.56, P = 0.014) were associated with poorer quality of life. The symptom burden experienced by patients undergoing CAR-T treatment is substantial during their hospitalization, and it is closely associated with a diminished quality of life. It is imperative for clinical medical staff to be attentive to the symptom burden of CAR-T patients and to enhance the effectiveness of symptom management interventions.

Longitudinal Trajectory of Patient-Reported Fatigue in Patients Undergoing Thoracoscopic Lung Cancer Surgery

BACKGROUND

Postoperative fatigue is widely recognized as one of the most prevalent adverse effects of surgery, representing a critical determinant of functional recovery and quality of life. However, fatigue is commonly measured at a single time point, failing to capture its dynamic nature. This study aimed to characterize the longitudinal trajectories of postoperative fatigue and identify the potential factors.

METHODS

This retrospective study included patients with lung cancer who underwent thoracoscopic surgery between March 2021 and October 2023. Patients completed the Perioperative Symptom Assessment for Lung Surgery Scale (PSA-Lung) daily for 7 days after surgery. Latent class mixed modeling was used to analyze the longitudinal patient-reported data and identify subgroups based on trajectory features.

RESULTS

A total of 1,096 patients were included. Three-cluster trajectory model provided the best fit, consisting of deterioration-fatigue group (17.7%), recovery-fatigue group (31.4%) and mild-fatigue group (50.9%). Compared with the mild-fatigue group, patients with comorbidities had a higher risk of being categorized into the recovery-fatigue group (odds ratio 1.44, 95% confidence interval 1.02-2.04; p = 0.040). The presence of recovery-fatigue was associated with lower preoperative hemoglobin level (p = 0.025). Moreover, lower preoperative body mass index and albumin level increased the likelihood of being classified as the deterioration-fatigue group (p = 0.022 and p = 0.026, respectively).

CONCLUSIONS

This study elucidated the heterogeneity of fatigue trajectories, with half of the patients experiencing either recovery-fatigue or deterioration-fatigue. The severity of postoperative fatigue was found to be worse in patients with comorbidities or poor nutritional status.

Randomized clinical trial of a digital integrative medicine intervention among patients undergoing active cancer treatment

Exercise and mindfulness-based interventions have growing evidence for managing fatigue and comorbid symptoms; however, packaging them in a cohesive digital way for patients undergoing cancer treatment has not been evaluated. We conducted a randomized controlled trial to assess the impact of a 12 week digital integrative medicine program, Integrative Medicine at Home (IM@Home), versus enhanced usual care on fatigue severity (primary outcome), comorbid symptoms and acute healthcare utilization (secondary outcomes), in 200 patients with solid tumors experiencing fatigue during treatment. Fatigue severity decreased more in IM@Home than in the control (1.99 vs. 1.51 points; p = 0.04). IM@Home participants also had reduced symptom distress (p = 0.003), anxiety (p = 0.03), and depression (p = 0.02). Acute healthcare utilization was lower with IM@Home, with fewer emergency department visits (rate ratio 0.49; p = 0.04), hospitalizations (4% vs. 12.9%; p = 0.03), and shorter hospital stays (4.25 vs. 10 days; p < 0.001). These promising findings should be confirmed in phase III clinical trials. "Study registered at clinicaltrials.gov (NCT05053230) on 09-20-2021".

Symptom clusters and impact on quality of life in lung cancer patients undergoing chemotherapy

PURPOSE

To identify symptom clusters (SCs) in lung cancer patients undergoing chemotherapy and explore their impact on health-related quality of life (HRQoL).

METHODS

Patients were invited to complete the Chinese version of the M.D. Anderson Symptom Inventory with the Lung Cancer Module and the Quality of Life Questionnaire-core 30. Network analysis was employed to identify SCs. The associations between SCs and each function of HRQoL were examined using the Pearson correlation matrix. Multiple linear regression was applied to analyze the influencing factors of each function of HRQoL.

RESULTS

A total of 623 lung cancer patients who were receiving chemotherapy were recruited. The global health status of lung cancer patients was 59.71 ± 21.09, and 89.73% of patients developed symptoms. Three SCs (Somato-psychological SC, Respiratory SC, and Gastrointestinal SC) were identified, and Somato-psychological SC and Gastrointestinal SC were identified as influencing factors for HRQoL in lung cancer patients.

CONCLUSION

Most lung cancer patients who undergo chemotherapy experience a range of symptoms, which can be categorized into three SCs. The Somato-psychological SC and Gastrointestinal SC negatively impacted patients' HRQoL. Health care providers should prioritize monitoring these SCs to identify high-risk patients early and implement targeted preventive and intervention measures for each SC, aiming to alleviate symptom burden and enhance HRQoL.

Understanding veterans' experiences with lung cancer and psychological distress: A multimethod approach

Psychological distress while coping with cancer is a highly prevalent and yet underrecognized and burdensome adverse effect of cancer diagnosis and treatment. Left unaddressed, psychological distress can further exacerbate poor mental health, negatively influence health management behaviors, and lead to a worsening quality of life. This multimethod study primarily focused on understanding veterans' psychological distress and personal experiences living with lung cancer (an underrepresented patient population). In a sample of 60 veterans diagnosed with either nonsmall cell lung cancer (NSCLC) or small cell lung cancer (SCLC), we found that distress is common across clinical psychology measures of depression (37% [using the Patient Health Questionnaire, PHQ-9 measure]), anxiety (35% [using the Generalized Anxiety Disorder, GAD-7 measure]), and cancer-related posttraumatic stress (13% [using the Posttraumatic Stress Symptom Checklist measure]). A total of 23% of the sample endorsed distress scores on two or more mental health screeners. Using a broader cancer-specific distress measure (National Comprehensive Cancer Network), 67% of our sample scored above the clinical cutoff (i.e., ≥ 3), and in the follow-up symptom checklist of the National Comprehensive Cancer Network measure, a majority endorsed feeling sadness (75%), worry (73%), and depression (60%). Qualitative analysis with a subset of 25 veterans highlighted that psychological distress is common, variable in nature, and quite bothersome. Future research should (a) identify veterans at risk for distress while living with lung cancer and (b) test supportive mental health interventions to target psychological distress among this vulnerable veteran population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Descriptors and factors affecting patients' symptom experiences for symptom self-management throughout palliative radiotherapy for advanced lung cancer: A systematic review

Objective

Palliative thoracic radiotherapy is a key treatment option for symptom management in advanced lung cancer. Continuous symptom monitoring is critical to ensuring optimal therapeutic outcomes and preserving patients' well-being. This systematic review aimed to explore patients' symptom experiences during palliative thoracic radiotherapy for advanced lung cancer.

