Karin Ahlberg

Assessment and management of cancer-related fatigue in adults

Fatigue is one of the most prevalent and distressing symptoms of cancer, and is a common side-effect of many of the treatments available for the management of malignant disease. We critically assess the evidence for cancer-related fatigue and its treatment in adults. Little is known about the cause and mechanisms of fatigue, and research into methods of alleviating the condition has focused on treatment for anaemia and behavioural interventions, such as exercise, both of which are effective in reducing fatigue. Although research into the condition has increased considerably in the past decade, important gaps in knowledge remain.

Health-related quality of life during adjuvant treatment for breast cancer among postmenopausal women.

The purpose of the present study was twofold: first, to describe changes of Health-Related Quality of Life (HRQoL) during the adjuvant treatment among postmenopausal women with breast cancer; second, in the same population to identify the best predictors of Overall Quality of Life (QoL) after treatment, from perceived functioning, symptoms, emotional distress and clinical/demographic variables measured at baseline. The study group was 150 women (> or = 55 years of age) scheduled for adjuvant chemotherapy (CT, n=75) or radiotherapy (RT, n=75). They were examined before (baseline), during and after completing the treatment. Data about QoL, perceived functioning, symptoms and emotional distress were collected with the European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30, BR23 and Hospital Anxiety and Depression Scale (HADS) questionnaires. The general finding was that the adjuvant treatments were associated with decrease in overall QoL, physical and role functioning, anxiety and body image, as well as with increase in fatigue, dyspnoea, pain, nausea/vomiting, constipation and systemic therapy side effects measured over time. For women receiving CT, better emotional functioning and less pain at baseline predicted better overall QoL at the end of the treatment. For women receiving RT, better physical and emotional functioning, less breast symptoms and lower tumour stage at baseline predicted better overall QoL at the end of the treatment.

Levels of Fatigue Compared to Levels of Cytokines and Hemoglobin during Pelvic Radiotherapy: a Pilot Study

Cancer-related fatigue (CRF) is a prevalent and distressing symptom experienced by patients during cancer therapy. One proposed mechanism for the development of fatigue is the increased secretion of proinflammatory cytokines and/or the development of anemia. The major purpose of this pilot study was to investigate the levels of fatigue and cytokines during radiation therapy and determine whether there was a correlation between the two. A secondary purpose was to explore the relationships among hemoglobin values, cytokines, and fatigue. Participants included 15 women diagnosed with uterine cancer, who received curative external radiation therapy. Fatigue was assessed by a self-report instrument (Multidimensional Fatigue Inventory [MFI-20]) and hemoglobin and cytokines (Il-1, Il-6, and TNF-α) were measured before, during, and after radiotherapy. The degree of fatigue increased during radiotherapy without a significant change in IL-1, IL-6, or TNF-α levels. There was no significant correlation between changes in general fatigue and the changes in IL-1 and TNF-α. There was a significant negative correlation between the change in IL-6 and general fatigue. The hemoglobin levels did decrease significantly during radiotherapy, but there was no significant correlation between general fatigue and hemoglobin after 3 weeks of therapy or after the completion of therapy. In conclusion, pelvic radiotherapy in women with uterine cancer is associated with increased fatigue. There were no significant relationships between anemia or cytokine levels and fatigue. The pathogenesis of fatigue during radiation therapy remains to be elucidated.

Health-related quality of life in patients undergoing allogeneic stem cell transplantation after reduced intensity conditioning versus myeloablative conditioning.

