Cancerrelated fatigue and psychological distress depression and disability

Whereas physical markers of fatigue in cancer patients have been difficult to demonstrate consistently, the evidence for an association with depression and anxiety (reviewed in Chapter 10) is overwhelming. Indeed, it is difficult to find studies which have measured cancer-related fatigue and any measure of psychological distress which do not report an association. Thus Fulton (1997) reported an association between fatigue and anxiety and depression measured on the Hospital Anxiety and Depression Scale (Zigmond and Snaith 1983), Irvine et al. (1994) and Cimprich (1999) found associations with low mood and fatigue, Schneider (1998) found an association with fatigue and depression on the Beck Depression Inventory (Beck et al. 1961) and Broeckel et al. (1998) showed a strong association between fatigue and common psychiatric diagnoses such as depression and anxiety. Other studies showed similar associations on a variety of measures (Smets et al. 1996, 1998a,b; Akechi et al. 1999; Cimprich 1999). Fatigue is also strongly associated with sleep disturbance (Smets et al. 1998a,b; Broeckel et al. 1998). There has been less written about the role of patients' beliefs and behaviour as risk factors for perpetuating fatigue in cancer, but one study (Broeckel et al. 1998) found that in women undergoing chemotherapy for breast cancer, those who had the highest fatigue scores tended to use more 'catastrophizing' coping strategies. This finding might fit into a model of fatigue that suggests that patients' reactions to symptoms are crucial in terms of how disabling such symptoms become.

From a clinical viewpoint, the lack of association (or at least weak association) between disease activity and fatigue and the much stronger association between fatigue and psychological distress suggests that when a patient diagnosed with cancer presents with severe fatigue, an exhaustive physical assessment should be balanced with a detailed psychological one. Naturally the clinician will want to rule out a few specific and readily remedial physical causes of fatigue (such as anaemia); however, a detailed psychosocial assessment should then attempt to rule out the presence of depression and to tease out the patient's view of the meaning behind his or her symptom, and what it stops them from doing. As shown later in this book (Chapter 12) the best approach in patients whose disease status is relatively stable may share much with the cognitive behaviour therapy and graded exercise used in CFS.

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