Methods

Following PRISMA guidelines, we conducted a comprehensive search of MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO from database inception through August 31, 2023. Eligible studies included those examining the prevalence and severity of symptoms and side effects experienced by adult patients undergoing palliative thoracic radiotherapy for advanced lung cancer, regardless of treatment duration or dosage. Methodological quality was assessed using the standardized QualSyst tool, and data were synthesized narratively.

Results

A total of 8 studies met the inclusion criteria. Thirteen symptoms were reported prior to radiotherapy, with cough being the most common (62%). Symptom severity ranged from mild to severe, with dyspnoea recording the highest average score. Distress was not measured during this phase. Post-radiotherapy, fatigue was the most prevalent symptom (69%), followed by cough (64%) and dyspnoea (50%). Symptom severity varied across studies, with improvements noted in cough, dyspnoea, chest pain, and haemoptysis. Moderating factors influencing symptom prevalence and variation included performance status, weight loss, cancer stage, objective tumour response, and radiation-induced pulmonary changes.

Conclusions

Symptom control through palliative thoracic radiotherapy demonstrates variability in both frequency and severity of symptoms. Systematic monitoring is essential for identifying persistent symptoms and determining the need for more targeted supportive care interventions.

The Usefulness of Virtual Reality in Symptom Management during Chemotherapy in Lung Cancer Patients: A Quasi-Experimental Study

Background: Virtual reality (VR) emerges as a promising non-pharmacological intervention for managing symptoms and providing distraction during chemotherapy. This study aims to assess VR's effectiveness on cancer-related symptoms, vital signs, and the patients' perception of chemotherapy in lung cancer patients. Methods: A quasi-experimental study was conducted on 100 patients. Participants were allocated into an intervention group (n = 55), which experienced immersive VR, and a comparison group (n = 45), which received usual care. Data were collected through questionnaires and checklists, including feedback on the VR experience, pain, vital signs, and common cancer symptoms, assessed through the Edmonton Symptom Assessment Scale. Results: VR had a significant impact on reducing the perception of chemotherapy length. Patients reported high levels of satisfaction and tolerability. No adverse events were observed. VR did not have significant influence on pain intensity or vital signs. The only exceptions were oxygen saturation, where a significant difference (p = 0.02) was reported, and the perception of chemotherapy duration. Conclusions: As a non-pharmacological intervention, VR proves to be beneficial in minimizing the perceived length of chemotherapy sessions for lung cancer patients, enhancing their overall treatment experience. The intervention was found to be a safe, feasible, and well-accepted distraction technique. Future research should explore VR's potential effects on a wider range of symptoms and evaluate its impact on long-term outcomes.

The Role of Trait Emotional Intelligence in Quality of Life, Anxiety, and Depressive Symptoms After Radiotherapy in Lung Cancer Patients with Brain Metastases

Objective

We aimed to investigate the association of trait emotional intelligence (TEI), anxiety, depression, and quality of life (QoL) in lung cancer individuals with brain metastases receiving radiotherapy.

Methods

A total of 289 individuals with brain metastases from lung cancer after radiotherapy participated. Data were collected from October 2018 to December 2022. Data were collected on variables such as patient demographics, medical characteristics, TEI, anxiety, depression, and QoL. Pearson correlation analysis and structural equation modeling were used to analyze the data.

Results

Correlation coefficients between TEI and anxiety, depression, and QoL scores were -0.451 (P = .007), -0.580 (P = .002), and 0.391 (P = .009). The correlation coefficient for depression and QoL was -0.433 (P = .008). Anxiety and depression mediate the positive correlation between trait EI and QoL.

Conclusion

Individuals with high idiosyncrasies of emotional intelligence are able to more effectively regulate negative emotions associated with cancer symptoms and treatment, and thus better perceive QoL. Trait EI training can reduce anxiety and depression symptoms and further improve the QoL of lung cancer individuals.

A latent class analysis of family resilience and its relationship with fear of recurrence in lung cancer patients: a cross-sectional study

PURPOSE

Family resilience helps cancer-affected families overcome challenges and may influence an individual's fear of cancer recurrence (FCR). Identifying distinct classes of family resilience among lung cancer patients is crucial for tailored interventions. This study aimed to identify latent classes of family resilience in lung cancer patients and explore their relationships with FCR.

METHODS

Three hundred ten lung cancer patients from three hospitals in Fujian were recruited from June to September 2021. Clinical data were extracted from medical records, while sociodemographic details, family resilience, and FCR were self-reported. A latent class analysis was performed to identify family resilience classes.

RESULTS

A 4-class solution showed the best fit. Compared to Class 1, the patients who had no comorbidities (ORs = 3.480-16.005) had an increased likelihood of belonging to Class 2 and 3, while those who were not family breadwinners (ORs = 0.118-0.176) had a decreased likelihood. Further, the patients who (1) did not lack interest/pleasure in doing things during the past 2-week period (OR = 7.057), (2) were never smokers (OR = 6.230), and (3) were urban residents (OR = 8.985) had an increased likelihood of belonging to Class 4, while those who were (1) male (OR = 0.167), (2) not the family breadwinner (OR = 0.152), and (3) had none or only one child (OR = 0.203) had a decreased likelihood of belonging to Class 4. The FCR level differed significantly among these four classes.

