Lillian M. Nail

EXERCISE REDUCES DAILY FATIGUE IN WOMEN WITH BREAST CANCER RECEIVING CHEMOTHERAPY

PURPOSE Cancer treatment-related fatigue is the most prevalent and distressing symptom of cancer therapy. Interventions to minimize fatigue are needed. The purpose of this study was to examine the relationship between exercise and fatigue over the first three cycles of chemotherapy in women receiving either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin and cyclophosphamide (AC) for breast cancer. METHODS Seventy-two newly diagnosed women with breast cancer were instructed in a home-based moderate-intensity exercise intervention. Measures of functional ability, energy expenditure, and fatigue were obtained at baseline and posttest. Subjects maintained daily records of four types of fatigue, and exercise duration, intensity, and type. RESULTS Exercise significantly reduced all four levels of fatigue (P < 0.01). As the duration of exercise increased, the intensity of fatigue declined (P < 0.01). There was a significant carry-over effect of exercise on fatigue, but the effect lasted only 1 d. The level of fatigue at study entry was not associated with number of days of exercise or amount of exercise a woman engaged in. CONCLUSIONS The impact of exercise on fatigue was significant and suggests the effectiveness of a low- to moderate-intensity regular exercise program in maintaining functional ability and reducing fatigue in women with breast cancer receiving chemotherapy.

Psychometric testing of fatigue instruments for use with cancer patients

BACKGROUND Cancer treatment-related fatigue (CRF) is a common side effect of cancer treatment. A problem identified in most reviews of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state. The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study. The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment. OBJECTIVES The aims of this study were to determine the reliability, validity, and responsiveness of each instrument and to determine the ability of each instrument to capture CRF. METHODS Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale (F_POMS-sf), Multidimensional Assessment of Fatigue (MAF), Lee Fatigue Scale (LFS), and the Multidimensional Fatigue Inventory (MFI). Data were collected at a university-based clinical cancer center and a freestanding comprehensive cancer center. Subjects completed all study instruments, which were presented in random order, at a time when CRF was expected to be high and again when it was expected to be low. A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data. RESULTS Reliability estimates using Cronbachs alpha indicated that all instruments examined had good internal consistency. Test-retest correlations showed good stability for total scores on all the instruments, but some subscales of the LFS and MFI had marginal stability. Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity. All of the instruments showed responsiveness to changes in CRF related to treatment. CONCLUSIONS The results of the study provide researchers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF.

Motivational interviewing to increase physical activity in long-term cancer survivors: A randomized controlled trial

Background: Physical activity can confer many benefits on cancer survivors, including relief of persistent symptoms related to cancer treatment. Objectives: To evaluate the effect of a motivational interviewing (MI) intervention on increasing physical activity (Community Healthy Activities Model Program for Seniors questionnaire) and improving aerobic fitness (6-minute walk), health (Medical Outcomes Study Short-Form 36), and fatigue (Schwartz Cancer Fatigue Scale) in cancer survivors. A secondary purpose was to evaluate whether the effect of MI on physical activities depended on self-efficacy. Methods: Fifty-six physically inactive adult cancer survivors (mean = 42 months since completion of treatment) were assigned randomly to intervention and control groups. The MI intervention consisted of one in-person counseling session followed by two MI telephone calls over 6 months. Control group participants received two telephone calls without MI content. Outcomes were measured at baseline, 3 months, and 6 months, and were analyzed using multilevel modeling. Results: The results of the MI intervention explained significant group differences in regular physical activities (measured in caloric expenditure per week), controlling for time since completion of cancer treatment (p <.05). Aerobic fitness, physical and mental health, and fatigue were not different between groups. In the intervention group, individuals with high self-efficacy for exercise at baseline increased their physical activity more than those with low self-efficacy (p <.05). In the control group, increases in physical activity did not depend on self-efficacy. Discussion: Use of MI may increase physical activity in long-term cancer survivors, especially in persons with high self-efficacy for exercise. Multilevel modeling analysis revealed individual changes that would not have been shown by analysis of group means. Future studies with larger samples or more intense MI interventions may show changes in aerobic fitness, physical and mental health, and fatigue.

Fatigue Patterns Observed in Patients Receiving Chemotherapy and Radiotherapy

Abstract The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.

Fatigue in Patients With Cancer

PURPOSE/OBJECTIVES To provide a historic perspective on knowledge about fatigue in patients with cancer, review what is known, define gaps, and recommend future approaches. DATA SOURCES Published research reports, clinical papers, review articles, and practice guidelines. DATA SYNTHESIS Two tested interventions show consistent positive effects: treatment of chemotherapy-induced anemia and aerobic exercise. Other frequently suggested interventions, such as adequate nutrition, energy conservation, psychostimulants, antidepressants, and increased sleep and rest, either have not been tested or studies underway are not yet complete. Current practice guidelines are based on a combination of research and expert clinical judgment. CONCLUSIONS The knowledge base on fatigue continues to expand. Information about the mechanisms underlying fatigue is needed to develop innovative approaches to prevent and treat fatigue. IMPLICATIONS FOR NURSING Current practice guidelines should be used to guide care with the expectation that guidelines will evolve to incorporate the results of studies currently underway. Although specific gaps in knowledge need to be addressed to guide future practice, clinicians need to use existing knowledge in the care they are delivering today. All of the interventions proposed for managing cancer treatment-related fatigue are health policy challenges because they represent additions to usual care rather than replacements of existing components of care.

Process of coping with radiation therapy.