The aim of this prospective study was to describe health-related quality of life (HRQOL) in patients during the first year after stem cell transplantation (SCT) who were undergoing reduced intensive conditioning (RIC) compared with patients undergoing myeloablative conditioning (MAC). Fifty-seven patients (25 for MAC and 32 for RIC) were enrolled in the study. HRQOL was assessed at 6 occasions during the first year after SCT using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and the 19-item treatment-specific module High-Dose Chemotherapy. Both groups reported most symptoms and worst functioning 1 month after SCT, but there were substantial differences. The MAC group deteriorated considerably in 20 symptom scales compared with 8 in the RIC group (score differences <10; P values ranged from .001 to .05). Dry mouth, sore mouth, appetite loss, and change of taste were among the most frequent symptoms in both groups. Thereafter, the functioning improved and the symptom scores decreased and returned to baseline in both groups, except dry mouth, which remained a worse problem for the MAC group. Overall, the RIC group regained health and QOL faster than the MAC group did. However, there were no significant differences in global QOL between the groups 1 year after SCT.

Patients' perception of health-related quality of life during the first year after autologous and allogeneic stem cell transplantation.

Little attention has been paid to examine health-related quality of life (HRQoL) the first year post-transplant, despite that this period is crucial for returning to normal life and functioning and to prevent delayed psychosocial adjustment. The purpose of the present study was to describe HRQoL after autologous versus allogeneic stem cell transplantations during the first year post-transplant. The allogeneic group was further divided into two groups: allogeneic stem cell transplantation after reduced intensive conditioning and allogeneic stem cell transplantation after myeloablative conditioning. All together 202 patients were enrolled in the study. HRQoL was assessed by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the treatment-specific module High-Dose Chemotherapy (HDC-19). The questionnaires were filled out at six occasions (from inclusion to 12 months after transplantation). The reduced intensive conditioning group seemed to recover in the same way as the autologous group and these two groups were closer in their scoring compared with the myeloablative conditioning group. One month after the transplantation there were no significant differences in change scores between the autologous and reduced intensive conditioning group, and 1 year after the transplantation levels of symptoms and functioning were back to baseline or better. The myeloablative conditioning group, who perceived more symptoms and lower levels of functioning during the whole period, was still impaired in 10 out of 29 scales 1 year after the transplantation and no significant improvements compared with baseline were observed for this group.

Exploring a Link Between Fatigue and Intestinal Injury During Pelvic Radiotherapy

BACKGROUND The association between cancer-related fatigue and pathological processes in the body is largely unknown. This study was designed to investigate a possible linkage between fatigue and intestinal injury during pelvic radiotherapy. METHODS Twenty-nine women undergoing pelvic radiotherapy for anal or uterine cancer were prospectively followed. Fatigue and diarrhea were assessed using patient self-reported questionnaires. Plasma citrulline concentration, as a sign of intestinal injury, and C-reactive protein, orosomucoid, albumin, α(1)-antitrypsin, and haptoglobin, as signs of systemic inflammation, were analyzed. RESULTS Fatigue increased significantly (p < .001) and citrulline decreased significantly (p < .001) during treatment. A significant negative correlation (r = -0.40; p < .05) was found between fatigue and epithelial atrophy in the intestine (as assessed by plasma citrulline) after 3 weeks of treatment and a significant positive correlation (r = 0.75; p < .001) was found between fatigue and diarrhea. Signs of systemic inflammation were evident, with significant increases in serum orosomucoid, serum haptoglobin (p < .05) and serum α(1)-antitrypsin (p < .001) and a significant decrease in serum albumin (p < .001). CONCLUSION The present study indicates a link between fatigue and intestinal injury during pelvic radiotherapy. This observation should be considered as a preliminary finding because of the small sample size but may serve as a rationale for therapeutic interventions aimed at alleviating both fatigue and gastrointestinal symptoms during pelvic radiotherapy.