CONCLUSION

Our study identified four distinct classes of family resilience among Chinese lung cancer patients. FCR severity decreased with increasing levels of family resilience.

Impact of exercise interventions on quality of life and depression in lung cancer patients: A systematic review and meta-analysis

INTRODUCTION

Lung cancer is a leading cause of cancer-related mortality worldwide. Depression is also a common concern for lung cancer patients and is of concern because it negatively impacts overall well-being. This study summarizes the existing literature on the impact of exercise interventions on quality of life and depression in patients diagnosed with lung cancer.

METHODS

A systematic search of electronic databases was performed to identify relevant randomized controlled trials (RCTs) investigating the effects of exercise interventions on depression and quality of life in patients with lung cancer. Two evaluators collected information from the chosen studies utilizing a standardized data extraction form. The quality of the studies was evaluated using the Cochrane risk of bias tool.

RESULTS

Nine RCTs were included in the meta-analysis, with 798 participants. The pooled standardized mean difference (SMD) for the effect of exercise interventions on depression was -0.60, representing a statistically significant reduction in depression levels following exercise interventions (p < 0.001). The pooled SMD for the effect of exercise interventions on quality of life was 0.61, indicating a statistically significant association between quality of life and exercise interventions (p < 0.001).

CONCLUSION

There is evidence that exercise may benefit the mental health of individuals with lung cancer, including improvements in depression symptoms and quality of life, based on the intervention studies reviewed here. Given the heterogeneity in findings, however, additional randomized controlled trials are needed to augment the existing findings. Nevertheless, there appears to be sufficient evidence for now to encourage primary care physicians to recommend exercise for patients with lung cancer, while offering guidelines on how to gradually and safely increase physical activity depending on the patient's health status.

Confirmatory Factor Analysis and Measurement Invariance of the Functional Assessment of Cancer Therapy Lung Cancer Utility Index (FACT-LUI)

Background. A portion of the Functional Assessment of Cancer Therapy-Lung (FACT-L) instrument contributed to a previously published utility index, the FACT Lung Utility Index or FACT-LUI. Six FACT items representing lung cancer quality of life covered fatigue, pain, dyspnea, cough, anxiety, and depression. Two FACT items had been previously combined by the index authors into one for nausea and/or appetite loss, resulting in 7 final domains. Methods. The objective was to perform measurement invariance testing within a confirmatory factor analysis (CFA) framework to support the feasibility of using the FACT-LUI for non-preference-based psychometric applications. The original index patients comprised group 1, and similar FACT patient data (n = 249) from another published study comprised group 2. One 2-factor model and two 1-factor CFA models were evaluated to assess measurement invariance across groups, using varying degrees of item parceling and a small number of residual covariances, all justified by the literature. Results. The 1-factor models were most optimal. A 1-factor model with 1 pair of items parceled showed invariance to the partial scalar level using usual fit criteria across groups, requiring 2 unconstrained intercepts. A 1-factor model with 3 pairs of justified parcels showed full configural, metric, and scalar invariance across groups. Conclusions. The FACT-LUI items fit a partially to fully invariant 1-factor model, suggesting feasibility for non-preference-based applications. Implications. Results suggest useful incorporation of the FACT-LUI into clinical trials with no substantial increased respondent burden, allowing preference-based and other psychometric applications from the same index items.

Highlights

This work suggests that in addition to being originally designed for use as a utility index, the 7 FACT-LUI items together also fit simple CFA and measurement invariance models. This less expected result indicates that these items as a group are also potentially useful in non-preference-based applications.Clinical trials can make for challenging decisions concerning which patient-reported outcome measures to include without being burdensome. However, the literature suggests a need for improved reporting of quality of life in lung cancer in particular as well as cancer in general. Inclusion of more disease-specific items such as the FACT-LUI may allow for information gathering of both preference-based and non-preference-based data with less demand on patients, similar to what has been done with some generic instruments.

Profile and quality of life of the adult population in good health according to the level of vitality: European NHWS cross sectional analysis

BACKGROUND

The World Health Organization's definition of health highlights the importance of mental and physical wellbeing and not only disease state. However, lack of awareness on the burden of impaired vitality and its impact on the quality of life of the general healthy population prevents healthcare providers from delivering appropriate solutions and advice. This study aims to better characterize this population in Europe and identify the profile and the health reported outcomes associated with impaired vitality.

METHODS

This retrospective observational study included National Health and Wellness Survey (NHWS) data collected in healthy participants aged 18-65 years from five European Union countries in 2018. Socio-demographic and lifestyle characteristics, comorbidities, attitudes towards healthcare systems, Patient Activation Measure, health-related quality of life outcomes (EQ-5D), and work productivity and activity impairment were analysed according to SF-12 vitality score subgroups (≥ 60, 50- < 60, 40- < 50, < 40).

RESULTS

A total of 24,295 participants were enrolled in the main analysis. Being a female, younger, having a lower income and being obese or having sleep and mental disorders was associated with an increased risk of impaired vitality. This was associated with a higher consumption of healthcare resources along with having a weak patient-physician relationship. Participants who were disengaged in the self-management of their health were 2.6 times more likely to have a low level of vitality. For participants in the lowest vitality group, odds of mobility problems increased by 3.4, impairment of usual activity by 5.8, increased of pain and discomfort by 5.6 and depression and anxiety by 10.3, compared with participants in the highest vitality group. Also, odds of presenteeism increased by 3.7, overall work impairment by 3.4 and daily activity losses by 7.1.

CONCLUSION

Evidence-based trends facilitate the identification of a healthy population with impaired vitality in real-world practice. This study highlights the actual burden of low vitality on daily life activities, particularly on mental health and reduced work productivity. Additionally, our results underline the importance of self-engagement in the management of vitality impairment and highlights the need to implement strategies to address this public health concern in the affected population (HCP-patient communication, supplements, meditation).

