Severe fatigue and related factors in cancer patients before the initiation of treatment

The fatigue-inducing effects of cancer and its therapy are characterized by decreased physical activity in the absence of any motivational deficit

Although cancer and its therapy are well known to be associated with fatigue, the exact nature of cancer-related fatigue remains ill-defined. We previously reported that fatigue-like behavior induced independently by tumor growth and by the chemotherapeutic agent cisplatin is characterized by reduced voluntary wheel running and an intact motivation to expand effort for food rewards. The present set of experiments was initiated to characterize the functional consequences of fatigue induced by chemoradiotherapy in tumor-bearing mice and relate them to changes in the expression of genes coding for inflammation, mitochondria dynamics and metabolism. Two syngeneic murine models of cancer were selected for this purpose, a model of human papilloma virus-related head and neck cancer and a model of lung cancer. In both models, tumor-bearing mice were submitted to chemoradiotherapy to limit tumor progression. Two dimensions of fatigue were assessed, the physical dimension by changes in physical activity in mice trained to run in wheels and the motivational dimension by changes in the performance of mice trained to nose poke to obtain a food reward in a progressive ratio schedule of food reinforcement. Chemoradiotherapy reliably decreased wheel running activity but had no effect on performance in the progressive ratio in both murine models of cancer. These effects were the same for the two murine models of cancer and did not differ according to sex. Livers and brains were collected at the end of the experiments for qRT-PCR analysis of expression of genes coding for inflammation, mitochondria dynamics, and metabolism. The observed changes were mainly apparent in the liver and typical of activation of type I interferon and NF-κB-dependent signaling, with alterations in mitochondrial dynamics and a shift toward glycolysis. Although the importance of these alterations for the pathophysiology of cancer-related fatigue remains to be explored, the present findings indicate that fatigue brought on by cancer therapy in tumor-bearing mice is more physical than motivational.

Associations of Health-Related Quality of Life and Sleep Disturbance With Cardiovascular Disease Risk in Postmenopausal Breast Cancer Survivors

BACKGROUND

Breast cancer (BC) survivors are at an increased risk of long-term cardiovascular disease (CVD), often attributed to cancer treatment. However, cancer treatment may also negatively impact health-related quality of life (HRQoL), a risk factor of CVD in the general population.

OBJECTIVE

We examined whether sleep disturbance, and physical or mental HRQoL were associated with CVD risk in BC survivors.

METHODS

We conducted a longitudinal analysis in the Women's Health Initiative of postmenopausal women given a diagnosis of invasive BC during follow-up through 2010 with no history of CVD before BC. The primary outcome was incident CVD, defined as physician-adjudicated coronary heart disease or stroke, after BC. Physical and mental HRQoL, measured by the Short-Form 36 Physical and Mental Component Summary scores, and sleep disturbance, measured by the Women's Health Initiative Insomnia Rating Scale, were recorded post BC. Time-dependent Cox proportional hazards models were used starting at BC diagnosis until 2010 or censoring and adjusted for relevant confounders.

RESULTS

In 2884 BC survivors, 157 developed CVD during a median follow-up of 9.5 years. After adjustment, higher Physical Component Summary scores were significantly associated with a lower risk of CVD (hazard ratio, 0.90 [95% confidence interval, 0.81-0.99]; per 5-point increment in Physical Component Summary). No associations with CVD were found for Mental Component Summary or Insomnia Rating Scale.

CONCLUSION

In BC survivors, poor physical HRQoL is a significant predictor of CVD.

IMPLICATIONS FOR PRACTICE

Our findings highlight the importance for nurses to assess and promote physical HRQoL as part of a holistic approach to mitigating the risk of CVD in BC survivors.

Determinants of Cancer-Related Fatigue among Cancer Patients: A Systematic Review

Objectives: This systematic review aims to assess and explore various determinants of cancer- related fatigue. Methods: A systematic search of various determinants of Cancer-related fatigue (CRF) was performed in different databases like PubMed, Google Scholar, Science Direct and Clinical Key dating from 1990 to September 2020. Results: A total of 6115 studies were screened and 95 articles related to determinants of fatigue were retained. Various modifiable and non-modifiable determinants including socio-demographic, clinical, treatment related, plasma biomarker related, genetic, behavioural, concurrent symptoms related and psychological determinants were identified. Depression was one of the significant factors reported in 28% of studies, followed by pain, (17%), performance status (16%), chemotherapy and anxiety (15%). Conclusion: It is recommended that nurses and clinicians should anticipate, identify and take appropriate interventions to manage those modifiable factors. Ultimately, managing the modifiable factors helps in the comprehensive care of cancer patients.

Effectiveness of Therapeutic Exercise Models on Cancer-Related Fatigue in Patients With Cancer Undergoing Chemotherapy: A Systematic Review and Network Meta-analysis

OBJECTIVE

To assess and compare the effectiveness of different exercise modalities in reducing cancer-related fatigue (CRF) in patients with cancer undergoing chemotherapy. Exercise intensities for selected exercise types were also compared.

DATA SOURCES

We conducted a search in MEDLINE, Embase, CINAHL, Scopus, SPORTDiscus, and Web of Science from inception to October 15, 2021.

STUDY SELECTION

Randomized controlled trials concerning the effectiveness of exercise modalities on CRF in patients with cancer undergoing chemotherapy were included.

DATA EXTRACTION

Study characteristics were extracted using a structured protocol. Methodological quality was assessed employing the PEDro scale and risk of bias was assessed using the Revised Cochrane Risk of Bias Tool for Randomized Trials. The certainty of evidence was assessed based on Grading of Recommendations, Assessment, Development and Evaluation. The measure of effect used was the adjusted standardized mean difference (SMD) or Hedge's g, together with the corresponding 95% confidence intervals (CI).

DATA SYNTHESIS

Forty-seven studies were included. Data were pooled employing a random-effects model. There was a trend that adding low-intensity aerobic and resistance exercise (SMD=1.28, 95% CI -0.18; 2.75, P=.086), or moderate-intensity aerobic and resistance exercise (SMD=0.85; 95% CI -0.12; 1.82, P=.087), was more effective than adding flexibility training to usual care (UC). There was also a trend that UC alone was less effective than adding moderate-intensity aerobic and resistance exercise (SMD=-0.47, 95% CI -0.96, 0.02, P=.060) to UC.

CONCLUSIONS

The addition of low- to moderate-intensity aerobic and/or resistance exercise demonstrated a positive trend for improvement in CRF in patients with cancer undergoing chemotherapy, when compared with UC alone or UC with flexibility training.

Physical Activity as a Treatment for Cancer-Related Fatigue in Children, Adolescents and Young Adults: A Systematic Review

Background: Cancer-related fatigue (CRF) is one of the most common and distressing symptoms in paediatric oncology. Based on previous studies, physical activity interventions are considered to be effective in reducing CRF in adult cancer patients. Aim: The aim of this systematic review is to investigate whether physical activity interventions can reduce CRF in paediatric patients undergoing cancer treatment. Methodology: A systematic literature search was conducted in PubMed and Sport-Discus in October 2021 to identify intervention studies examining the effects of physical activity on CRF in cancer patients ≤ 21 years of age. Their methodological quality was assessed using the JBI Critical Appraisal Tool. Results: A total of 20 studies (seven randomized-controlled, six quasi-experimental and seven single-arm intervention trials) were included in the review. Nine studies reported significant positive effects of physical activity interventions on CRF in group comparison or within groups. Eleven trials reported no significant changes in CRF. Conclusion: Physical activity as a therapeutic intervention in paediatric oncology may have the potential to reduce CRF in childhood cancer patients undergoing cancer treatment. Further high-quality studies with large samples are needed to verify these results and to assess the interdependence of dose and response of physical activity interventions.

The GDF15-GFRAL axis mediates chemotherapy-induced fatigue in mice

Cancer-related fatigue is defined as a distressing persistent subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and that interferes with usual functioning. This form of fatigue is highly prevalent during cancer treatment and in some patients, it can persist for years after treatment has ended. An understanding of the mechanisms that drive cancer-related fatigue is still lacking, which hampers the identification of effective treatment options. Various chemotherapeutic agents including cisplatin are known to induce mitochondrial dysfunction and this effect is known to mediate chemotherapy-induced peripheral neuropathy and cognitive dysfunction. Mitochondrial dysfunction results in the release of mitokines that act locally and at distance to promote metabolic and behavioral adjustments to this form of cellular stress. One of these mitokines, growth differentiation factor 15 (GDF15) and its receptor, glial cell line-derived neurotrophic factor family receptor α-like (GFRAL), have received special attention in oncology as activation of GFRAL mediates the anorexic response that is responsible for cancer anorexia. The present study was initiated to determine whether GDF15 and GFRAL are involved in cisplatin-induced fatigue. We first tested the ability of cisplatin to increase circulating GDF15 in mice before assessing whether GDF15 can induce behavioral fatigue measured by decreased wheel running in healthy mice and increase behavioral fatigue induced by cisplatin. Mice administered a long acting form of GDF15, mGDF15-fc, decreased their voluntary wheel running activity. When the same treatment was administered to mice receiving cisplatin, it increased the amplitude and duration of cisplatin-induced decrease in wheel running. To determine whether endogenous GDF15 mediates the behavioral fatigue induced by cisplatin, we then administered a neutralizing monoclonal antibody to GFRAL to mice injected with cisplatin. The GFRAL neutralizing antibody mostly prevented cisplatin-induced decrease in wheel running and accelerated recovery. Taken together these findings demonstrate for the first time the role of the GDF15/GFRAL axis in cisplatin-induced behaviors and indicate that this axis could be a promising therapeutic target for the treatment of cancer-related fatigue.

