Risk factors for fatigue in cancer

If fatigue is strongly related to cancer, are there other risk factors among cancer patients which predict who is most likely to suffer from fatigue? The literature here

Table 1.2 Key studies assessing prevalence of fatigue in cancer patients

Study

Population

Prevalence of fatigue

Ashbury et al. (1998)

913 cancer patients recruited by advertisements. Had to have received treatment for cancer in previous 2 years

Fatigue most common symptom affecting 78%. Fatigue rated as causing difficulties with functional activities in 71% of sample

Blade et al. (1996)

72 patients under age 40 presenting to Mayo Clinic (USA) with multiple myeloma

'One-third' complained of weakness and fatigue—from case note review

Degner and Sloan (1995)

434 newly diagnosed patients with lung cancer. Consecutive sample from two tertiary referral clinics in Manitoba, Canada

Fatigue present in 39% (defined as high score on a symptom distress inventory). Fatigue was most common of 13 symptoms

Donnelly et al. (1995)

Consecutive sample of 1000 advanced cancer patients (mixed diagnoses) referred to a palliative care services in Cleveland, Ohio

48% with 'clinically important' fatigue; 47% with; clinically important' weakness

Glaus (1998)

499 mixed cancer patients identified from inpatients and outpatients in four Swiss hospitals

Loss of energy reported in 53%; weakness in 49% on fatigue assessment questionnaire

Hickok et al. (1996)

50 consecutive patients receiving radiotherapy for lung cancer in a cancer centre in Rochester, USA

78% experienced fatigue at some point during radiotherapy

Hopwood and Stephens (1995)

650 patients entering a UK multicentre randomized trial into the treatment of lung cancer

'Tiredness' and 'loss of energy' were the two most common symptoms, present in over 80% of patients

Irvine et al. (1994)

Convenience sample of 104 patients with mixed cancer diagnoses (mainly breast) about to undergo radiotherapy (55) or chemotherapy (49) in a Canadian hospital

39% fatigued (score >25 on Pearsons Byars Fatigue Feeling Checklist) pretreatment. Post-treatment 61%—similar figures for chemotherapy and radiotherapy

Kurtz et al. (1994)

208 mixed cancer (solid tumour and lymphoma) patients undergoing treatment for new disease or recurrence. All with caregiver prepared to participate

Fatigue reported by 78.4% who survived >1 year, 77.1% who survived 6 months-1 year and 83.9% who survived less than 6 months

Loge et al. (1999)

557 Hodgkin disease survivors identified from cancer centres in Norway

26% of survivors were fatigue cases (< 4 on Chalder questionnaire with at least 6 month duration

(continued)

(continued)

Table 1.2 (continued) Key studies assessing prevalence of fatigue in cancer patients

Study

Population

Prevalence of fatigue

Mendoza et al. (1999)

305 consecutive inpatients and outpatients with cancer presenting to cancer centre in Texas, USA

35% of patients but 5% of controls had 'severe fatigue' (7-10 on Brief Fatigue Inventory)

Nail et al. (1991)

49 patients with cancer receiving chemotherapy in

Rochester, USA. Used a self-care diary to report symptoms

2 days after treatment, fatigue was reported in 81%, and was most common symptom

Newell et al. (1998)

204 mixed cancer patients attending outpatients in a medical oncology unit in Australia

66.4% reported fatigue in past week

Ng and von Gunten (1998)

100 consecutive hospice patients admitted acutely to a US teaching hospital

83% weakness, 81% fatigue. Fatigue 'main complaint' in 6%

Richardson and Ream (1996)

109 patients undergoing chemotherapy for mixed cancers in UK. Patients were asked to keep a symptom diary during treatment

90% reported fatigue at some point during diary keeping period

Savage et al. (1997)

430 patients with new onset chronic myeloid leukaemia identified from a UK cancer centre

33.5% had fatigue or lethargy recorded as clinical feature in case notes at presentation

Smets et al. (1998a)

154 consecutive disease-free patients recruited 9 months post radiotherapy

In first 3 months post radiotherapy 32% had moderate fatigue and 19% very much

Smets et al. (1996)

141 patients in Holland in last week of radiotherapy.

134 cancer patients in Scotland undergoing radiotherapy

Dutch sample: 54% moderate or severe tiredness; 31% lack of energy. Scotland: 40% and 35% respectively

Smets et al. (1998b)

250 patients undergoing radiotherapy for various cancers with curative intent interviewed before and 2 weeks after completion of radiotherapy

After treatment: 40% reported feeling tired most of the time during treatment. 44% experienced increase in fatigue, 26% a decrease and 30% no change

Stone et al. (1999)

95 patients with advanced cancer from palliative care services in UK

'Severe subjective fatigue' defined as score of greater than the 95% percentile for a control population present in 75% of patients

Vaino and Auvinen (1996)

1840 mixed cancer patients from seven hospices in USA, Europe and Australia

No direct questions on fatigue. Weakness present in 35-75% of sample depending on site of cancer. Weakness and pain most common two symptoms

Vogelzang et al. (1997)

419 cancer patients who had received chemo- or radiotherapy

78% experienced fatigue during course of disease and treatment. 32% experienced fatigue on daily basis

becomes very complex, but for simplicity we will group the risk factors into sociode-mographic factors, disease-specific risk factors, and depression, pain, and disability.

Sociodemographic risk factors for fatigue in cancer

The pattern of increased risk of fatigue among women which was so clearly demonstrated in population-based studies of healthy individuals is not so obvious in cancer-related fatigue. Of nine studies identified which assessed the relationship, five found no difference between men and women (Hickok et al. 1996; Smets et al. 1998a; Glaus 1998; Donnelly et al. 1995; Stone et al. 1999), whilst the remaining four (Vogelzang et al. 1997; Smets et al. 1998 b; Loge et al. 1999; Akechi et al. 1999) showed that women had more fatigue than men. The key difference between papers which appear to show a difference and those which do not is the disease stage or time from treatment—those that found a difference in rates between men and women tended to have taken samples with earlier disease or 'survivors' in whom the disease had remitted. It may be that with less aggressive or remitted disease, the pattern of fatigue becomes closer to that of the general population.

The pattern of fatigue in cancer according to age is confusing. There might be an expectation that younger cancer patients suffer less fatigue, but Hickok et al. (1996) found a U-shaped distribution of fatigue in cancer patients according to age, with fatigue symptoms at their highest in relatively young adults (aged less than 50) and the over 70s. Glaus (1998) found a slightly more complex biphasic relationship, with younger patients having more affective symptoms of fatigue whilst the older group had more physical symptoms of fatigue. Two other studies reported a relationship between age and fatigue—Loge et al. (1999) found that older patients were more fatigued and Vogelzang et al. (1997) found younger patients were more fatigued. The remaining studies showed no relationship (Andrykowski et al. 1998; Smets et al. 1998a; Stone et al. 1999; Cimprich 1999; Hann et al. 1999).

One other remaining sociodemographic characteristic was widely studied, namely educational status. Here there appears to be a consistent association, with most studies reporting greater fatigue in the less well educated (Irvine et al. 1994; Mast 1998; Loge et al. 1999) although, as ever, there are exceptions, with one study (Akechi et al. 1999) describing the opposite relationship.

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