Using health-related social media to understand the experiences of adults with lung cancer in the era of immuno-oncology and targeted therapies: an observational study (Preprint)

BACKGROUND

The treatment of non-small cell lung cancer (NSCLC) has evolved dramatically with the approval of immuno-oncology (IO) and targeted therapies (TTs). Insights on the patient experience with these therapies and their impacts are lacking. Health-related social media has been increasingly used by patients to share their disease and treatment experiences, thus representing a valuable source of real-world data to understand the patient's voice and uncover potential unmet needs.

OBJECTIVE

This study aimed to describe the experiences of patients with NSCLC as reported in discussions posted on lung cancer-specific social media with respect to their disease symptoms and associated impacts.

METHODS

Publicly available posts (2010-2019) were extracted from selected lung cancer- or NSCLC-specific websites. Social media users (patients and caregivers posting on these websites) were stratified by metastatic- and adjuvant-eligible subgroups and treatment received using natural language processing (NLP) and machine learning methods. Automated identification of symptoms was conducted using NLP. Qualitative data analysis (QDA) was conducted on random samples of posts mentioning pain-related, fatigue-related, respiratory-related, or infection-related symptoms to capture the patient experience with these and associated impacts.

RESULTS

Overall, 1724 users (50,390 posts) and 574 users (4531 posts) were included in the metastatic group and adjuvant group, respectively. Among users in the metastatic group, pain, discomfort, and fatigue were the most commonly mentioned symptoms (49.7% and 39.6%, respectively), and in the QDA (258 posts from 134 users), the most frequent impacts related to physical impairments, sleep, and eating habits. Among users in the adjuvant group, pain, discomfort, and respiratory symptoms were the most commonly mentioned (44.8% and 23.9%, respectively), and impacts identified in the QDA (154 posts from 92 users) were mostly related to physical functioning.

CONCLUSIONS

Findings from this exploratory observational analysis of social media among patients and caregivers informed the lived experience of NSCLC in the era of novel therapies, shedding light on most reported symptoms and their impacts. These findings can be used to inform future research on NSCLC treatment development and patient management.

Developing and testing the ExerciseGuide UK website for people with lung cancer: reflections on the added value of patient and public involvement within a doctoral degree

BACKGROUND

Lung cancer has one of the highest incidence and mortality rates worldwide. Physical activity can provide those diagnosed with lung cancer with several physical and psychological benefits. However, the examination of digitally delivered physical activity to those with lung cancer is not as researched as other common cancers. Often, those diagnosed with lung cancer are older adults (65 years or older). Older adults are often wrongly assumed to lack digital skills, interest, and not engage with digital technology regularly. Although individuals are interested, would involving older people in designing of websites and apps result in better engagement?

MAIN BODY

In this article, the authors discuss the process of adapting a digital platform with a patient and public involvement group to provide those who have received a lung cancer diagnosis with a tailored physical activity program and health educational modules. We discuss the influence of recurrent patient and public involvement on the study, the patient and public involvement members, and the doctoral researcher.

CONCLUSION

Working with a patient and public involvement group over several months, especially potential users of a digital intervention, may enhance its relevance, accessibility, and usability. By engaging with patients, family, or caregivers for someone with lung cancer, the doctoral student gained insight into the needs of the study population and what to consider during development. All group members expressed their interest and enjoyment in their involvement, and several are now active members of a wider patient and public involvement network.

Gender Differences in Quality of Life of Metastatic Lung Cancer Patients

Background

Gender aspects in lung cancer patients are a topic of growing interest. But little is known about gender aspects affecting the quality of life (QoL) for those with this life-threatening disease. The aim of the following study was to investigate how gender differences affect QoL in metastatic lung cancer patients.

Methods

In a prospective, multicenter study patients filled out the EORTC QLQ-C30 questionnaire and the recently updated lung cancer module QLQ-LC29 at an undefined point in time during first-line therapy. Gender differences were calculated for all QoL scores using ANCOVAs, which controlled for confounders.

Results

A total of 130 patients with metastatic lung cancer (UICC stage IV) (46 female and 84 male, mean age 66 years) were enrolled in this study by completing the questionnaires. The only significant gender difference in QoL was found regarding hair loss (mean women= 42.498, mean men=25.490, p-value= 0.010), although women received fewer chemotherapy treatments than men (women n=34, 74% and men n=68, 84%).

Conclusion

This study provides evidence that the typical cancer related gender difference effect on QoL, suggesting that men suffer less than women, cannot be found in metastatic tumor stages of lung cancer patients.

Effects of Acceptance and Commitment Therapy on fatigue interference and health-related quality of life among patients with advanced lung cancer: A pilot randomized controlled trial

Objective

The present study aimed to examine the feasibility and preliminary effects of Acceptance and Commitment Therapy (ACT) on fatigue interference and health-related quality of life in patients with advanced lung cancer.

Methods

In a single-blinded, parallel-group randomized controlled trial, 40 patients with advanced lung cancer were randomized to either the intervention group, which received the four-session individual ACT in 4 weeks, or the control group, which received usual care. The outcomes were evaluated at baseline and one week postintervention.

Results

Intervention feasibility and acceptability were established with a high attendance rate of 88.75% and a high retention rate of 75%. Approximately 95% of the participants reported satisfaction with the intervention. Despite the insignificant effects on fatigue interference, statistically significant interactions effects of ACT for health-related quality of life (P ​= ​0.001), cancer-related fatigue (P ​< ​0.001), depressive symptoms (P ​< ​0.001), anxiety (P ​< ​0.001), and distress (P ​= ​0.003) were noted.

Conclusions

This pilot trial supports the feasibility and acceptability of conducting ACT for patients with advanced lung cancer. The findings show the potential positive effects of ACT on health-related quality of life. Future studies with full-scale samples are recommended to evaluate the long-term effects of ACT on fatigue interference.