Effects of a Plant-Based High-Protein Diet on Fatigue in Breast Cancer Patients Undergoing Adjuvant Chemotherapy - a Randomized Controlled Trial

BACKGROUND

Breast cancer patients undergoing chemotherapy (CT) experience fatigue and other side-effects. Studies exploring interventions with a plant-based, high-protein diet on fatigue and body composition are lacking. The effects of these interventions on fatigue, body mass index (BMI), and body composition were evaluated.

METHOD

Newly diagnosed breast cancer patients who were scheduled for adjuvant CT (n = 103) were randomly assigned to the intervention or control group. Study outcomes included fatigue using fatigue symptom inventory and body composition using bioelectric impedance analyzer done at the start of CT, 3rd CT, and 3 weeks after CT. Linear mixed models were used to compare groups over time.

RESULTS

Fatigue decreased from 57% to 28% in the intervention group and increased from 65% to 78% in the control group (p < 0.001). BMI decreased by 0.7 ± 0.8 kg/m2 in the intervention group, while the decrease was 0.4 ± 1.3 kg/m2 in the control group (p = 0.015). Fat mass decreased in the intervention group (p < 0.001) and muscle mass improved in the intervention group and decreased in the control group (p < 0.05).

CONCLUSIONS

A plant-based, high-protein diet during CT resulted in positive changes in fatigue, BMI and body composition.

Time course and predictors of persistent cancer-related fatigue in long-term breast cancer survivors: a prospective observational study

PURPOSE

The present study investigated whether the level of cancer-related fatigue (CRF) after finishing oncology treatment was related to higher levels of persistent CRF and its relationship with both functional and psychological disturbances. Second, to identify potential predictors of persistent CRF.

METHODS

Eighty BC survivors were classified into non-fatigued (≤ 3.9) or fatigued (≥ 4), according to their Piper Fatigue Scale total score after finishing oncology treatment. The time course of fatigue and the impact on its domains, pain, mood state, perceived physical fitness, the level of physical activity, and quality of life were assessed at ≥ 5 years.

RESULTS

Women classified as fatigued after finishing oncology treatment had not only a higher prevalence of persistent CRF (41.2%) at the reassessment, but also greater levels of pain (P = .006 to .048) and mood disturbances (P = .007 to .015), and lower levels of physical fitness condition (P = .002 to .039) and quality of life (P < .001 to < .05) over time. Regression analyses revealed that "sadness/depression," "global health status," "physical activity level," and "type of treatment" were significant predictors of persistent CRF (r² = .692).

CONCLUSION

Higher levels of CRF implied greater levels of persistent CRF and a lower functional and psychological profile over time. 69.2% of of persistent CRF was explained.

The prognostic role of fatigue, depression and anxiety on postoperative outcomes after pancreatectomy for pancreatic cancer. A prospective observational study (FAT-PRO study)

OBJECTIVES

This study aims to assess the prevalence of preoperative fatigue, depression and anxiety among patients undergoing pancreatic surgery for pancreatic cancer (PC), and possible relationship with postoperative outcomes.

METHODS

Prospective data from 162 consecutive patients undergoing pancreatectomy for PC at a third-level referral centers for pancreatic surgery were collected. All patients preoperatively completed four questionnaires assessing depression (PHQ-9), anxiety (STAI-Y2), chronic illness fatigue (FACIT-F) and cancer therapy fatigue (FACT-G).

RESULTS

Forty patients (25%) where in the first quartile for chronic illness (FACIT-F ≤34) and/or cancer therapy (FACT-G ≤78) fatigue, 26 patients (16%) met the criteria for major depression (PHQ-9 ≥10) and 34 patients (21%) had anxiety symptoms (STAI-Y2 ≥40). Cancer therapy fatigue was significantly associated with higher rates of morbidity (70% vs 49%), major morbidity (Clavien-Dindo ≥3) (28% vs 11%), post-pancreatectomy hemorrhage (18% vs 4%), pulmonary complications (20% vs 9%) and mortality (8% vs null) (all P ≤ 0.01). Major depression was associated with higher rates of post-pancreatectomy hemorrhage and readmission (23% vs 5%). Multivariable logistic regression analysis of preoperative factors confirmed diabetes (OR 2.71, 95%CI 1.01-7.20; P = 0.04), ASA score ≥3 (OR 4.12, 95%CI 1.52-11.21; P < 0.01) and cancer therapy fatigue (OR 2.95, 95%CI 1.01-8.74; P = 0.04) to be independent predictors of major morbidity.

CONCLUSIONS

Higher levels of fatigue (in particular cancer therapy fatigue) strongly correlates with worse postoperative outcomes.

High weekly integral dose and larger fraction size increase risk of fatigue and worsening of functional outcomes following radiotherapy for localized prostate cancer

Introduction

We hypothesized that increasing the pelvic integral dose (ID) and a higher dose per fraction correlate with worsening fatigue and functional outcomes in localized prostate cancer (PCa) patients treated with external beam radiotherapy (EBRT).

Methods

The study design was a retrospective analysis of two prospective observational cohorts, REQUITE (development, n=543) and DUE-01 (validation, n=228). Data were available for comorbidities, medication, androgen deprivation therapy, previous surgeries, smoking, age, and body mass index. The ID was calculated as the product of the mean body dose and body volume. The weekly ID accounted for differences in fractionation. The worsening (end of radiotherapy versus baseline) of European Organisation for Research and Treatment of Cancer EORTC) Quality of Life Questionnaire (QLQ)-C30 scores in physical/role/social functioning and fatigue symptom scales were evaluated, and two outcome measures were defined as worsening in ≥2 (WS2) or ≥3 (WS3) scales, respectively. The weekly ID and clinical risk factors were tested in multivariable logistic regression analysis.

Results

In REQUITE, WS2 was seen in 28% and WS3 in 16% of patients. The median weekly ID was 13.1 L·Gy/week [interquartile (IQ) range 10.2-19.3]. The weekly ID, diabetes, the use of intensity-modulated radiotherapy, and the dose per fraction were significantly associated with WS2 [AUC (area under the receiver operating characteristics curve) =0.59; 95% CI 0.55-0.63] and WS3 (AUC=0.60; 95% CI 0.55-0.64). The prevalence of WS2 (15.3%) and WS3 (6.1%) was lower in DUE-01, but the median weekly ID was higher (15.8 L·Gy/week; IQ range 13.2-19.3). The model for WS2 was validated with reduced discrimination (AUC=0.52 95% CI 0.47-0.61), The AUC for WS3 was 0.58.

Conclusion

Increasing the weekly ID and the dose per fraction lead to the worsening of fatigue and functional outcomes in patients with localized PCa treated with EBRT.

Mammary tumors alter the fecal bacteriome and permit enteric bacterial translocation

Background

Cancer patients experience gastrointestinal and behavioral symptoms, and are at increased risk of systemic infection and inflammation. These conditions are a major source of morbidity and decreased quality of life prior to cancer treatment, but poorly defined etiologies impede successful treatment. The gastrointestinal microbiota shape inflammation, influence cancer progression and treatment, and colonize tumors. However, research has not directly determined if peripheral tumors influence the microbiome and intestinal physiology, thus influencing gastrointestinal and behavioral symptoms. Therefore, the purpose of this study was to examine consequences of orthotopic, syngeneic mammary tumor implantation, growth, and resection on fecal bacteriome composition and intestinal barrier function in relation to systemic inflammation and enteric bacterial translocation in mice.

Methods

Female mice were randomized to 3 experimental groups: sham surgical control, tumor recipients, and tumor recipients later receiving tumor-resection. Mice were sacrificed three weeks after tumor implantation or resection for collection of stool, colon, spleen, and brain tissue and analysis.