Performance of the Swedish version of the Revised Piper Fatigue Scale

PURPOSE The Revised Piper Fatigue scale is one of the most widely used instruments internationally to assess cancer-related fatigue. The aim of the present study was to evaluate selected psychometric properties of a Swedish version of the RPFS (SPFS). METHODS An earlier translation of the SPFS was further evaluated and developed. The new version was mailed to 300 patients undergoing curative radiotherapy. The internal validity was assessed using Principal Axis Factor Analysis with oblimin rotation and multitrait analysis. External validity was examined in relation to the Multidimensional Fatigue Inventory-20 (MFI-20) and in known-groups analyses. RESULTS Totally 196 patients (response rate = 65%) returned evaluable questionnaires. Principal axis factoring analysis yielded three factors (74% of the variance) rather than four as in the original RPFS. Multitrait analyses confirmed the adequacy of scaling assumptions. Known-groups analyses failed to support the discriminative validity. Concurrent validity was satisfactory. CONCLUSION The new Swedish version of the RPFS showed good acceptability, reliability and convergent and- discriminant item-scale validity. Our results converge with other international versions of the RPFS in failing to support the four-dimension conceptual model of the instrument. Hence, RPFS suitability for use in international comparisons may be limited which also may have implications for cross-cultural validity of the newly released 12-item version of the RPFS. Further research on the Swedish version should address reasons for high missing rates for certain items in the subscale of affective meaning, further evaluation of the discriminative validity and assessment of its sensitivity in detecting changes over time.

Pain and pain management in hospitalized patients before and after an intervention

Abstract Background and aim Studies have shown that pain is common among hospitalized patients and that there is a lack of compliance with pain management guidelines. Improving pain management does not only involve developing new drugs or technology; even more important is an effective organisation that utilises existing expertise. The aim of this study was to investigate whether pain in hospitalized patients can be reduced by implementing evidence-based pain management guidelines, providing education for staff and an organisation that includes pain responsibility nurses. Methods A cross-sectional study was carried out between 2009 and 2010 at two hospitals in southwest Sweden, comprising a baseline survey followed by an intervention. The study involved 306 patients, who answered questions about pain intensity at rest and while moving, disturbed sleep due to pain and whether they had used a pain rating scale while in hospital. Medical records were scrutinised for analgesic prescriptions. An intervention then took place, involving implementation of evidence-based guidelines, staff education and the introduction of pain responsibility nurses. A follow-up survey was carried out in 2012, in which 293 patients answered the same questions and their medical records were also reviewed. The baseline results were then compared with those of the follow-up survey. Results When compared with the baseline survey, the follow-up survey revealed significant differences in the use of validated pain rating instruments as well as the prescription of more appropriate analgesics. Prescription of paracetamol increased significantly in the follow-up survey; 56% of the patients were prescribed paracetamol on a regular basis, compared with 42% at baseline. There was also a significant increase in the use of strong opioids, from 38% at baseline to 55% at follow-up. Prescriptions of weak opioids decreased from 16% at baseline to 4% at follow-up. No significant differences were observed in patient pain levels in the follow-up survey. At baseline, 29% of the patients reported moderate to severe pain at rest (NRS 4–10) and at follow-up that figure was 24% (NRS 4–10). In both surveys, 41% reported moderate to severe pain (NRS 5–10) during movement. Thirty-nine percent reported disturbed sleep at night at both baseline and follow-up. Conclusions This study demonstrates that evidence-based guidelines made accessible to all staff as a pocket size booklet and on the intranet, in combination with staff education, pain responsibility nurses who informed other staff on their own wards, improved the prescription of analgesics in the hospitals studied. In order to achieve a noticeable effect for patients, i.e., reduced pain levels, an intervention containing more components than those employed in the present study is required. Implications Nurses and physicians need greater knowledge about the importance of pain rating. A vital part of pain management at hospitals is continuous evaluation of treatment outcomes to prevent severe pain and disturbed sleep. The complexity of pain and pain management requires commitment, time and knowledge on the part of healthcare staff. Multi-professional pain teams that support ward staff in pain management are necessary in order to reduce suffering and unnecessary pain in hospitalized patients.

3076 POSTER Fatigue Experienced by Patients During Cancer Treatment – the Psychometric Properties of the Swedish Version of the Revised Piper Fatigue Scale

Fatigue experienced by patients during cancer treatment : the psychometric properties of the swedish version of the revised piper fatigue scale