Prognostic value of Quality of life (QoL) assessment among Tunisian lung cancer patients

OBJECTIF

Etudier la valeur pronostique de l'évaluation de la qualité de vie (QDV) pour la survie chez les patients Tunisiens atteints du CDP. Méthodes: Une étude prospective de cohorte a été réalisée entre Janvier 2018 et Juin 2019. Le Performance status (PS), QoL questionnairecore30 (QLQ-C30), QoL questionnaire-Lung Cancer 13 (QLQ-LC13) et European QoL-5 dimensions-3level version questionnaire (EQ-5D-3L) ont été utilisés pour l'évaluation de la QDV. Les patients ont été divisés en 2 groupes selon le score global QLQ-C30, un Déficit Cliniquement Significatif (DCS) a été considéré si le score était ≤50. Les modèles de régression de Cox et Stepwise ont été réalisée pour évaluer la signification pronostique de la QDV. La survie globale (SG) a été calculée à l'aide de la méthode de Kaplan-Meier. Le test du log-rank a été utilisé pour comparer les courbes de survie. Le seuil de valeur de p pour la signification statistique était de 0,05. Résultats: Cent patients ont été inclus. La médiane de SG des patients avec DCS en qualité de vie était significativement inférieure à celle des patients sans déficit : respectivement 365 jours versus 467 jours, (test du log-rank, p = 0,036). De même pour la médiane de survie sans progression : 122 jours versus 326 jours pour ceux qui n'ont pas signalé de différence significative en QDV (test du log-rank, p = 0,05). L'analyse de régression multivariée stepwise a montré que le score global de QDV (QLQ-C30) était un facteur prédictif significatif de SG (coefficient estimate (CE)= 0.336, p=0.005), ainsi que le stade IV (CE=-0.193, p=0.033) et la progression tumorale (CE =-0.238, p=0.047).

CONCLUSION

La QDV était un facteur prédictif de survie dans notre cohorte de patients atteints de CDP. Cela devrait recommander une intervention active en soins palliatifs précoces pour les patients présentant un déficit significatif en QDV.

Lung Cancer and Self-Management Interventions: A Systematic Review of Randomised Controlled Trials

Background: Lung cancer is the most common cancer worldwide. Evidence suggests self-management (SM) interventions benefit cancer patients. This review aims to determine the effectiveness of SM interventions for lung cancer patients. Method: Searches occurred in PubMed, Cinahl, ProQuest, Psych Info, Scopus, and Medline, using predefined criteria, assessing randomised controlled trials (RCTs). Results: Five hundred and eighty-seven studies were yielded, 10 RCTs met criteria. Of the total patient pool, 1001 of 1089 had Non-Small Cell Lung Cancer (NSCLC). Six studies tested home-based SM exercise, two studies SM education, and one each for diary utilisation and symptom reporting. Fatigue was the most targeted function. Other functions targeted included exercise capacity, anxiety, depression, quality of life (QoL), sleep quality, and symptom burden. Six studies met their primary endpoints (five SM exercise, one SM education). Positive outcomes are described for fatigue, anxiety/depression, sleep quality, self-efficacy, and exercise capacity. With exception to fatigue, early-stage NSCLC, younger age, female, never smokers, partnered patients experienced increased treatment effect. Conclusions: SM interventions improve outcomes among some lung cancer patients. Interventions targeting fatigue yield benefit despite histology, stage or gender and could encourage broader cohort engagement. Consideration of patient characteristics may predict SM effect. Effectiveness of home-based SM exercise by NSCLC stage and SM tailored to sociodemographic variables requires further research.

Psychosocial Burden and Quality of Life of Lung Cancer Patients: Results of the EORTC QLQ-C30/QLQ-LC29 Questionnaire and Hornheide Screening Instrument

Background

Overall survival is the ultimate criterion for the therapy of lung cancer, but psychosocial care, which helps the patient to cope with the disease, becomes a more and more important issue in the treatment of this life-threatening disease.

Methods

We report the satellite project within a prospective, international, cross-cultural, multicenter study to validate the EORTC QLQ-LC29, a new designed module to assess the quality of life of lung cancer patients. The participants filled in the EORTC QLQ-C30, the recently updated lung cancer module QLQ-LC29 and the Hornheide questionnaire (HSI).

Results

A total of 81 patients (32 female and 49 male, mean age 65.2 years, SD = 9.7) were enrolled in this study by completing the questionnaires. Fatigue (mean 55.4, SD = 26.3) and dyspnea (mean 46.3, SD = 36.2) were the most prominent symptoms. Thirty-nine patients (48.1%) according to the HSI needed psychosocial support. When using the EORTC questionnaires as screening instrument with 50 as cut-off in contrast only 29.5% of our patients needed psychosocial support. The need for psychosocial support according to the HSI correlated most with the EORTC scales “fatigue” (38.3% overlap between the two questionnaires), “existential fear” (38.3% overlap between the two questionnaires) and worse “global quality of life” (27.2% overlap between the two questionnaires).

Conclusion

If psychosocial distress is at the core, the HSI is a suitable instrument for quick screening. The EORTC measures help to specify impaired quality of life areas and also cover somatic symptoms that are specific for cancer patients. Once psychosocial distress has been ascertained, clinicians should be particularly aware of specific problems regarding “fatigue”, “existential fear” and diminished “global quality of life”.

Trial Registration

clinicaltrials.gov, reference number NCT02745691. Registered 20 April 2016.

Feasibility, acceptability, and efficacy of online supportive care for individuals living with and beyond lung cancer: a systematic review

Purpose

To examine the evidence of the feasibility, acceptability, and potential efficacy of online supportive care interventions for people living with and beyond lung cancer (LWBLC).

Methods

Studies were identified through searches of Medline, EMBASE, PsychINFO, and CINAHL databases using a structured search strategy. The inclusion criteria (1) examined the feasibility, acceptability, and/or efficacy of an online intervention aiming to provide supportive care for people living with and beyond lung cancer; (2) delivered an intervention in a single arm or RCT study pre/post design; (3) if a mixed sample, presented independent lung cancer data.

