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  Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 55  |  Issue : 2  |  Page : 162-165
 

An evaluation of early-onset fatigue and the related coping strategies in patients with gastrointestinal cancer: A prospective pilot study


1 Department of Nursing, GI Unit, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Vikas Ostwal
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_568_17

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 » Abstract 


BACKGROUND: Cancer related fatigue (CRF) has been studied extensively and it has the worse impact as compared to pain on quality of life (QOL) of cancer patients. MATERIAL AND METHODS: Prospective study was conducted at Tata Memorial center in Gastrointestinal (GI) cancer patients to assess fatigue with FACIT and PIPER scales. This was also to assess qualitative data on coping strategies in these patients. RESULTS: Severe to moderate fatigue was commonly associated with sedentary to moderate activities (P = 0.049) whereas it was less common as education level increases (P = 0.031). Baseline pain was significantly associated with increase in fatigue (P = 0.033). This study also suggests that fatigue increases with as number of chemotherapy cycles increase. Qualitative data analysis revealed that majority of the patients used resting and energy conservation in the form of sitting, lying down. Most of them were following high protein diet (with or without supplementary protein powder) and little exercise such as walking. CONCLUSION: Patients with GI cancer receiving chemotherapy were found to have fatigue, which increased during the subsequent cycles. Patients with sedentary lifestyle and experiencing pain at baseline were found to have more fatigue. Coping strategies adopted by majority of patients were resting and a high-protein diet.


Keywords: Chemotherapy, coping strategies, fatigue, gastrointestinal cancers


How to cite this article:
Dsouza A, Kamboj R, Mandavkar S, Chavan N, Ramaswamy A, Ostwal V. An evaluation of early-onset fatigue and the related coping strategies in patients with gastrointestinal cancer: A prospective pilot study. Indian J Cancer 2018;55:162-5

How to cite this URL:
Dsouza A, Kamboj R, Mandavkar S, Chavan N, Ramaswamy A, Ostwal V. An evaluation of early-onset fatigue and the related coping strategies in patients with gastrointestinal cancer: A prospective pilot study. Indian J Cancer [serial online] 2018 [cited 2019 Mar 25];55:162-5. Available from: http://www.indianjcancer.com/text.asp?2018/55/2/162/249208



 » Introduction Top


Cancer-related fatigue (CRF) is a common clinical problem associated with the management of patients with cancer, whether it is prior, during, or posttreatment and it has the worse impact when compared with pain on quality of life (QOL) of patients with cancer.[1] CRF affects patient's QOL irrespective of cancer-directed treatment modality and continues to disrupt QOL in cancer survivors.[2],[3] While the burden of disease being a major contributor to the degree of fatigue is seen in patients with cancer, chemotherapy side effects may further accentuate fatigue initially till the time response to treatment is obtained.[4] This aspect of fatigue has been clearly shown in patients with breast cancer where fatigue increases after start of chemotherapy but reduces as the number of cycles increases.[5]

The basic pathophysiology behind the occurrence of CRF is not clear, which is probably the most important reason for not having standard treatment strategies to treat the same. The symptomatic management and psychosocial supports are being generally considered to manage CRF.[4] Patients with severe fatigue may benefit with treatment of sleep disturbances along with increase in physical activities.[6]

The presence of CRF along with chemotherapy-induced fatigue has been evaluated in different studies using different scales and this varies from 5% to 36% in various studies.[7],[8],[9] Data on fatigue especially baseline and with each cycle of chemotherapy for gastrointestinal (GI) cancers are scarce. Data from India with this regard are not found on literature search. We performed a prospective pilot study to assess CRF and chemotherapy-induced fatigue at cycles 1–3 of patients with GI cancers receiving biweekly chemotherapeutic regimens at GI Medical Oncology Department, Tata Memorial Center, Mumbai, with the following objectives:

  • To assess the degree of fatigue experienced by patients receiving chemotherapy for GI cancer
  • To assess the coping strategies adopted by patients with GI cancer receiving chemotherapy
  • To find the association between fatigue and selected variables, including baseline hemoglobin levels (g/dL), baseline albumin levels (g/dL), Eastern Cooperative Oncology Group Performance Status, comorbidities (present and absent), gender, travel time associated with visit to the hospital, baseline presence of pain, and degree of baseline physical activity.



  •  » Materials and Methods Top


    This is a prospective pilot study of patients with GI cancers receiving biweekly chemotherapeutic regimens which assessed the baseline levels of fatigue and change in severity of fatigue while on chemotherapy and coping strategies used by patients to deal with CRF. The nurses were trained specifically for the assessment of CRF and assessed patients under the guidance of medical oncologists.

    Qualitative–quantitative mixed method was used for this study. The research design used was nonexperimental qualitative–quantitative design. Patients receiving biweekly chemotherapeutic regimens – infusional 5-fluorouracil (5-FU), leucovorin, and oxaliplatin (mFOLFOX-6), infusional 5-FU, leucovorin, and irinotecan (mFOLFIRI), gemcitabine and oxaliplatin (GEMOX), and docetaxel for GI cancer – were included in the study. Convenient sampling was used for selecting samples, and purposive sampling was used to select samples for interview.