Results

Tumor-bearing mice exhibited several markers of colonic barrier disruption, including dampened expression of tight junction proteins (Cldn1 and Ocln) and elevated circulating lipopolysaccharide binding protein (LBP). Compromised colonic barrier integrity was associated with altered fecal bacterial profiles in tumor-mice, including lower relative abundance of Lactobacillus, but higher Bacteroides. Consistent with colonic barrier disruption and altered microbiomes, tumor-mice displayed markers of systemic inflammation including splenomegaly, higher splenic bacterial load, and elevated splenic and brain pro-inflammatory cytokines. Several  bacteria cultured from spleens had 16S rRNA gene amplicons matching those in fecal samples, suggesting they were of intestinal origin. Fecal Lactobacillus was highly-interrelated to physiological parameters disrupted by tumors via correlation network analysis. Tumor resection ameliorated circulating LBP, splenomegaly, and splenic cytokines, but not other parameters associated with loss of colonic barrier integrity and bacterial translocation.

Conclusions

Orthotopic mammary tumors alter the microbiome, reduce intestinal barrier function, increase translocation of enteric bacteria, and alter systemic inflammation. This provides insight into how tumors commence gastrointestinal and behavioral symptoms prior to treatment, and identify targets for future therapeutics, such as probiotic Lactobacillus supplementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09274-0.

Adrenal Gland Irradiation Causes Fatigue Accompanied by Reactive Changes in Cortisol Levels

BACKGROUND

Incidental radiotherapy (RT) to the adrenal gland may have systemic effects. This study aimed to investigate the effects of adrenal RT on fatigue.

METHODS

BALB/c mice were surgically explored to identify the left adrenal gland and delivered intra-operative RT. The swimming endurance test was used for endurance assessment to represent fatigue. Plasma levels of stress hormones and histopathological features were examined. Three patients with inevitable RT to the adrenal gland were enrolled for the preliminary study. Serum levels of cortisol, aldosterone, and adrenocorticotropic hormone (ACTH) were measured before and after RT. Fatigue score by using the fatigue severity scale and RT dosimetric parameters were collected.

RESULTS

In the experimental mouse model, adrenal RT decreased baseline cortisol from 274.6 ± 37.8 to 193.6 ± 29.4 ng/mL (p = 0.007) and swimming endurance time from 3.7 ± 0.3 to 1.7 ± 0.6 min (p = 0.02). In histopathological assessment, the irradiated adrenal glands showed RT injury features in the adrenal cortex. In the enrolled patients, baseline cortisol significantly declined after RT. There were no significant differences in the levels of morning cortisol, aldosterone, and ACTH before and after RT.

CONCLUSIONS

The RT dose distributed to the adrenal gland may correlate with unwanted adverse effects, including fatigue and adrenal hormone alterations.

Physiological and psychosocial correlates of cancer-related fatigue

PURPOSE

Cancer-related fatigue (CRF) is a common and distressing symptom of cancer that may persist for years following treatment completion. However, little is known about the pathophysiology of CRF. Using a comprehensive group of gold-standard physiological and psychosocial assessments, this study aimed to identify correlates of CRF in a heterogenous group of cancer survivors.

METHODS

Using a cross-sectional design to determine the physiological and psychosocial correlates of CRF, ninety-three cancer survivors (51 fatigued, 42 non-fatigued) completed assessments of performance fatigability (i.e. the decline in muscle strength during cycling), cardiopulmonary exercise testing, venous blood samples for whole blood cell count and inflammatory markers and body composition. Participants also completed questionnaires measuring demographic, treatment-related, and psychosocial variables.

RESULTS

Performance fatigability, time-to-task-failure, peak oxygen uptake (V̇O_2peak), tumor necrosis factor-α (TNF-α), body fat percentage, and lean mass index were associated with CRF severity. Performance fatigability, V̇O_2peak, TNF-α, and age explained 35% of the variance in CRF severity. Those with clinically-relevant CRF reported more pain, more depressive symptoms, less perceived social support, and were less physically active than non-fatigued cancer survivors.

CONCLUSIONS

The present study utilised a comprehensive group of gold-standard physiological and psychosocial assessments and the results give potential insight into the mechanisms underpinning the association between physical inactivity, physical deconditioning and CRF.

IMPLICATIONS FOR CANCER SURVIVORS

Given the associations between CRF and both physiological and psychosocial measures, this study identifies targets that can be measured by rehabilitation professionals and used to guide tailored interventions to reduce fatigue.

Trajectories of fatigue in cancer patients during psychological care

OBJECTIVE

Psycho-oncological institutions offer specialized care for cancer patients. Little is known how this care might impact fatigue. This study aimed to identify fatigue trajectories during psychological care, examined factors distinguishing these trajectories and predicted fatigue severity after nine months of psychological care.

DESIGN

Naturalistic, longitudinal study of 238 cancer patients receiving psycho-oncological care in the Netherlands. Data were collected before initiation of psychological care (T1) and three (T2) and nine months (T3) afterwards. Latent class growth analysis, repeated measure analyses (RMA) and linear regression analysis were performed.

MAIN OUTCOME MEASURES

Fatigue severity: Checklist Individual Strength.

RESULTS

Three fatigue trajectories were identified: high- (30%), moderate- (62%) and low-level fatigue (8%). While statistically significant decreases in fatigue were found, this decrease was not clinically relevant. RMA showed main effects for time for fatigue trajectories on depression, anxiety, personal control and illness cognitions. Fatigue severity and physical symptoms at T1, but not demographic or clinical factors, were predictive of fatigue severity at T3.

CONCLUSIONS

Fatigue is very common during psycho-oncological care, and notably not clinically improving. As symptoms of fatigue, depression, anxiety and physical symptoms often cluster, supplementary fatigue treatment should be considered when it is decided to treat other symptoms first.

Trajectories of Cognitive Function Prior to Cancer Diagnosis: A Population-Based Study

BACKGROUND

An emerging body of research suggests that noncentral nervous system cancer may negatively impact the brain apart from effects of cancer treatment. However, studies assessing cognitive function in newly diagnosed cancer patients cannot exclude selection bias and psychological effects of cancer diagnosis. To overcome these limitations, we investigated trajectories of cognitive function of patients before cancer diagnosis.

METHODS

Between 1989 and 2013, a total of 2059 participants from the population-based Rotterdam Study were diagnosed with noncentral nervous system cancer. Cognitive assessments were performed every 3 to 5 years using a neuropsychological battery. The general cognitive factor was composed of individual cognitive tests to assess global cognition. Using linear mixed models, we compared change in cognitive function of cancer case patients before diagnosis with cognitive change of age-matched cancer-free control subjects (1:2). In addition, we performed sensitivity analyses by discarding assessments of control subjects 5 years before the end of follow-up to exclude effects from potential undiagnosed cancer. All statistical tests were two-sided.

RESULTS

The Word Learning Test immediate recall declined faster among case patients than among control subjects (-0.05, 95% confidence interval = -0.09 to -0.01 vs 0.01, 95% confidence interval = -0.01 to 0.03; P for difference = .003). However, this difference was not statistically significant in sensitivity analyses. Furthermore, no statistically significant differences were observed in change of other individual cognitive tests and of the general cognitive factor.

CONCLUSIONS

In this study, we evaluated cognitive function in a large group of cancer patients prior to diagnosis, thereby excluding the psychological impact of cancer diagnosis and biased patient selection. In contrast to previous studies shortly after cancer diagnosis, we found no difference in change of cognitive function between cancer patients and control subjects.

Prevalence of Fatigue in Patients With Cancer: A Systematic Review and Meta-Analysis

CONTEXT

Fatigue is a particularly common and troubling symptom that has a negative impact on quality of life throughout all phases of treatment and stages of the illness among patients with cancer.

OBJECTIVES

The objective of this meta-analysis is to examine the present status of fatigue prevalence in patients with cancer.

METHODS

The following databases were searched: PubMed, MEDLINE, EMBASE, PsycINFO, Cochrane Library, from inception up to February 2020. Prevalence rates were pooled with meta-analysis using a random-effects model. Heterogeneity was tested using I-squared (I²) statistics.

RESULTS

A total of 129 studies (N = 71,568) published between 1993 and 2020 met the inclusion criteria. The overall prevalence of fatigue was 49% (34,947 of 71,656 participants, 95% CI = 45-53) with significant heterogeneity between studies (P < 0.000; τ² = 0.0000; I² = 98.88%). Subgroup analyses show that the prevalence of fatigue related to type of cancer ranged from 26.2% in patients with gynecological cancer to 56.3% in studies that included mixed types of cancer. In advanced cancer stage patients, the highest prevalence of fatigue (60.6%) was reported. Fatigue prevalence rates were 62% during treatment and 51% during mixed treatment status. The prevalence of fatigue decreased from 64% in studies published from 1996 to 2000 to 43% in studies published from 2016 to 2020. Metaregression identified female gender as a significant moderator for higher prevalence of fatigue, whereas mean age is not associated with fatigue.

CONCLUSION

This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce fatigue and improve the quality of life of patients with cancer.