Results

Eight studies were included; two randomised controlled trials (RCTs). Included studies reported on the following outcomes: feasibility and acceptability of an online, supportive care intervention, and/or changes in quality of life, emotional functioning, physical functioning, and/or symptom distress.

Conclusion

Preliminary evidence suggests that online supportive care among individuals LWBLC is feasible and acceptable, although there is little high-level evidence. Most were small pilot and feasibility studies, suggesting that online supportive care in this group is in its infancy. The integration of online supportive care into the cancer pathway may improve quality of life, physical and emotional functioning, and reduce symptom distress. Online modalities of supportive care can increase reach and accessibility of supportive care platforms, which could provide tailored support. People LWBLC display high symptom burden and unmet supportive care needs. More research is needed to address the dearth of literature in online supportive care for people LWBLC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06274-x.

LncRNA MIR155HG functions as a ceRNA for inhibition of lung adenocarcinoma growth and prediction of prognosis

Introduction

Long non-coding RNAs (lncRNAs) functioning as competing endogenous RNAs (ceRNAs) play critical roles in tumour progression. However, prognosis-related ceRNA networks in lung adenocarcinoma (LUAD) have not been well characterised.

Material and methods

LUAD datasets were downloaded from the TCGA database, and the patients were divided into metastasis and non-metastasis groups. The differential expression of lncRNAs (DELs), miRNAs (DEMs), and mRNAs (DEGs) was analysed using the Limma package. Next, interactions between miRNA, lncRNA, and mRNA were predicted by miRcode, miRTar-Base, miRDB, and TargetScan. The ceRNA network was constructed based on these interactions using Cytoscape software. DEG enrichment analysis was performed by GO and KEGG. After the prognosis analysis, we further screened molecules and constructed the prognosis-related ceRNA network. Moreover, the interactions between lncRNA, miRNA, and mRNA were validated by biological experiments.

Results

854 DELs, 150 DEMs, and 2211 DEGs between metastasis and non-metastasis LUAD patients were identified. Functional enrichment analysis suggested that DEGs were closely related to key biological processes involved in LUAD progression. The prognosis-related ceRNA network included 1 miRNA, 2 lncRNAs, and 4 mRNAs. In this network, MIR155HG and ADAMTS9-AS2 can function as ceRNAs of miR-212 to regulate EPM2AIP1, LAX1, PRICKLE2, and CD226. Moreover, our study confirmed that MIR155HG inhibited the proliferation, migration, and invasion of LUAD cells by sponging miR-212-3p to regulate CD226.

Conclusions

This ceRNA network contributes to understanding the pathogenesis of LUAD. Furthermore, the molecules in the network are valuable predictive factors for LUAD prognosis as well as potential therapeutic biomarkers.

Relationships of Symptom Groups and Functioning Domains in Patients with Advanced-Stage Non-Small Cell Lung Cancer Undergoing Treatment: A Cross-Sectional Study

The purpose of this study was to describe the symptoms experienced by patients with non-small cell lung cancer (NSCLC), examine whether different symptom groups significantly affected different functioning domains in these patients, and determine the effect of the "lack of energy" and "pain" symptom groups on the different functioning domains of health-related quality of life (HRQOL). From a single tertiary institution, this cross-sectional study enrolled 135 consecutive NSCLC patients who were mostly undergoing chemotherapy and were in the advanced stage (National University Hospital, Daegu, South Korea). Clinical and self-reported demographic information and data on different functioning domains (from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30)), symptom experience (from the EORTC QLQ-LC13), and the Symptom Distress Scale (SDS) were examined. The four most common symptoms were fatigue (69%), pain (47%), dyspnea (38%), and lack of appetite (36%). The "pain" symptom group was negatively associated with physical, emotional, cognitive, and role functioning. The "lack of energy" symptom group was negatively associated with physical, role, emotional, social, and cognitive functioning. The "lack of energy" symptom group explained the most variance for physical and role functioning, and the "pain" symptom group explained the most variance for emotional functioning. Impaired concentration explained the most variance for cognitive functioning.

Humanistic burden of living with anaplastic lymphoma kinase-positive non-small-cell lung cancer: findings from the ALKConnect patient insight network and research platform

Aim:

Evaluate real-world patient preferences, experiences and outcomes (health-related quality of life [HRQoL]) from patients with anaplastic lymphoma kinase-positive (ALK+) non-small-cell lung cancer (NSCLC) utilizing the ALKConnect Patient Insight Network.

Patients & methods:

Demographics, disease history/status/treatment, patient preferences and HRQoL (MD Anderson Symptom Inventory lung cancer module, reported as symptom severity and interference) were evaluated for US adults with ALK+ NSCLC.

Results:

Among 104 patients (median age: 53.0 years, 67.3% female, 40.0% employed), HRQoL and 3-month delay in disease progression were important treatment attributes. Burdensome symptoms included fatigue and disturbed sleep. Symptoms interfered most with work and day-to-day activity. Higher HRQoL was associated with ALK tyrosine kinase inhibitor (TKI) treatment and employment.

Conclusion:

ALKConnect demonstrated that disease progression, HRQoL, fatigue/sleep, ALK TKIs and employment matter in ALK+ NSCLC.

Understanding Symptom Burden in Patients With Advanced Cancer Living in Rural Areas

OBJECTIVES

To evaluate the feasibility of using a biobehavioral approach to examine symptom burden in rural residents with advanced cancer.

SAMPLE & SETTING

21 patients with advanced lung, colorectal, or pancreatic cancer were enrolled at the University of Iowa in Iowa City.

METHODS & VARIABLES

Using Cleeland's cytokine-immunologic model of symptom expression, symptom burden (i.e., severity, count, and interference) and inflammatory cytokines were measured for 24 weeks. Potential predictors included demographics, clinical characteristics, optimism, social support, and cancer-related stress. Descriptive statistics, Wilcoxon rank-sum, and Fisher's exact test were used for analysis.

