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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

Anita Dsouza1, Richa Kamboj1, Sarika Mandavkar1, Neeta Chavan1, Anant Ramaswamy2, Vikas Ostwal2,  
1 Department of Nursing, GI Unit, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Vikas Ostwal
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India

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.



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;55:162-165


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 Dec 11 ];55:162-165
Available from: http://www.indianjcancer.com/text.asp?2018/55/2/162/249208


Full Text

 Introduction



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 cancerTo assess the coping strategies adopted by patients with GI cancer receiving chemotherapyTo 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



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 ageDiagnosed with primary GI cancerReceiving neoadjuvant/palliative chemotherapy for GI cancerCould read, write, and speak Hindi, Marathi, and EnglishWilling 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 studyMajor comorbid conditions such as stroke, acute myocardial ischemia or unstable angina, and acute pulmonary diseases during the past 6 months before recruitment into the studyAcute 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.

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 Results



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}

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



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



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.

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