Attitudes About Coping With Fatigue in Patients With Gastric Cancer: A Q-Methodology Study

Cancer-related fatigue is the most common symptom in patients with cancer. Coping methods for cancer-related fatigue differ from those of patients without cancer, as the situations faced by patients with cancer are unique. This study aimed to identify subjectivity concerning coping with fatigue in Korean patients with gastric cancer. Q-methodology was used to examine subjective perceptions regarding coping with fatigue among Korean patients with gastric cancer. A convenience sample of 33 participants, who had been hospitalized in 2 university hospitals in South Korea, was recruited to participate in the study and 37 selected Q-samples were classified into a normal forced distribution using a 9-point bipolar grid. The obtained data were analyzed by using PC-QUANL for Windows. Three factors representing distinct attitudes about coping with fatigue emerged among Korean patients with gastric cancer: an optimistic mind, dependency on medicine, and exercise preference. The 3 factors explained 39.4% of the total variance (23.7%, 7.9%, and 7.8%, respectively). Based on the study findings, it is important to develop customized nursing interventions that consider the characteristics of each patient group with gastric cancer. Health professionals should assess the attitudes of patients with gastric cancer about coping with fatigue, explore their situation, and consider their lifestyle.

Toll-like receptor 4 mediates the development of fatigue in the murine Lewis Lung Carcinoma model independently of activation of macrophages and microglia

Cancer-related fatigue at the time of tumor diagnosis is commonly attributed to inflammation associated with the disease process. However, we have previously demonstrated that running wheel deficits occur well before increased expression of proinflammatory cytokines in the liver and brain in a murine model of human papilloma virus-related head and neck cancer (mEER). Further, we have demonstrated that genetic deletion of type I interleukin-1 receptor and MyD88 has no effect. In the current investigation we sought to test the generality of this finding by assessing whether there is a role for toll-like receptor (TLR) 4-dependent inflammation in the fatigue-like behavior observed in mice with Lewis Lung Carcinoma (LLC) or mEER tumors. Genetic deletion of TLR4 attenuated tumor-induced elevations in liver pro-inflammatory cytokine expression in both models. However, it only abrogated wheel running deficits in LLC tumor bearing mice. To determine whether TLR4 signaling in the LLC model involves innate immune cells, mice were treated with the colony stimulating factor (CSF)-1 receptor antagonist PLX-5622 before and throughout tumor development to deplete microglia and peripheral macrophages. Administration of PLX-5622 had no protective effect on wheel running deficits in either mEER or LLC tumor models despite effective depletion of microglia and a down regulation of peripheral proinflammatory cytokine expression. These results indicate that the TLR4 signaling that mediates fatigue-like behavior in LLC mice is not dependent upon microglial or peripheral macrophage activation. Based on the literature and our data demonstrating attenuation of ubiquitin proteasome pathway activation in the gastrocnemius muscle of Tlr4^-/- mice implanted with LLC cells, we interpret our current findings as indication that skeletal muscle TLR4 signaling may be involved. These results are important in that they add to the evidence that tumor-induced fatigue develops independently from classical neuroinflammation.

High Health-Related Quality of Life During Dendritic Cell Vaccination Therapy in Patients With Castration-Resistant Prostate Cancer

Background

Maintaining health-related quality of life (HRQoL) is highly desirable during systemic therapies for patients with castration-resistant prostate cancer (CRPC). Patient-reported outcome measures (PROs) were studied in our phase IIa trial on cellular-based immunotherapy with dendritic cells (DC).

Methods

We treated 21 chemo-naive asymptomatic or minimally symptomatic patients with CRPC with maximally three cycles of DC vaccinations (ClinicalTrials.gov, NCT02692976). Here, we report the impact of DC vaccination on HRQoL. PROs were assessed using the EORTC-QLQ-C30, the EORTC-QLQ-PR25, Checklist Individual Strength (CIS20-R), and Beck Depression Inventory Primary Care questionnaires. Short-term and long-term vaccine-related effects on HRQoL were studied.

Results

Questionnaires were collected at baseline (n=20), week 6 (n=19), week 12 (n=18), week 24 (n=13), week 50 (n=8) and week 100 (n=2). No clinically relevant differences in symptom-related outcome, functioning-related outcome, and Global Health Status were observed directly after the first cycle of DC vaccinations (week 6) and at follow-up (week 12) compared to baseline. HRQoL remained high throughout the vaccination cycle and six weeks afterward. In radiographic non-progressive patients, who continued DC vaccination, high HRQoL scores were observed up to one and two years after study enrolment.

Conclusions

Patients with asymptomatic or minimally symptomatic CRPC show high HRQoL throughout DC-based immunotherapy. This is a clinically relevant finding in this older-aged patient population with advanced prostate cancer.

Factors associated with fatigue one month after surgery in patients with gastrointestinal cancer

OBJECTIVE

The purpose of this study was to examine the factors associated with the occurrence of cancer-related fatigue (CRF) one month after surgery in patients with gastrointestinal cancer.

METHOD

The study included 96 patients with gastrointestinal cancer (50 males and 46 females, mean age 62.7 ± 11.4 years). Data of the Cancer Fatigue Scale (CFS), 6-minute walk distance (6MWD), and hospital anxiety and depression scale (HADS) were obtained before surgery and one month after surgery. The subjects were divided into the following two groups: severe CRF group (CFS score of ≥19 points) and mild CRF group (CFS score of <19 points). Each parameter was compared between the severe and mild CRF groups. The factors associated with CRF were identified by logistic regression analysis involving factors with significant differences between the groups.

RESULT

The CFS score showed a significant interaction, and the CFS score, 6MWD, and HADS score showed significant differences both before and one month after surgery between the two groups. The CFS score was significantly higher in the severe CRF group than in the mild CRF group both before and one month after surgery. Additionally, the 6MWD was significantly lower in the severe CRF group than in the mild CRF group both before and one month after surgery. The factors identified on logistic regression analysis were the preoperative CFS score and preoperative 6MWD.

CONCLUSION

CRF occurring one month after surgery might be affected by preoperative fatigue and preoperative exercise tolerance.

Beating Cancer-Related Fatigue With the Untire Mobile App: Protocol for a Waiting List Randomized Controlled Trial

Background

Many cancer patients and survivors worldwide experience disabling fatigue as the main side effect of their illness and the treatments involved. Face-to-face therapy is effective in treating cancer-related fatigue (CRF), but it is also resource-intensive. Offering a self-management program via a mobile phone app (ie, the Untire app), based on elements of effective face-to-face treatments, might increase the number of patients receiving adequate support for fatigue and decrease care costs.

Objective

The aim of this protocol is to describe a randomized controlled trial (RCT) to assess the effectiveness of the Untire app in reducing fatigue in cancer patients and survivors after 12 weeks of app use as compared with a waiting list control group. Substudies nested within this trial include questions concerning the reach and costs of online recruitment and uptake and usage of the Untire app.

Methods

The Untire app study is a waiting list RCT targeting cancer patients and survivors who experience moderate to severe fatigue via social media (Facebook and Instagram) across 4 English-speaking countries (Australia, Canada, the United Kingdom, and the United States). The Untire app includes psychoeducation and exercises concerning energy conservation, activity management, optimizing restful sleep, mindfulness-based stress reduction, psychosocial support, cognitive behavioral therapy, and physical activity. After randomization, participants in the intervention group could access the Untire app immediately, whereas control participants had no access to the Untire app until the primary follow-up assessment at 12 weeks. Participants completed questionnaires at baseline before randomization and after 4, 8, 12, and 24 weeks. The study outcomes are fatigue (primary) and quality of life (QoL; secondary). Potential moderators and mediators of the hypothesized treatment effect on levels of fatigue and QoL were also assessed. Link clicks and app activation are used to assess reach and uptake, respectively. Log data are used to explore the characteristics of app use. Sample size calculations for the primary outcome showed that we needed to include 164 participants with complete 12-week measures both in the intervention and the control groups. The intention-to-treat approach is used in the primary analyses, which refers to analyzing all participants regardless of their app use.

Results

Participants were recruited from March to October 2018. The last participant completed the 24-week assessment in March 2019.

Conclusions

This mobile health (mHealth) RCT recruited participants online in multiple countries to examine the uptake and effectiveness of the Untire self-management app to reduce CRF. Many advantages of mHealth apps are assumed, such as the immediate access to the app, the low thresholds to seek support, and the absence of contact with care professionals that will reduce costs. If found effective, this app can easily be offered worldwide to patients experiencing CRF.

Trial Registration

Netherlands Trial Register NL6642; https://www.trialregister.nl/trial/6642.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15969

Changes in fatigue in rectal cancer patients before and after therapy: a systematic review and meta-analysis

PURPOSE

Fatigue is a common problem among rectal cancer patients and can affect their quality of life. This study conducted a systematic review to better understand changes in fatigue severity in rectal cancer patients before, during, and after they undergo therapy.