RESULTS

Recruitment and retention rates were similar for rural and nonrural patients. Demographics, optimism, and social support were no different between groups. The cancer-related stress total score for rural patients was nearly half of the score of nonrural patients, with rural patients reporting significantly less avoidance. Symptom severity for the five worst symptoms remained moderate during the 24 weeks, whereas nonrural residents reported steady declines in severity of their five worst symptoms. Significant differences in inflammatory cytokines between groups were only found at one time point.

IMPLICATIONS FOR NURSING

Rural residents who seek care at a cancer center may be clinically and demographically more similar to their nonrural counterparts than to rural residents seeking local care.

Severe symptoms persist for Up to one year after diagnosis of stage I-III lung cancer: An analysis of province-wide patient reported outcomes

OBJECTIVES

Lung cancer is associated with significant disease- and treatment-related morbidity. The Edmonton Symptom Assessment System (ESAS) is a tool developed to elicit patients' own assessment of the severity of common cancer-associated symptoms. The objective of this study was to examine symptom severity in the 12 months following diagnosis of lung cancer, and to identify predictors of high symptom burden.

MATERIALS AND METHODS

This was a retrospective population-based cohort study, including patients with stage I-III lung cancer diagnosed between 2007-2016, and who had symptom screening in the 12 months following diagnosis. The proportion of patients reporting severe symptoms (ESAS ≥ 7) in the year following diagnosis was plotted over time. Multivariable regression models were constructed to identify factors associated with severe symptoms.

RESULTS

69,440 unique symptom assessments were reported by 11,075 lung cancer patients. Tiredness was the most prevalent severe symptom (47.3 %), followed by shortness of breath (39.4 %) and poor wellbeing (36.5 %) among all disease stages. Patients diagnosed with higher stage disease reported more severe symptoms, but symptom trajectories were similar for all stages in the year following diagnosis. Disease stage (RR 1.10-2.01), comorbidity burden (RR 1.17-1.51), degree of socioeconomic marginalization (RR1.15-1.45), and female sex (RR 1.15-1.50) were associated with reporting severe symptoms in the year following diagnosis.

CONCLUSION

Severe physical and psychological symptoms persist throughout the first year following lung cancer diagnosis, regardless of disease stage. Those at risk of experiencing high symptom burden may benefit from targeted supportive care interventions, including psychosocial support aimed at improving health-related quality of life.

Herbal medicine on cancer-related fatigue of lung cancer survivors: Protocol for a systematic review

BACKGROUND

Lung cancer is one of the most common cancers worldwide, and approximately half of the patients with lung cancer receiving chemotherapy suffer from cancer-related fatigue (CRF). Herbal medicines (HMs) have been used in Oriental countries for centuries as tonics. Various beneficial effects of HM on fatigue and cancer have been reported. However, the effectiveness and safety of HM for CRF in lung cancer patients have not been synthesized. The purpose of this systematic review is to evaluate the effectiveness and safety of HM for CRF in patients with lung cancer, regardless of their cancer type or stage.

METHODS AND ANALYSIS

A comprehensive search will be conducted in 12 electronic medical databases including 5 English-language databases (Medline via PubMed, EMBASE via Elsevier, the Cochrane Central Register of Controlled Trials [CENTRAL], the Allied and Complementary Medicine Database [AMED] via EBSCO, and the Cumulative Index to Nursing and Allied Health Literature [CINAHL] via EBSCO), 4 Korean-language databases (Oriental Medicine Advanced Searching Integrated System [OASIS], Koreanstudies Information Service System [KISS], Research Information Service System [RISS], and Korea Citation Index [KCI]), 2 Chinese-language databases (China National Knowledge Infrastructure [CNKI] and Wanfang Data), and 1 Japanese-language database (CiNii). Only randomized controlled trials (RCTs) and quasi-RCTs on HM for CRF will be allowed. The severity of fatigue assessed using a validated tool will be considered as theprimary outcome. The secondary outcomes will include the patients' quality of life, activities of daily life, incidence of adverse events, and total effective rate. Two independent researchers will perform the study selection, data extraction, and quality assessment. RevMan version 5.3 will be used for data synthesis. The methodological quality of the included RCTs will be assessed using the Cochrane Collaboration's risk of bias tool. In the meta-analysis, for dichotomous data and continuous data, risk ratio and mean difference, respectively, will be estimated with their 95% confidence intervals. According to the heterogeneity, either a fixed-effects or a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review will be disseminated through a peer-reviewed publication or conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019141660.

Impact on Health-Related Quality of Life of Video-Assisted Thoracoscopic Surgery for Lung Cancer

Background

Video-assisted thoracoscopic surgery (VATS) approaches are increasingly used in lung cancer surgery, but little is known about their impact on patients’ health-related quality of life (HRQL). This prospective study measured recovery and HRQL in the year after VATS for non-small cell lung cancer (NSCLC) and explored the feasibility of HRQL data collection in patients undergoing VATS or open lung resection.

Patients and Methods

Consecutive patients referred for surgical assessment (VATS or open surgery) for proven/suspected NSCLC completed HRQL and fatigue assessments before and 1, 3, 6 and 12 months post-surgery. Mean HRQL scores were calculated for patients who underwent VATS (segmental, wedge or lobectomy resection). Paired t-tests compared mean HRQL between baseline and expected worst (1 month), early (3 months) and longer-term (12 months) recovery time points.

Results

A total of 92 patients received VATS, and 18 open surgery. Questionnaire response rates were high (pre-surgery 96–100%; follow-up 67–85%). Pre-surgery, VATS patients reported mostly high (good) functional health scores [(European Organisation for Research and Treatment of Cancer) EORTC function scores > 80] and low (mild) symptom scores (EORTC symptom scores < 20). One-month post-surgery, patients reported clinically and statistically significant deterioration in overall health and physical, role and social function (19–36 points), and increased fatigue, pain, dyspnoea, appetite loss and constipation [EORTC 12–26; multidimensional fatigue inventory (MFI-20) 3–5]. HRQL had not fully recovered 12 months post-surgery, with reduced physical, role and social function (10–14) and persistent fatigue and dyspnoea (EORTC 12–22; MFI-20 2.7–3.2).