    Inclusion criteria

    The inclusion criteria of this study were as follows:

    • Above 18 years of age
    • Diagnosed with primary GI cancer
    • Receiving neoadjuvant/palliative chemotherapy for GI cancer
    • Could read, write, and speak Hindi, Marathi, and English
    • Willing to participate in the study.


    Exclusion criteria

    The exclusion criteria of this study were as follows:

    • Patients who have received chemotherapy/radiotherapy/surgery treatment 1 year before recruitment into the study
    • Major comorbid conditions such as stroke, acute myocardial ischemia or unstable angina, and acute pulmonary diseases during the past 6 months before recruitment into the study
    • Acute or chronic psychiatric or medical comorbidities leading to the use of antipsychiatric/anxiolytics/antidepressants or any therapy leading to the development of fatigue other than diagnosis of cancer and chemotherapy treatment.


    Sample data were collected using Piper et al.[10] and Functional Assessment of Chronic Illness Therapy (FACIT)[11] scales. Piper and FACIT scales are internationally recognized and validated CRF scales which can comprehensively assess the fatigue. These scales are validated in various studies and countries, for example, French study[12] showed correlation of almost 98% including subscales using Piper scale. These scales assess the perception of fatigue, level, and its impact on day-to-day activities, psychosocial, personal, behavioral, and cognitive areas. These scales were administered by two trained nurses at five different data points, that is, before beginning their first chemotherapy cycle, on days 8–10 after first chemotherapy cycle followed by 1 day before their second chemotherapy cycle, then on days 8–10 after their second chemotherapy, cycle finally followed by 1 day before their third chemotherapy cycle. The degree of fatigue was calculated using frequency percentage. It was categorized as mild, moderate, and severe fatigue. Reliability of the tool was ensured using a dry run method. A pilot study was conducted on eight participants to assess the feasibility of the study and was found to be feasible. Qualitative data are collected through an informal interview. The frequency of coping strategy use was measured in percentage (detailed methodology is given in Annexure 1). This study has received approval from the Institutional Ethics Committee with approval number being IEC/0117/1800/001.




     » Results Top


    In all, 43 patients were included in the study. The majority of participants were in the age group of more than 50 years (53.9%), with a majority being male (55.8%); the majority of participants were educated till higher secondary (62.79%), the majority of them (67.44%) were having hemoglobin levels between 9.0 and 12.0 g/dL; most of them (93.03%) were having albumin levels between 3.5 and 5.5 g/dL; and the majority of them (53.48%) were not experiencing pain before starting chemotherapy.

    Degree of fatigue

    The baseline levels of fatigue were mild and moderate in 76.7% and 23.3% of patients, respectively. On days 8–10 of chemotherapy cycle 1, 62.8% of samples experienced mild fatigue and 37.2% experienced moderate fatigue. One day before chemotherapy cycle 2, 48.8% of samples experienced mild fatigue and 51.2% of them experienced moderate fatigue. On days 8–10 of chemotherapy cycle 2, 9.3% of samples experienced mild fatigue, whereas 90.7% of them experienced moderate fatigue. One day before chemotherapy cycle 3, 14% of samples experienced mild fatigue, whereas 74.4% experienced moderate fatigue and 11.6% experienced severe fatigue. This concludes that fatigue increases with increase in the number of chemotherapy cycles.

    Of the factors associated with fatigue, there was a statistically significant correlation between baseline presence of pain and development of moderate-to-severe pain (P = 0.033). Similarly, patients with a sedentary-moderate level of physical activity had a greater level of moderate-to-severe fatigue (P = 0.049). None of the other factors evaluated correlated with degree or development of fatigue [Table 1]. Severe-to-moderate fatigue was seen less commonly as education level increased (P = 0.031).
    Table 1: Association of baseline parameters and severity of fatigue

    Click here to view


    Quality data analysis revealed that the majority of the patients used resting and energy conservation in the form of sitting and lying down. Most of them were following high-protein diet (with or without supplementary protein powder) and little exercise such as walking. Patients were using some or the other measures for recreation such as television and magazines. Most of them were positive about them and were psychologically strong.


     » Discussion Top


    Various causal factors have been evaluated as being causes for CRF. These include disease burden, chemotherapy,[13] being single,[14] comorbidities, poor nutrition, concomitant medications,[15] decreased sleep,[16] and inflammation.[17] CRF is generally seen in 4%–91% of patients.[18] Data are not much for GI cancers specifically; a small study had shown it to be 22%.[19] The coping strategies used by patients and therapies offered by oncologists to decrease the impact of fatigue should be directed to these factors. Most of the studies have looked at CRF in patients with breast cancer or have taken into account multiple cancers under a single umbrella. We specifically looked at patients with GI cancer receiving biweekly chemotherapy at multiple time points. GI CRF was more in those who have a higher level of baseline pain and a sedentary lifestyle. Most importantly, fatigue increased as the number of cycles of chemotherapy increased. While our study only encompassed patients for a short duration (approximately 1 month), it is a pointer toward chemotherapy being a cause of fatigue in the early phase of therapy.