Evaluated the ability of self-regulation and emotional-drive theories to explain effects of an informational intervention entailing descriptions of the experience in concrete objective terms on outcomes of coping with radiation therapy (RT) in men (N = 84) with prostate cancer. The experimental group had significantly less disruption in function during and for 3 months following RT than the comparison group. The intervention had no significant effect on negative mood. Consistent with self-regulation theory, similarity between expectations and experience and degree of understanding of the experience mediated the effect of the intervention on function. Emotional-drive theory was not supported. These results are consistent with prior research with surgical patients and support the relevance of the information-processing explanations of self-regulation theory to coping with stressful experiences associated with physical illness.

Fatigue and Weakness in Cancer Patients: The Symptom Experience

OBJECTIVES To distinguish between fatigue and weakness and review symptom management for both and to suggest directions for research and practice. DATA SOURCES Articles and book chapters pertaining to fatigue and weakness. CONCLUSIONS Fatigue and weakness are important but long-neglected symptoms, and comparatively little effort has been invested in developing techniques to mitigate these symptoms. Research is needed to differentiate between these concepts, to determine the relation between fatigue and weakness, to delineate their causes, and to develop interventions aimed at the prevention and treatment of these symptoms. IMPLICATIONS FOR NURSING PRACTICE Early assessment of risk factors, mobility and sensory problems, and usual level of activity will help identify those patients who may benefit from nursing interventions or referrals for occupational or physical therapy. It is important to repeatedly evaluate these symptoms in relation to treatment, situational changes, interventions used to manage other symptoms, and tumor progression. Developing clinical guidelines and intervention strategies will contribute greatly to the functional independence and the quality of life of patients.

Measurement of Fatigue: Determining Minimally Important Clinical Differences

The purpose was to determine the minimally important clinical difference (MICD) in fatigue as measured by the Profile of Mood States, Schwartz Cancer Fatigue Scale (SCFS), General Fatigue Scale, and a 10-point single-item fatigue measure. The MICD is the smallest amount of change in a symptom (e.g., fatigue) measure that signifies an important change in that symptom. Subjects rated the degree of change in their fatigue over 2 days on a Global Rating Scale. 103 patients were enrolled on this multisite prospective repeated measures design. MICD was determined following established procedures at two time points. Statistically significant changes were observed for moderate and large changes in fatigue, but not for small changes. The scales were sensitive to increases in fatigue over time. The MICD, presented as mean change, for each scale and per item on each scale is: POMS = 5.6, per item = 1.1, SCFS = 5.0, per item = 0.8, GFS = 9.7, per item = 1.0, and the single item measure of fatigue was 2.4 points. This information may be useful in interpreting scale scores and planning studies using these measures.

The Cancer Chemotherapy Drug Etoposide (VP-16) Induces Proinflammatory Cytokine Production and Sickness Behavior–like Symptoms in a Mouse Model of Cancer Chemotherapy–Related Symptoms

Cancer chemotherapy–related symptoms such as fatigue, malaise, loss of interest in social activities, difficulty concentrating, and changes in sleep patterns can lead to treatment delays, dose reductions, or termination and have a profound effect on the physical, psychosocial, and economic aspects of quality of life. Clinicians have long suspected that these symptoms are similar to those associated with “sickness behavior,” which is triggered by the production of the inflammatory cytokines IL-1β, TNF-α, and IL-6 by macrophages and other cells of the innate immune system in response to immune challenge. The p38 mitogen-activated protein kinase (p38 MAPK) plays a central role in the production of these cytokines and consequently the induction of sickness behavior. Several cancer chemotherapy drugs have been shown to activate p38 MAPK, but whether these drugs can also induce the production of inflammatory cytokines to cause sickness behavior is unknown. The aim of this study was to determine whether the cancer chemotherapy drug etoposide (VP-16), which is known to activate p38 MAPK, could induce inflammatory cytokine production by murine macrophages and sickness-like behaviors when injected into mice. VP-16 activated p38 MAPK and induced IL-6 production in murine macrophages in a p38 MAPK– dependent manner. VP-16 administration rapidly increased serum levels of IL-6 in healthy mice and induced sickness-like behaviors as evidenced by a decrease in food intake, body weight, hemoglobin level, and voluntary wheel-running activity. These findings support the idea that the induction of IL-1β, TNF-α, and IL-6 by cancer chemotherapy drugs underlies the fatigue and associated symptoms experienced by people undergoing cancer chemotherapy.

Operationalizing symptom distress in adults with cancer: a literature synthesis.

PURPOSE/OBJECTIVES To address inconsistencies in the definition and operationalization of symptom distress by synthesizing the literature on cancer-related symptom distress in adults. DATA SOURCES Electronic nursing, psychology, and medicine databases; online meeting abstracts; and various print sources. DATA SYNTHESIS Eight distinct methods of operationalizing the concept were identified. Gender, ethnic, developmental, cultural, and individual differences in symptom distress have not been identified. Relationships among symptom frequency, intensity, and distress are unclear. CONCLUSIONS Lack of clarity and consensus in defining and operationalizing symptom distress hinder meta-analysis, research synthesis, and research utilization. Symptom distress may be emerging as a component of the multidimensional symptom experience. IMPLICATIONS FOR NURSING Defining and operationalizing symptom distress consistently will enhance research synthesis and assist clinicians with more effectively meeting the needs of people with cancer. Research is needed to identify the meanings of symptom distress to patients with cancer and to differentiate symptom distress from symptom frequency and intensity.