METHODS

We used preset keywords to search the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and ProQuest databases for relevant studies published between 2000 and 2018, and data analysis was performed using Comprehensive Meta-Analysis (CMA) software (version 2.2.048) and SPSS software (version 19.0). In total, nine articles with complete data were included in our meta-analysis.

RESULTS

Fatigue conditions were compared before the start of therapy (baseline) and at 1 month (time 1), 3 months (time 2), 6 months (time 3), and 12 months (time 4) after the start of therapy. The standardized mean differences (SMDs) of the pooling effects size were 1.013 (95% confidence interval (CI) 0.217-1.810), - 0.551 (95% CI - 0.647 to - 0.456), - 0.330 (95% CI - 0.427 to - 0.233), and - 0.149 (95% CI - 0.221 to - 0.078), respectively. Subsequent analysis with a linear mixed effect model revealed that the estimate of the time variable was - 0.226 (p = 0.047), which indicates that the severity of fatigue varies over time and over the course of treatment. The results reveal that fatigue affects rectal cancer patients even before they start therapy.

CONCLUSION

Although fatigue worsened during the first month after cancer therapy, it gradually improved thereafter.

A Randomized Study of Yoga for Fatigue and Quality of Life in Women with Breast Cancer Undergoing (Neo) Adjuvant Chemotherapy

OBJECTIVES

To compare the effectiveness of yoga added to standard care (SC) versus SC only, in women with breast cancer during chemotherapy.

DESIGN

A multicenter pragmatic, randomized controlled study.

SETTINGS/LOCATION

Three hospitals in the Netherlands.

SUBJECTS

Women with stage I-III breast cancer undergoing chemotherapy.

INTERVENTIONS

Women were randomized either to a program based on Dru Yoga, once a week yoga sessions for 12 weeks (N = 47), or SC only (N = 36).

OUTCOME MEASURES

Primary outcome fatigue (Multidimensional Fatigue Inventory [MFI]; general fatigue) and secondary outcomes fatigue (MFI, Fatigue Quality List [FQL]), quality of life (30-item Quality of Life Questionnaire-C of the European Organization for Research and Treatment of Cancer [EORTC-QLQ-C-30]) and psychological distress (Hospital Anxiety Depression Scale [HADS], Impact of Events Scale [IES]) were measured at baseline (T0), 3 months (T1), and 6 months (T2) and analyzed on observed cases. Other outcomes were adequate relief, reintegration to work, and adverse events.

RESULTS

No significant differences were found in general fatigue at T1 (MFI: yoga; 14.6 ± 4.5 vs. SC; 14.2 ± 4.2, p = 0.987). Similar findings were observed for other fatigue (sub)scales of MFI and FQL and functional domains of EORTC. With respect to EORTCs symptom scales, women in the yoga group reported significantly less nausea and vomiting compared with SC at T2 (p = 0.004), but not at T1 (p = 0.807). Depressive symptoms were significantly lower with yoga at T1 (HADS: yoga; 4.7 ± 4.1 vs. SC; 5.1 ± 4.2, p = 0.031). More women in the yoga group experienced adequate relief compared with SC at T1 (yoga; 51% vs. SC; 19%) and had returned to work at T2 (yoga; 53% vs. SC; 23%). No adverse events were reported with yoga.

CONCLUSIONS

A Dru-based yoga program failed to demonstrate a significant beneficial effect on fatigue. Possible favorable effects of the yoga program on nausea and vomiting and early return to work in breast cancer survivors warrant further research.

Prevalence of severe fatigue among adults with cystic fibrosis: A single center study

BACKGROUND

With life expectancy increasing among patients with cystic fibrosis (CF), the prevalence of complications such as fatigue is also expected to increase. Our aim was to investigate the prevalence of severe fatigue among adults with CF and to identify factors associated with fatigue.

METHODS

Adult patients with CF receiving treatment at a single center were invited to complete three questionnaires. We then studied the associations between fatigue and clinically measured parameters and between fatigue and patient-reported outcomes.

RESULTS

A total of 77 patients (age 19-54years; 56% males; mean FEV₁: 63%) completed the questionnaires (43% response rate). The prevalence of severe fatigue among these patients was 26%. The variance in fatigue was explained partially by clinically measured parameters. However, patient-reported outcomes were stronger independently associated with fatigue and included the patients' reported respiratory symptoms, emotional functioning, and social functioning.

CONCLUSIONS

Fatigue is a clinically important and highly prevalent issue among adults with CF and is associated with a significant reduction in health-related quality of life and participation in society. In addition, fatigue is associated more strongly with the patient's perception of symptoms and well-being than with clinically measured parameters.

Evaluation of fatigue in patients with pancreatic cancer receiving chemotherapy treatment: a cross-sectional observational study

BACKGROUND AND AIM OF THE WORK

Cancer-related fatigue (CRF) is one of the most common symptoms experienced by cancer patients (CPs) and negatively affects quality of life. Although CRF is frequently experienced, it is often underreported, underdiagnosed and undertreated. The objectives of this study were to evaluate the level of fatigue in patients with pancreatic cancer undergoing chemotherapy and to analyse its correlation with patients' demographic and clinical variables.

METHODS

A cross-sectional observational study was implemented in the Oncology Day Hospital of a Northern Italian hospital. A sample of 48 patients receiving chemotherapy were evaluated through the Brief Fatigue Inventory Italian version (BFI-I) between 1 May and 12 October 2016. Data were statistically analysed.

RESULTS

Most of our patients (94%) experienced fatigue. Women as well as patients with an age ≥65 years reported more fatigue. Anemia, pain and a weight loss of over 16 kg in the last 6 months were significantly related to the perception of fatigue. Regarding life habits, smoking was related to high global score of BFI-I.

CONCLUSIONS

In accordance with literature, our study suggests that fatigue is a frequent symptom influenced by many constitutional, clinical and environmental factors. Our results highlight the need for an early and regular evaluation of fatigue among cancer patients, in order to implement all those pharmacological and non-pharmacological interventions with proven efficacy in attenuating this symptom.

Physical Behavior Profiles in Chronic Cancer-Related Fatigue

PURPOSE

Increasing physical activity level is a generally effective intervention goal for patients who suffer from chronic cancer-related fatigue (CCRF). However, patients are unlikely to benefit equally from these interventions, as their behavioral starting points might vary substantially. Therefore, we explored patterns of physical behavior of participants who suffer from CCRF.

METHODS

Baseline data of a randomized controlled trial were used for a latent profile analysis on nine accelerometer-derived physical behavior measures, describing levels and patterns of physical activity, moderate-to-vigorous intensity physical activity (MVPA), and sedentary behavior. The relation between participant characteristics and the latent profiles was analyzed.

RESULTS

Accelerometer data of 172 participants from the Netherlands was analyzed. Three latent profiles were distinguished that differed most on physical activity level and total time spent in MVPA. Eighty-eight percent of all participants were assigned to a profile with a probability higher than 8. Age and perceiving limitations by comorbid conditions and pain were significant covariates of profile membership.

CONCLUSIONS

We distinguished three physical behavior profiles. The differences between the patterns indicate that the heterogeneity of this sample requires patients to have substantially different treatment goals. Further research should test the applicability of these profiles in clinical practice.

Nausea and disturbed sleep as predictors of cancer-related fatigue in breast cancer patients: a multicenter NCORP study

PURPOSE

Cancer-related fatigue (CRF) is a prevalent and distressing side effect of cancer and its treatment that remains inadequately understood and poorly managed. A better understanding of the factors contributing to CRF could result in more effective strategies for the prevention and treatment of CRF. The objectives of this study were to examine the prevalence, severity, and potential predictors for the early onset of CRF after chemotherapy cycle 1 in breast cancer patients.

METHODS

We report on a secondary data analysis of 548 female breast cancer patients from a phase III multi-center randomized controlled trial examining antiemetic efficacy. CRF was assessed by the Brief Fatigue Inventory at pre- and post-chemotherapy cycle 1 as well as by the four-day diary.

RESULTS

The prevalence of clinically relevant post-CRF was 75%. Linear regression showed that pre-treatment CRF, greater nausea, disturbed sleep, and younger age were significant risk factors for post-CRF (adjusted R² = 0.39; P < 0.0001). Path modeling showed that nausea severity influenced post-CRF both directly and indirectly by influencing disturbed sleep. Similarly, pre-treatment CRF influenced post-CRF directly as well as indirectly through both nausea severity and disturbed sleep. Pearson correlations showed that changes in CRF over time were significantly correlated with concurrent changes in nausea severity (r = 0.41; P < 0.0001) and in disturbed sleep (r = 0.20; P < 0.0001).