Conclusions

Lung resection has a considerable detrimental impact on patients’ HRQL that is not fully resolved 12 months post-surgery, despite a VATS approach.

Graphic Abstract

Electronic supplementary material

The online version of this article (10.1245/s10434-019-08090-4) contains supplementary material, which is available to authorized users.

Predicting postoperative fatigue in surgically treated lung cancer patients in Norway: a longitudinal 5-month follow-up study

OBJECTIVES

Despite the negative influence of fatigue on quality of life in patients who undergo lung cancer surgery, little is known about the possible predictors of postoperative fatigue. The aim of this study was to examine demographic and clinical characteristics that might predict postoperative fatigue 5 months after lung cancer surgery.

DESIGN

A prospective longitudinal follow-up study comprising preoperative and postoperative questionnaires, including Lee Fatigue Scale, and sociodemographic and clinical data.

SETTING

Three university hospitals in Norway (eg, Oslo University Hospital, St. Olav University Hospital and Haukeland University Hospital).

PARTICIPANTS

In total, 196 surgically treated patients who answered the questionnaires both preoperatively and at 5-month follow-up with valid fatigue scores.

RESULTS

Bivariate analyses showed that preoperative fatigue was associated with comorbidities and the symptoms of shortness of breath, cough, depression, anxiety, sleep disturbance and pain. Only cough was directly associated with preoperative fatigue in a regression model. Comorbidities and the symptoms of shortness of breath, cough, depression and sleep disturbance were associated with postoperative fatigue in the bivariate analyses, but only shortness of breath was associated with postoperative fatigue in the regression model. We did not find any significant correlations between fatigue and any treatment variable.

CONCLUSION

Clinicians should pay special attention to lung symptoms and be aware that these may lead to long-term postoperative fatigue. Further research should examine whether interventions reducing lung symptoms, such as shortness of breath and coughing, may prevent development of fatigue in patients undergoing lung cancer surgery.

Effect of the Chinese Medicine YangZheng XiaoJi on Reducing Fatigue in Mice with Orthotopic Transplantation of Colon Cancer

Background

Fatigue is a common, distressing, and persistent symptom for patients with malignant tumor including colorectal cancer (CRC). Although studies of cancer-related fatigue (CRF) have sprung out in recent years, the pathophysiological mechanisms that induce CRF remain unclear, and effective therapeutic interventions have yet to be established.

Methods

To investigate the effect of the traditional Chinese medicine YangZheng XiaoJi (YZXJ) on CRF, we constructed orthotopic colon cancer mice, randomly divided into YZXJ group and control (NS) group. Physical or mental fatigue was respectively assessed by swimming exhaustion time or suspension tail resting time. At the end of the experiment, serum was collected to measure the expression level of inflammatory factors by ELISA and feces to microbiota changes by 16s rDNA, and hepatic glycogen content was detected via the anthrone method.

Result

The nutritional status of the YZXJ group was better than that of the control group, and there was no statistical difference in tumor weight. The swimming exhaustion times of YZXJ group and control group were (162.80 ± 14.67) s and (117.60 ± 13.42, P < 0.05) s, respectively; the suspension tail resting time of YZXJ group was shorter than that of the control group (49.85 ± 4.56) s and (68.83 ± 7.26) s, P < 0.05)). Serum levels of IL-1β and IL-6 in YZXJ group were significantly lower than the control group (P < 0.05). Liver glycogen in YZXJ group was (5.18 ± 3.11) mg/g liver tissue, which was significantly higher than that in control group (2.95 ± 2.06) mg/g liver tissue (P < 0.05). At phylum level, increased abundance of Bacteroidetes, Verrucomicrobia, Actinobacteria, and Cyanobacteria and decreased Proteobacteria in YZXJ group emerged as the top differences between the two groups, and the Firmicutes/Bacteroidetes ratio was decreased in YZXJ group compared to the control group. At genus level, the abundance of Parabacteroides, unidentified Saprospiraceae, and Elizabethkingia which all belong to phylum Bacteroidetes were increased, while Arcobacter, Marinobacter, Alkanindiges, Sulfuricurvum, Haliangium, and Thiobacillus in phylum Proteobacteria were decreased after YZXJ intervention. YZXJ can also increase Pirellula, Microbacterium, and Alpinimonas and decrease Rubrobacter and Iamia.

Conclusion

YZXJ may reduce the physical and mental fatigue caused by colorectal cancer by inhibiting inflammatory reaction, promoting hepatic glycogen synthesis, and changing the composition of intestinal microbiota.

The Association between Epidermal Growth Factor Receptor (EGFR) Gene Polymorphisms and Lung Cancer Risk

Lung cancer is the leading cause of cancer death globally. The epidermal growth factor receptor (EGFR) plays an important role in cell proliferation and signaling. In this study, we examined the association between EGFR gene polymorphisms and lung cancer risk among the Jordanian population. A total of 129 patients with primary lung cancer and 129 matched healthy controls were recruited into this study. EGFR rs712829, rs712830, rs2072454, and rs11543848 single nucleotide polymorphisms (SNPs) were genotyped to test for their association with lung cancer risk. A significant association was observed between the rs712829 SNP and lung cancer risk (p < 0.05) where the GG + GT genotypes were higher in lung cancer patients when compared to controls. In addition, no association was detected between rs712830, rs2072454, and rs11543848 SNPs and lung cancer risk. When patients were stratified according to the lung cancer type, a significant association was detected between both rs712829 and rs2072454 and adenocarcinoma lung cancer (p < 0.05). Haplotype analysis of all four SNPs showed a significant association between the TCCG haplotype and both lung cancer and the adenocarcinoma subtype (p < 0.001). In conclusion, EGFR rs712829, rs2072454 SNPs, and TCCG haplotypes are associated with a risk of lung cancer among Jordanians. Since genetic associations are affected by the genetic background of populations, more studies in other Arab populations are required to confirm the present findings.