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Impact
of Adjuvant Breast Cancer Chemotherapy on Fatigue, Other Symptoms, and Quality
of Life
Katherine L. Byar,
MSN, APRN, BC, Ann M. Berger, PhD, RN, AOCN®, FAAN,
Suzanne L. Bakken, MSN, APRN, and Melissa A. Cetak, MSN, APRN, BC, OCN®
Purpose/Objectives:
To identify
differences in fatigue, other physical symptoms, and psychological symptoms and
their relationship to quality of life (QOL) during chemotherapy and as long as
one year after.
Design: Longitudinal, descriptive design
embedded in a pilot intervention study.
Setting:
Midwestern urban
oncology clinics and patient homes.
Sample:
25 Caucasian women,
aged 40–65 years (–X = 54.3), with stage I or II breast cancer receiving
doxorubicin-based chemotherapy.
Methods:
The Piper Fatigue
Scale, Hospital Anxiety and Depression Scale, Symptom Experience Scale, and
Medical Outcomes Study Short-Form General Health Survey were completed before
and after each treatment; 30, 60, and 90 days after the last treatment; and one
year after the first treatment.
Main
Research Variables:
Fatigue, physical and psychological symptoms, and QOL.
Findings:
Fatigue levels were
moderately intense during treatments and decreased significantly over time.
Sleep disturbances and pain were the most frequent, intense, and distressing
other physical symptoms. Anxiety was highest at baseline, and depression was
highest during the fourth chemotherapy treatment. Fatigue was correlated with
other physical and psychological symptoms at some times during treatments and
consistently following treatments. Higher fatigue was associated with lower QOL
in several domains.
Conclusions:
Fatigue is
associated with other physical and psychological symptoms that fluctuate during
and after treatment. Higher fatigue compromises QOL.
Implications
for Nursing: Interventions
targeting primary or cluster symptoms can reduce the impact of adjuvant
chemotherapy on fatigue, other symptoms, and QOL.
Key Points
·
Fatigue
is a moderately intense symptom during adjuvant breast cancer chemotherapy that
decreases, but does not return to low levels for all women, after active
treatment.
·
Frequent
and problematic symptoms associated with fatigue are pain, sleep disturbances,
nausea, concentration disturbances, anxiety, and depression.
·
Higher
levels of fatigue are related to lower quality of life in most domains during
and after adjuvant breast cancer chemotherapy.
Since
the 1970s, cancer has gone from being a fatal disease to a chronic illness,
with approximately 64% of adults diagnosed with cancer expected to be alive five years after diagnosis (Division of Cancer Control
and Population Sciences, 2005). The use of combined modality therapy has
contributed to the improved outcomes and has lengthened the survival curve (Ganz et al., 2002). As more women receive adjuvant
chemotherapy for breast cancer, recognition grows of the potential for acute
and long-term symptoms and decreased quality of life (QOL) among survivors
whose five-year survival rate is 97% for localized disease and 80% for regional
disease (American Cancer Society, 2005; Knobf, 2000).
Cross-sectional studies have found that women with breast cancer report
fatigue, decreased stamina, depression, and poor sleep quality long after
completing therapy that affects their QOL (Bower et al., 2000; Broeckel, Jacobsen, Horton, Balducci,
& Lyman, 1998; Cella, Davis, Breitbart,
& Curt, 2001). Despite this knowledge, healthcare providers have little
understanding of the characteristics of and relationships among the symptoms
and QOL and how they change over time.
The
overall purpose of the current study was to describe the impact of adjuvant
chemotherapy for breast cancer on fatigue, other symptoms, and QOL during and
after treatment. Specific aims were to
1. Identify differences
in fatigue, other physical symptoms (nausea, pain, appetite, sleep
disturbances, bowel patterns, concentration, and appearance), and psychological
symptoms (anxiety and depression) across four cycles of chemotherapy; at 30,
60, and 90 days after the last treatment; and one year after the first
treatment.
2. Identify
relationships among (a) fatigue and other physical and psychological symptoms
at baseline, after selected treatments, and at selected times after the last
treatment and (b) fatigue and QOL at baseline, 60 days after the last
treatment, and one year after the first treatment.
Conceptual Framework
Piper’s
Integrated Fatigue Model, which proposes 14 factors that influence fatigue in
patients with cancer, guided the study (Piper, Lindsey, & Dodd, 1987). The
intervention for the pilot study attempted to positively influence the
relationship illustrated in the model between sleep/wake patterns and fatigue.