    These data on GI patients from India also looking at coping strategies might help in defining the possible therapeutic measures such as stretching exercises, yoga, and increased involvement of trained nurses in counseling and support measures. While there are no definitive coping or management strategies that have resulted in alleviation of fatigue, the most commonly used strategy in our patients appears to be rest. Whether this is appropriate remains to be seen, as a moderate degree of exercise has been shown to improve fatigue as opposed to a limited level of physical activity. For GI cancer chemotherapy treatment, especially when patients are being treated with palliative intent, fatigue is always a commonly neglected but an important factor responsible for detrimental QOL.

    This study is a small sample size pilot study to highlight the importance of CRF in GI cancers. We have followed patients for three cycles only. Ideally, four to six cycles would have been better. The effect of the intervention on CRF was also not tested. Large scale studies would be required to evaluate coping strategies used by patients with CRF before further recommendations can be made to patients regarding the use of these interventions when receiving chemotherapy.


     » Conclusion Top


    Patients with GI cancer receiving chemotherapy were found to have fatigue, which increased during subsequent cycles. Patients with sedentary lifestyle and experiencing pain at baseline were found to have more fatigue. Coping strategies adopted by a majority of patients were resting and a high-protein diet.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.

     
     » References Top

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    Curt GA. Impact of fatigue on quality of life in oncology patients. Semin Hematol 2000;37:14-7.  Back to cited text no. 1
        
    2.
    Clark EJ, Stovall EL, Leigh S, Siu AL, Austin DK, Rowland JH. Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability. National Coalition for Cancer Survivorship; 1996.  Back to cited text no. 2
        
    3.
    LaVoy EC, Fagundes CP, Dantzer R. Exercise, inflammation, and fatigue in cancer survivors. Exerc Immunol Rev 2016;22:82-93.  Back to cited text no. 3
        
    4.
    Jacobsen PB, Hann DM, Azzarello LM, Horton J, Balducci L, Lyman GH, et al. Fatigue in women receiving adjuvant chemotherapy for breast cancer: Characteristics, course, and correlates. J Pain Symptom Manage 1999;18:233-42.  Back to cited text no. 4
        
    5.
    de Jong N, Candel MJ, Schouten HC, Abu-Saad HH, Courtens AM. Prevalence and course of fatigue in breast cancer patients receiving adjuvant chemotherapy. Ann Oncol 2004;15:896-905.  Back to cited text no. 5
        
    6.
    Peters ME, Goedendorp MM, Verhagen SA, van der Graaf WT, Bleijenberg G. Exploring the contribution of psychosocial factors to fatigue in patients with advanced incurable cancer. Psychooncology 2014;23:773-9.  Back to cited text no. 6
        
    7.
    Wang XS, Zhao F, Fisch MJ, O'Mara AM, Cella D, Mendoza TR, et al. Prevalence and characteristics of moderate to severe fatigue: A multicenter study in cancer patients and survivors. Cancer 2014;120:425-32.  Back to cited text no. 7
        
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    Aapro M, Scotte F, Bouillet T, Currow D, Vigano A. A practical approach to fatigue management in colorectal cancer. Clin Colorectal Cancer 2017;16:275-85.  Back to cited text no. 8
        
    9.
    Kogure E, Hara T, Ishii T, Maeda M. Changes in fatigue and physical function with age for patients with gastrointestinal cancer in the perioperative period: A comparison between older and young patients. J Phys Ther Sci 2017;29:2004-8.  Back to cited text no. 9
        
    10.
    Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM, et al. The revised piper fatigue scale: Psychometric evaluation in women with breast cancer. Oncol Nurs Forum 1998;25:677-84.  Back to cited text no. 10
        
    11.
    Webster K, Cella D, Yost K. The functional assessment of chronic illness therapy (FACIT) measurement system: Properties, applications, and interpretation. Health Qual Life Outcomes 2003;1:79.  Back to cited text no. 11
        
    12.
    Gledhill JA, Rodary C, Mahé C, Laizet C. French validation of the revised piper fatigue scale. Rech Soins Infirm 2002;68:50-65.  Back to cited text no. 12
        
    13.
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    Bower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR, et al. Fatigue in breast cancer survivors: Occurrence, correlates, and impact on quality of life. J Clin Oncol 2000;18:743-53.  Back to cited text no. 14
        
    15.
    Donovan KA, Small BJ, Andrykowski MA, Munster P, Jacobsen PB. Utility of a cognitive-behavioral model to predict fatigue following breast cancer treatment. Health Psychol 2007;26:464-72.  Back to cited text no. 15
        
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    Mitchell SA. Cancer-related fatigue: State of the science. PM R 2010;2:364-83.  Back to cited text no. 16
        
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    Barsevick A, Frost M, Zwinderman A, Hall P, Halyard M, GENEQOL Consortium, et al. I'm so tired: Biological and genetic mechanisms of cancer-related fatigue. Qual Life Res 2010;19:1419-27.  Back to cited text no. 17
        
    18.
    Lawrence DP, Kupelnick B, Miller K, Devine D, Lau J. Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients. J Natl Cancer Inst Monogr 2004;32:40-50.  Back to cited text no. 18
        
    19.
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