CONCLUSION

This study showed a high prevalence (75%) of clinically relevant CRF in breast cancer patients following their initial chemotherapy, and that nausea severity, disturbed sleep, pre-treatment CRF, and age were significant predictors of symptom.

Translation and validation of the Cancer-Related Fatigue Scale in Greek in a sample of patients with advanced prostate cancer

OBJECTIVE

To translate and validate the Cancer-Related Fatigue (CRF) Scale in the Greek language.

DESIGN

A cross-sectional descriptive design was used in order to translate and validate the CRF Scale in Greek. Factor analyses were performed to understand the psychometric properties of the scale and to establish construct, criterion and convergent validity.

SETTING

Outpatients' oncology clinics of two public hospitals in Cyprus.

PARTICIPANTS

148 patients with advanced prostate cancer undergoing chemotherapy.

RESULTS

The Cancer Fatigue Scale (CFS) had good stability (test-retest reliability r=0.79, p<0.001) and good internal consistency (Cronbach's α coefficient for all 15 items α=0.916). Furthermore, the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO value) was found to be 0.743 and considered to be satisfactory (>0.5). The correlations between the CFS physical scale (CFS-FS scale) and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 physical subscales were found to be significant (r=-0.715). The same occurred between CFS cognitive and EORTC cognitive subscale (r=-0.579). Overall, the criterion validity was verified. The same occurs for the convergent validity of the CFS since all correlations with the Global Health Status (q29-q30) were found to be significant.

CONCLUSIONS

This is the first validation study of the CRF Scale in Greek and warrant of its use in the assessment of prostate cancer patient's related fatigue. However, further testing and validation is needed in the early stages of the disease and in patients in later chemotherapy cycles.

Relationships among psychoneurological symptoms and levels of C-reactive protein over 2 years in women with early-stage breast cancer

PURPOSE

The aim of the present study was to explore clusters of psychoneurological symptoms and inflammation (levels of C-reactive protein) over time in a cohort of women with early-stage breast cancer. Specifically, we examined the relationships among affective symptoms (depression, anxiety, fatigue, sleep disturbances, pain, and perceived stress), domains of cognitive performance, and levels of peripheral C-reactive over a period of 2 years.

METHODS

This was a prospective, longitudinal study of 77 women diagnosed with early-stage breast cancer. Data collection, including symptom questionnaires, performance-based cognitive testing, and blood draws, took place at 5 time points: prior to initiating adjuvant chemotherapy, prior to the fourth chemotherapy treatment, and at 6, 12, and 24 months after the initiation of chemotherapy.

RESULTS

Exploratory factor analysis with varimax orthogonal rotation was used to examine the covariance among symptoms at each visit. Using the factor scores and weighted sums, three clusters were identified: global cognition, affective symptoms, and cognitive efficiency. Peripheral levels of C-reactive protein were inversely correlated with the cognitive efficiency factor across time.

CONCLUSIONS

The findings suggest that objectively measured domains of cognitive function occur independently of other affective symptoms that are commonly reported by women with breast cancer in long-term survivorship. The cognitive efficiency symptom cluster may be amenable to interventions targeted to biological influences that reduce levels of C-reactive protein.

The Distress Thermometer for screening for severe fatigue in newly diagnosed breast and colorectal cancer patients

OBJECTIVE

Internationally, the Distress Thermometer and associated Problem List are increasingly used in oncology as screening tools for psychological distress. Cancer-related fatigue is common but often overlooked in clinical practice. We examined if severe fatigue in cancer patients can be identified with the fatigue item of the Problem List.

METHODS

Newly diagnosed breast (N = 334) and colorectal (N = 179) cancer patients were screened for severe fatigue, which was defined as having a positive score on the fatigue item of the Problem List. The Fatigue Severity subscale of the Checklist Individual Strength was used as gold standard measure for severe fatigue.

RESULTS

In total, 78% of breast cancer patients and 81% of colorectal cancer patients were correctly identified with the fatigue item. The sensitivity was 89% in breast cancer patients and 91% in colorectal cancer patients. The specificity was 75% in breast cancer patients and 77% in colorectal cancer patients. The positive predictive value was 53% in breast cancer patients and 64% in colorectal cancer patients, whereas the negative predictive value was 95% in both tumor types.

CONCLUSIONS

The fatigue item of the Problem List performs satisfactorily as a quick screening tool for severe fatigue. However, a positive screen should be followed up with a more thorough assessment of fatigue, ie, a questionnaire with a validated cutoff point. Given time pressure of clinicians, this already implemented and brief screening tool may prevent severe fatigue from going undetected in clinical practice.

Fatigue in people with localized colorectal cancer who do and do not receive chemotherapy: a longitudinal prospective study

BACKGROUND

Fatigue is associated with cancer and chemotherapy and may be sustained. Here, we describe a prospective longitudinal study evaluating fatigue and putative mechanisms in people with colorectal cancer (CRC).

PATIENTS AND METHODS

People with localized CRC completed the Functional Assessment of Cancer Treatment-Fatigue (FACT-F) questionnaire at baseline (before chemotherapy, if given), 6, 12, and 24 months. Healthy controls (HCs) were assessed at the first three time points. Fatigue was defined by standardized FACT-F scores ≤68/100. Quality-of-life (QoL, assessed by the FACT-G questionnaire), affective, and cognitive symptoms were evaluated. Associations were sought between fatigue, baseline factors, and blood tests (including hemoglobin, cytokines, and sex hormones). Regression analyses, Fisher's exact tests, and Wilcoxon rank-sum tests assessed levels of fatigue at each time point and change in fatigue from baseline. A repeated-measures analysis investigated prognostic factors of fatigue across all time points.

RESULTS

A total of 289 subjects with localized CRC (173 received chemotherapy) and 72 HCs were assessed. More CRC patients had fatigue than HCs at baseline (52% versus 26%, P < 0.001). Fatigue was increased in the chemotherapy (CTh) group at 6 months [CTh+ 70% versus CTh- 31% (P < 0.001), HCs 22%] and remained more common at 12 [CTh+ 44% versus CTh- 31% (P = 0.079)] and 24 months [CTh+ 39% versus CTh- 24% (P = 0.047)]. There was no significant difference between those not receiving chemotherapy and HCs at follow-up assessments. Fatigue was associated with poor QoL, affective and cognitive symptoms, but not consistently with cytokine levels. Predictors for sustained fatigue were baseline fatigue, treatment group, cognitive and affective symptoms, poorer QoL, and comorbidities.

CONCLUSIONS

CRC patients have more fatigue than HCs at baseline. Fatigue peaks immediately after adjuvant chemotherapy, but remains common for 2 years in those who receive chemotherapy. Cognitive and affective symptoms, QoL, comorbidities, chemotherapy, and baseline fatigue predict for longer term fatigue.

Fatigue and Sleep Experiences at Home in Children and Adolescents With Cancer

PURPOSE/OBJECTIVES

To (a) investigate fatigue and sleep patterns of children and adolescents at home and (b) examine factors associated with fatigue and sleep..

DESIGN

Descriptive with repeated measures
.

SETTING

Homes of study participants in Los Angeles and Orange, California
.

SAMPLE

35 children and adolescents with cancer.

METHODS

Data were collected using the PedsQL Multidimensional Fatigue Scale, which was completed once at home by each participant, and sleep actigraphs, which were worn for five days at home following discharge from hospitalization
.

MAIN RESEARCH VARIABLES

General fatigue, cognitive fatigue, sleep-rest fatigue, sleep duration, sleep quantity, sleep efficiency, and wake after sleep onset
.

FINDINGS

More than half of the participants had problems with fatigue at home. Significant correlations were found between sleep/rest fatigue and sleep duration. Factors that affected fatigue were age, gender, and cancer diagnosis. Adolescents had more problems with fatigue than children, and female patients had more problems with fatigue than male patients. Patients with sarcoma had more problems with fatigue than those with leukemia, lymphoma, and other cancer diagnoses. Adolescents slept less than children.

CONCLUSIONS

Children and adolescents with cancer have fatigue and sleep problems at home that vary by age, gender, and cancer diagnosis
.

IMPLICATIONS FOR NURSING

Data from the current study support the need for nurses to provide teaching about fatigue and sleep at home in children and adolescents with cancer. Future studies are needed to examine interventions that may alleviate fatigue and improve sleep at home
.

The association between patient's and partner's fatigue in couples coping with colorectal cancer: a longitudinal study

Background

Couples coping with colorectal cancer were monitored during the first year after diagnosis to evaluate the following: (i) levels of patients’ and partners’ fatigue—hereby comparing their scores to each other and a normative population, (ii) association between patients’ and partners’ fatigue, (iii) the course of partners’ fatigue, and (iv) biopsychosocial predictors of the partners’ fatigue, including the patients’ level of fatigue.

