Cancer-related fatigue interferes with activities of daily living among 753 patiens receiving chemotherapy: A URCC CCOP study
Reviewer: Christine Hill, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: June 2, 2008
Presenter: K.M. Mustian Presenter's Affiliation: University of Rochester Cacner Center, Rochester, NY Type of Session: Scientific
Cancer-related fatigue (CRF) is common in cancer patients, and may be under-diagnosed, under-recognized, and under-treated (Savard, 2001).
Cancer-related fatigue is in all likelihood multifactorial, and probably results from several aspects of cancer diagnosis and treatment:
Patients with cancer report insomnia, poor sleep quality, and short sleep duration.
On testing, cancer patients have been found to have low sleep efficiency (ratio of time asleep to total time in bed) (Owen, 1999).
Sleep disturbances may be partially attributable to anxiety related to cancer diagnosis, cancer pain, treatment-related side effects (i.e. nausea, vomiting, neuropathy), and time spent admitted to the hospital.
Other contributions to CRF may include medications such as opiates and benzodiazepines, nutritional deficiencies, and concurrent psychiatric illness.
Cancer-related fatigue has been demonstrated to be present frequently at the time of cancer diagnosis, to persist through cancer treatment, and to persist in some cases for years after treatment has been completed (Lindley, 1998).
Quality of life (QOL) may be significantly negatively impacted by CRF, and all aspects of QOL (physical, functional, emotional, cognitive, and social) may be affected.
Decreased QOL may contribute to increased psychosocial stress, as well as employment issues, financial difficulties, and family/ marital difficulties.
Although most oncology healthcare providers are aware of the potential global impact of fatigue on QOL, the effects of fatigue on specific activities of daily living (ADLs) have not specifically been studied in the past.
This study was undertaken in order to assess the interference of CRF with ADLs early in the course of cancer treatment.
Materials and Methods
Cancer-related fatigue was assessed for 753 patients who had been enrolled on a clinical trial conducted by the University of Rochester Cancer Center Research Base.
Data was gathered through use of questions from the Multidimensional Assessment of Fatigue instrument, anchored with a 10-point Likert Scale on which 1 = “Not at all,” and 10 = “A great deal.”
Patients reported data regarding fatigue on two occasions, seven days after completion of each of the first two chemotherapy cycles.
The impact of fatigue on several specific ADLs was assessed; these included walking, household chores, cooking, bathing, dressing, working, running errands, functioning socially, engaging in leisure activity, exercising, and engaging in sexual activity.
Data was gathered from 753 patients with mixed cancer diagnoses.
Patients were 64% female, and 75% Caucasian.
Median age was 57 years.
Sixty-one percent of patients were married/ partnered.
Primary cancer diagnosis was breast in 44% of patients, hematologic in 13%, and lung in 12%.
Twenty-six percent of patients were being treated for metastatic disease.
Fifty-eight percent of patients had undergone prior surgery, 12% prior chemotherapy, and 9% prior radiotherapy.
Fatigue was reported by 85.4% of patients following the first chemotherapy cycle, 79.3% following the second cycle, and 73% following both cycles.
Median fatigue score was 5.0 (moderate) in patients reporting fatigue only after cycle 1; 4.7 in those reporting fatigue only after cycle 2; and 5.9 in those reporting fatigue after both cycles.
Following cycle 1, over 80% of patients reporting fatigue described it as interfering with walking, completing household chores, cooking, running errands, socializing, and engaging in leisure activities.
Over 70% reported interference with working and exercising.
Over 60% reported interference with bathing, dressing, and engaging in sexual activity.
Of the 11 ADLs assessed, interference was noted in 9.
The interference severity ratios ranged from 4-5 (moderate).
Following cycle 2, over 90% of patients reporting fatigue described it as interfering with walking, completing household chores, and running errands.
Over 80% reported interference with cooking, socializing, and engaging in leisure activities.