Method

Couples (n = 171) preoperatively completed questions regarding age and sex as well as questionnaires assessing neuroticism and trait anxiety. Questionnaires assessing fatigue, anxiety, and depressive symptoms were measured preoperative (time-0) and 3 (time-1), 6 (time-2), and 12 months (time-3) postoperative. Patients’ clinical characteristics were retrieved from the Eindhoven Cancer Registry. Descriptive statistics, correlations, and linear mixed effect models were used.

Results

Compared with a normative population, partners’ fatigue was similar (p > .05), while patients’ fatigue was higher at Time-2 and Time-3 (p values <.001). At each time point, correlations between patients’ and partners’ fatigue were small (r < .30). Partner’s course of fatigue was as follows: 18.2 at time-0, 19.0 at time-1, 19.4 at time-2, and 19.2 at time-3 (p = 0.64). Scoring higher on neuroticism (β = .12) and trait anxiety (β = .23), and more depressive symptoms (β = .30) significantly contributed to higher partners’ fatigue.

Conclusion

Trait anxiety, neuroticism, and depressive symptoms predicted higher levels of partners’ fatigue, while demographic factors, patients’ fatigue, and clinical factors did not. Health professionals are advised to be alert for partners with a vulnerable personality and depressive symptoms. If needed, they can for instance refer to a psychologist for treatment.

Chemotherapy-Induced Fatigue Correlates With Higher Fatigue Scores Before Treatment

PURPOSE

Cancer chemotherapy can induce fatigue in about 20% to 30% of patients. So far, there is very little information as to the predictors of chemotherapy-induced fatigue (CIF). We evaluated potential predictors of CIF in a sample of patients with cancer with several types of solid tumors scheduled to receive chemotherapy according to institutional protocols.

METHODS

Before their first and second chemotherapy cycles, patients answered to the Brief Fatigue Inventory (BFI), Chalder, Mini Nutritional Assessment (MNA), Stress thermometer, and HADS questionnaires as well as provided blood samples for inflammatory markers.

RESULTS

We evaluated 52 patients, 37 (71%) were female and mean age was 53 years. The most common tumors were breast cancer 21 (40%) and gastrointestinal tumors 12 (23%). Although 14 (25.2%) patients had an increase in their fatigue BFI scores equal or above 3 points from baseline, we observed no significant overall differences between BFI scores before and after chemotherapy. The only 2 factors associated with an increase of 3 points in the BFI scores after chemotherapy were race and higher baseline BFI levels. By multivariate analysis, overall BFI and Chalder scores after chemotherapy also correlated significantly with their respective baseline scores before treatment. HADS scores before treatment correlated with overall BFI scores postchemotherapy, whereas MNA scores before chemotherapy and female sex correlated with higher Chalder scores after treatment.

CONCLUSION

We conclude that fatigue induced by chemotherapy is common and consistently associated with higher fatigue scores before treatment. Screening for fatigue before chemotherapy may help to identify patients who are prone to develop CIF.

Fatigue in chronic hepatitis C infection: Understanding patients' experience from a cognitive-behavioural perspective

OBJECTIVES

Fatigue is a leading concern of patients with chronic hepatitis C virus (HCV) infection. Despite its clinical significance, fatigue in HCV is poorly understood and therefore invariably under-treated. A cognitive-behavioural approach offers a framework to understand and treat fatigue, but the characteristics of fatigue in chronic HCV infection have not been documented from a cognitive-behavioural perspective. This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue.

DESIGN

Cross-sectional, qualitative using a critical realism approach.

METHODS

Fourteen individuals (64% women; age >18 years) participated in semi-structured interviews. The interviews documented the features, course, and perceived antecedents of fatigue; fatigue-specific cognitions; fatigue management behaviours; and the functional impact of fatigue.

RESULTS

Participants' descriptions included the aspects of fatigue that have been targets of cognitive-behavioural therapy in other medical conditions, including attributing fatigue to the illness; expectation of chronicity; low control; and fatigue-driven coping. There were also components of fatigue experience that appear to be unique characteristics of fatigue related to HCV, including predominantly physical fatigue; high acceptance of fatigue; and liver-protective diet as a fatigue management behaviour.

CONCLUSIONS

This was the first study to document the experience of fatigue in chronic HCV infection in a cognitive-behavioural framework. The findings suggest that the cognitive-behavioural approach can be applied to fatigue in chronic HCV infection. This would open an avenue to alleviate fatigue and thus improve the primary patient-reported outcome of the disease.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Fatigue is a key patient-reported outcome measure of chronic hepatitis C virus (HCV) infection. Fatigue management is not part of the standard care, because fatigue is poorly characterized in this population. What does this study add? A cognitive-behavioural approach can be applied to understand fatigue in HCV infection. Identified aspects of fatigue (antecedents, consequences, cognitions, behaviours) that can be treatment targets. Cognitive-behavioural therapy would open a new treatment avenue to alleviate fatigue in HCV infection.

Randomized sham controlled trial of cranial microcurrent stimulation for symptoms of depression, anxiety, pain, fatigue and sleep disturbances in women receiving chemotherapy for early-stage breast cancer

Purpose

Women with breast cancer may experience symptoms of depression, anxiety, pain, fatigue and sleep disturbances during chemotherapy. However, there are few modalities that address multiple, commonly occurring symptoms that may occur in individuals receiving cancer treatment. Cranial electrical stimulation (CES) is a treatment that is FDA cleared for depression, anxiety and insomnia. CES is applied via electrodes placed on the ear that deliver pulsed, low amplitude electrical current to the head.

Methods

This phase III randomized, sham-controlled study aimed to examine the effects of cranial microcurrent stimulation on symptoms of depression, anxiety, pain, fatigue, and sleep disturbances in women receiving chemotherapy for early-stage breast cancer. Patients were randomly assigned to either an actual or sham device and used the device daily for 1 h. The study was registered at clinicaltrials.gov, NCT00902330.

Results

The sample included N = 167 women with early-stage breast cancer. Symptom severity of depression, anxiety, and fatigue and sleep disturbances were generally mild to moderate. Levels of pain were low. Anxiety was highest prior to the initial chemotherapy and decreased over time. The primary outcome assessment (symptoms of depression, anxiety, fatigue, pain, sleep disturbances) revealed no statistically significant differences between the two groups, actual CES vs. sham.

Conclusion

In this study, women receiving chemotherapy for breast cancer experienced multiple symptoms in the mild to moderate range. Although there is no evidence for the routine use of CES during the chemotherapy period for symptom management in women with breast cancer, further symptom management modalities should be evaluated to mitigate symptoms of depression, anxiety, fatigue, pain and sleep disturbances over the course of chemotherapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-1151-z) contains supplementary material, which is available to authorized users.

Cancer related fatigue syndrome in neoplastic diseases

Fatigue is one of the most important factors which has a considerable influence on treatment and the life quality of oncological patients. The fatigue syndrome is often diagnosed during cancer treatment and this syndrome is not related to the physical effort. Cancer related fatigue is a patient's subjective, psychologically, physically and emotionally based feeling. It is disproportionate to patient's daily activity. The pathogenesis of this syndrome remains still unknown. However, on the basis of various questionnaires, it is possible to test the disease's complex nature. Cancer related fatigue causes deterioration of patient's life along with lower motivation to struggle with the disease. It is thought that the factor which increases the incidence of cancer related fatigue is a long-term use of drugs such as opioids, benzodiazepine, and medicines containing codeine, tranquilizers, anxiolytics and antidepressants. On the basis of the results, one can choose an appropriate treatment method for cancer related fatigue such as rehabilitation, psychotherapy or public assistance. A great number of patients consider excessive fatigue a typical concomitant symptom in neoplastic disease; therefore, they do not report it. It is of a paramount importance to make patients aware of the fact that cancer related fatigue is a serious disease which can be treated.

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer-reviewed, English-language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full-text, English-language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality.

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.

Comparison of problems and unmet needs of patients with advanced cancer in a European country and an Asian country

BACKGROUND

Patients with advanced cancer experience problems and unmet needs. However, we assume that patients with advanced cancer will have more problems and unmet needs in a country with a lower economic status than in an economically stronger country. We studied whether patients with advanced cancer in Indonesia have more problems and unmet needs than a similar group of patients in the Netherlands.

METHODS

We performed a cross-sectional survey. We compared the data for 180 Indonesian and 94 Dutch patients relating to 24 items of the Problems and Needs in Palliative Care-short version questionnaire. We performed descriptive and χ(2) analysis with Bonferroni correction.

RESULTS

The prevalence of most physical problems, including pain, was similar in the 2 groups. In Indonesia, financial problems were the most common: 70 to 80% vs. 30 to 42% in the Netherlands. In Indonesia, 25 to 50% of the patients reported psychological and autonomy problems versus 55 to 86% in the Netherlands. The Indonesian group had many more unmet needs for each problem (> 54%) than the Dutch group (< 35%).