Over 70% reported interference with working and exercise.
Over 60% reported interference with bathing, dressing, and sexual activity.
Of the 11 ADLs assessed, interference was noted in 10.
The interference severity ratios ranged from 4-5 (moderate).
Between cycles 1 and 2, patients reported an average increase of 4.5% interference with 11 ADLs (p < 0.05).
An increase in total ADLs affected was also described between the two cycles.
On average, female patients, Caucasians, and patients with metastatic disease reported the greatest degree of interference.
The authors conclude that CRF appears to be present as early in the course of cancer treatment as the first chemotherapy cycle.
They note that CRF appears to interfere significantly with many essential ADLs, and most significantly with walking, completing household chores, and running errands.
They note also that the number of patients reporting fatigue, as well as the number of ADLs interfered with, increased from chemotherapy cycle 1 to chemotherapy cycle 2; however, both the degree of fatigue and its interference with ADLs remained relatively constant at a “moderate” level.
Cancer-related fatigue is an extremely important factor in caring for cancer patients, and may significantly affect QOL for them. Cancer-related fatigue has been demonstrated to impact physical, social, psychological, and spiritual well-being (Ferrell, 1996).
The effects of CRF may be far-reaching. Patients with CRF report decreased ability to cope with pain, increased conflict regarding family roles, increased anxiety, fear, frustration, and depression, as well as increased feelings of hopelessness (Ferrell, 1996).
The National Comprehensive Cancer Network (NCCN) has developed CRF guidelines, and has defined CRF as “a disturbing, persistent, subjective sense of physical, emotional, and cognitive tiredness . . . that interferes with normal functioning.”
The NCCN recognizes that contributing factors to CRF likely include pain, anemia, nutrition, sleep disturbances, activity levels, and co-morbidities.
Despite recognition of the importance of CRF by both individuals and national organizations, research on and treatment of CRF remain difficult.
Dr. Betty Ferrell and colleagues of City of Hope Medical Center have identified several barriers to gathering of information regarding CRF.
They note that many physicians, nurses, and patients tend to believe that CRF is not treatable.
They also cite patient fears that increasing fatigue may imply worse disease, and that reporting fatigue to physicians may cause distraction and lead to decreased chemotherapy dosing or chance of enrollment on clinical trials.
Finally, they note that many patients have limited access to physical therapy, nutritional support, and psychosocial support due to insurance and managed care restrictions.
This study represents a large and systematic assessment of fatigue in over 700 patients following the first two cycles of chemotherapy.
The results of this study certainly demonstrate that CRF may have huge impacts on the lives of individuals, affecting one of the most basic ADLs, walking, in over 90% of cases.
Certainly, the frequency with which patients reported interference by CRF with walking, completing household chores, running errands, cooking, working and participating in social and leisure activities should increase healthcare provider awareness of the need for support and assistance with these activities.
For example, transportation to the hospital for treatments and within the hospital, where distances to be walked may be quite long, may be quite burdensome to patients.
Awareness of these issues and advocacy for increased access to physical therapy, nutritional counseling, and psychosocial supports are essential in caring for oncology patients; this study offers clear evidence that such services are necessary.
This study is somewhat limited by both the absence of baseline fatigue assessment, and by the relatively brief period over which fatigue was assessed.
In this study, whether patients had had previous treatments was not included in the analysis of which patients reported fatigue and interference with ADLs.
Since effects of prior surgery, chemotherapy, and radiotherapy may persist for years following treatment, this information could be very valuable in understanding which patients are at greatest risk for ADL-interfering CRF.
Additionally, fatigue from co-morbidities was not assessed in this trial, as no baseline survey was done before chemotherapy was initiated.
Still, this study offers clear evidence in a large cohort of patients that CRF is a common problem which often affects basic ADLs. The importance of support from healthcare providers, as well as continued research into treatment and reduction of CRF, are reinforced by the data presented here.