CONCLUSION

Apparently, economic and cultural differences hardly influence physical problems. Nonetheless, fewer Indonesian patients reported psychological and autonomy problems than Dutch patients. This difference contradicts our hypothesis. However, we found more unmet needs for professional attention in Indonesia than in the Netherlands, which is compatible with our hypothesis. These simple comparative data provide interesting insights into problems and unmet needs and give rise to our new hypothesis about cultural influences. This hypothesis should be studied in more depth.

Symptoms, clusters and quality of life prior to surgery for breast cancer

AIMS AND OBJECTIVES

To examine the pretreatment symptoms and symptom clusters that women awaiting breast cancer surgery are experiencing and the impact of these symptoms on their quality of life.

BACKGROUND

Most women diagnosed with breast cancer will have surgery as a first-line treatment. The presence of presurgery symptoms may be significant in contributing to distress and impaired quality of life. While it seems that women with breast cancer may experience the symptoms of fatigue, pain, depression and sleep disturbance as a cluster, this has not yet been confirmed by empirical research in the presurgery time period.

DESIGN

A multiple-point prospective longitudinal cohort panel design is used.

METHODS

Presurgery symptoms and quality of life were assessed using the Hospital Anxiety and Depression Scale, Insomnia Severity Index, Functional Assessment of Cancer Therapy-Fatigue, Brief Pain Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30(3).

RESULTS

Participants (n = 94, age range 30-92) experienced symptoms prior to surgery, with pain being a more prevalent symptom (35%) than fatigue (32%), sleep disturbances (25·5%) or depression (11%). global quality of life was significantly impacted on by fatigue and showed a moderate correlation with emotional functioning and a weak correlation with physical and social functioning. Hierarchical cluster analysis identified the presence of five clusters with symptoms present in differing intensities in each cluster.

CONCLUSION

In this cohort of women, healthy other than having a diagnosis of breast cancer, symptoms were impacting on quality of life. It is evident that clusters of symptoms are present presurgery that must be assessed and managed.

RELEVANCE TO PRACTICE

Healthcare delivery systems must ensure that early symptoms are addressed effectively in the presurgery period to improve quality of life and reduce adverse outcomes postsurgery.

Cancer-related fatigue in breast cancer patients after surgery: a multicomponent model using partial least squares-path modeling

OBJECTIVE

The aim of this study is to examine factors contributing to cancer-related fatigue (CRF) in breast cancer patients who have undergone surgery.

METHODS

Sixty women (mean age: 50.0) completed self-rated questionnaires assessing components of CRF, muscular and cognitive functions. Also, physiological and subjective data were gathered. Data were analyzed using partial least squares variance-based structural equation modeling in order to examine factors contributing to CRF after breast surgery.

RESULTS

The tested model was robust in terms of its measurement quality (reliability and validity). According to the structural model results, emotional distress (β = 0.59; p < 0.001), pain (β = 0.23; p < 0.05), and altered vigilance (β = 0.30; p < 0.05) were associated with CRF, accounting for 61% of the explained variance. Also, emotional distress (β = 0.41; p < 0.05) and pain (β = 0.40; p < 0.05) were related to low physical function and accounted for 41% of the explained variance. However, the relationship between low physical function and CRF was weak and nonsignificant (β = 0.01; p > 0.05).

CONCLUSION

Emotional distress, altered vigilance capacity, and pain are associated with CRF in postsurgical breast cancer. In addition, emotional distress and pain are related to diminished physical function, which, in turn, has no significant impact on CRF. The current model should be examined in subsequent phases of the treatment (chemotherapy and/or radiotherapy) when side effects are more pronounced and may lead to increased intensity of CRF and low physical function.

Postsurgical physical activity and fatigue-related daily interference in women with non-metastatic breast cancer

PURPOSE

Women undergoing surgery for breast cancer experience side effects, such as fatigue, reduced quality of life (QOL) and depression. Physical activity (PA) is associated with improved psychological adjustment during treatment and survivorship, yet little is known about how PA relates to fatigue, depression and QOL in the period following surgery for breast cancer. The purpose of the study was to examine the relationships between these constructs in women who recently underwent surgery for breast cancer.

METHODS

At 2-10 weeks post-surgery, 240 women with non-metastatic breast cancer reported intensity and duration of moderate and vigorous PA (MVPA), fatigue (intensity and interference), depressed mood, clinician-rated depression and functional QOL.

RESULTS

In the path analysis models tested, women that reported greater weekly MVPA reported less fatigue interference, greater functional QOL, less depressed mood, and lower clinician-rated depression. Tests of indirect effects suggested that fatigue interference may be an intermediate pathway by which MVPA relates to functional QOL, clinician-rated depression and depressed mood.

CONCLUSION

Women who are more physically active in the months after breast cancer surgery show greater psychological adaptation in the initial phases of their treatment.

Recommendations for high-priority research on cancer-related fatigue in children and adults

Over the past decades, some scientific progress has been made in understanding and treating cancer-related fatigue (CRF). However, three major problems have limited further progress: lack of agreement about measurement, inadequate understanding of the underlying biology, and problems in the conduct of clinical trials for CRF. This commentary reports the recommendations of a National Cancer Institute Clinical Trials Planning Meeting and an ongoing National Cancer Institute working group to address these problems so that high-priority research and clinical trials can be conducted to advance the science of CRF and its treatment. Recommendations to address measurement issues included revising the current case definition to reflect more rigorous criteria, adopting the Patient Reported Outcomes Measurement Information System fatigue scales as standard measures of CRF, and linking legacy measures to the scales. With regard to the biology of CRF, the group identified the need for longitudinal research to examine biobehavioral mechanisms underlying CRF and testing mechanistic hypotheses within the context of intervention research. To address clinical trial issues, recommendations included using only placebo-controlled trial designs. setting eligibility to minimize sample heterogeneity or enable subgroup analysis, establishing a CRF severity threshold for participation in clinical trials, conducting dissemination trials of efficacious interventions (such as exercise), and combining nonpharmacologic and pharmacologic interventions to exploit the potential synergy between these approaches. Accomplishing these goals has the potential to advance the science of CRF and improve the clinical management of this troubling symptom.

Severe fatigue after kidney transplantation: a highly prevalent, disabling and multifactorial symptom

Fatigue is a common symptom of patients with chronic kidney disease, but seldom investigated after transplantation. We determined the prevalence, impact and related factors of severe fatigue in kidney transplant recipients (KTRs). Medical records and questionnaires were used to assess kidney function, donor characteristics, fatigue (Checklist Individual Strength), functional impairments (Sickness Impact Profile), work status, body mass index (BMI), pain, depressive symptoms, social support and sleeping problems in 180 participating KTRs. KTRs were compared with sex- and age-matched population-based controls. KTRs were significantly more often severely fatigued (39%) compared to matched controls (22%; P = 0.001). Severely fatigued KTRs had significantly more functional impairments than nonseverely fatigued recipients (effect size ≥ 0.7) P < 0.001, and less often a paid job (27% vs. 48%, P = 0.005). Univariate analysis showed that severely fatigued KTRs received more often a kidney from a deceased donor, had a higher BMI, more pain, discrepancy in social support, depressive symptoms and sleeping problems. In a multivariate analysis (n = 151) the latter two associations remained significant. Severe fatigue is a highly prevalent and disabling symptom in KTRs. Moreover, severe fatigue after kidney transplantation is more strongly related to behavioural and psychosocial factors than specific transplantation-related factors. Findings have implications for fatigue management.

Potential epigenetic mechanism(s) associated with the persistence of psychoneurological symptoms in women receiving chemotherapy for breast cancer: a hypothesis

Due to recent treatment advances, there have been improvements in the proportion of women surviving a diagnosis of breast cancer (BC). However, many of these survivors report persistent adverse side effects following treatment, such as cognitive dysfunction, depressive symptoms, anxiety, fatigue, sleep disturbances, and pain. Investigators have examined circulating levels of inflammatory markers, particularly serum cytokines, for a potential causal relationship to the development/persistence of these psychoneurological symptoms (PNS). While inflammatory activation, resulting from perceived stress or other factors, may directly contribute to the development of PNS, we offer an alternative hypothesis, suggesting that these symptoms are an early step in a cascade of biological changes leading to epigenetic alterations at the level of deoxyribonucleic acid (DNA) methylation, histone modifications, and/or chromatin structure/chromosomal instability. Given that epigenetic patterns have plasticity, if this conjectured relationship between epigenomic/acquired genomic alterations and the development/persistence of PNS is confirmed, it could provide foundational knowledge for future research leading to the recognition of predictive markers and/or treatments to alleviate PNS in women with BC. In this article, we discuss an evolving theory of the biological basis of PNS, integrating knowledge related to inflammation and DNA repair in the context of genetic and epigenetic science to expand the paradigm for understanding symptom acquisition/persistence following chemotherapy.