In prior studies, disturbances in sleep/wake patterns and increased symptoms
(including difficulty sleeping) have been shown to be associated with fatigue
(Berger & Farr, 1999; Berger & Higginbotham, 2000; Berger & Walker,
2001).
Literature Review
Fatigue
The
most common unrelieved and distressing symptom related to cancer and
chemotherapy treatment is fatigue (Patrick et al., 2004). Fatigue secondary to
cancer and its treatments differs from acute fatigue because patients continue
to suffer feelings of weakness and tiredness not fully relieved by rest (Cella et al., 2001).
Fatigue,
like pain, is not explained by physiologic mechanisms alone; it also must be
understood as a multidimensional concept that includes physical, psychological,
social, and spiritual aspects. It is a perception best measured by self-report
(Piper et al., 1998). Although literature focusing on fatigue has increased,
researchers still have not agreed on a universal definition of fatigue. For the
current study, fatigue was defined as “a subjective feeling of tiredness that
is influenced by circadian rhythm and can vary in unpleasantness, duration, and
intensity” (Piper et al., 1987, p. 19).
Women
receiving adjuvant therapy for breast cancer have indicated that fatigue is one
of the most common and distressing symptoms (de Jong,
Courtens, Abu-Saad, &
Schouten, 2002; Donovan et al., 2004). As many as 99% of women
studied experienced some level of fatigue during the course of treatment, and
more than 60% rated the level of fatigue as moderate to severe (Jacobsen et
al., 1999). Fatigue has been found to increase significantly after the first
cycle of chemotherapy and remain elevated during the following three cycles of
treatment (Jacobsen et al.).
Few
authors have contributed to the literature on fatigue after adjuvant treatment
for breast cancer, despite findings that fatigue persists in the weeks and
months after completion of treatment. Breast cancer survivors 3–36 months
following adjuvant chemotherapy have reported more fatigue than a comparison
group with no history of cancer (Broeckel et al.,
1998). About one-third of breast cancer survivors reported more severe fatigue
associated with higher levels of depression, pain, and sleep disturbances
(Bower et al., 2000).
Other
Physical and Psychological Symptoms
A
majority of women experience physical and psychological side effects associated
with cancer treatment (Badger, Braden, & Mishel,
2001). In addition to fatigue, women undergoing chemotherapy report a variety
of gastrointestinal, psychoneurologic, and menopausal
symptoms. Until recently, research has focused on individual symptoms such as
fatigue. However, researchers now are recognizing that some symptoms may be
interrelated even though they may not share the same etiology (Beck,
Fatigue
at the time of treatment and at cycle midpoints has been best explained and
predicted by levels of symptom severity (nausea, difficulty sleeping, and
negative mood) (Berger & Walker, 2001). A follow-up study throughout the
entire third cycle of chemotherapy confirmed that fatigue and symptom distress
occur in unison at most time points during chemotherapy treatment cycles and
during recovery (Berger & Higginbotham, 2000). Fatigue was
significantly predicted by depression, pain, current tamoxifen
use, mastectomy, and anxiety in a sample of 112 patients with breast cancer who
were at a clinic for treatment or follow-up examination (Haghighat,
Akbari, Holakouei, Rahimi, & Montazeri, 2003).
Adjuvant
therapy has been shown to result in adverse effects that affect physical health
status 5–10 years after the diagnosis of breast cancer (Ganz
et al., 2002). Increased fatigue among survivors has been related to poorer
sleep quality, more menopausal symptoms, greater use of catastrophizing,
and presence of a psychiatric disorder (Broeckel et
al., 1998). Multivariate analysis of 1,957 breast cancer
survivors that were one to five years after initial diagnosis found depression
and pain to be the strongest predictors of fatigue (Bower et al., 2000).
Despite advances in symptom management, these persistent and late side effects
remain major sources of distress for cancer survivors (Goodell
& Nail, 2005; Longman, Braden, & Mishel,
1999; Pasacreta, 1997). The effectiveness
of symptom management for persistent treatment-related side effects has become
a QOL indicator (Longman et al.).
Quality
of Life
Clinical
investigators have become increasingly more aware of the importance of QOL
during and after treatment. Interference with daily functioning and decreased
QOL have been reported in breast cancer survivors
(Bower et al., 2000; Broeckel, Jacobsen, Balducci, Horton, & Lyman, 2000). Breast cancer
survivors with no past systemic adjuvant therapy had better QOL in the domains
of physical functioning, physical role function, bodily pain, social
functioning, and general health than those who had received systemic adjuvant
therapy (chemotherapy or tamoxifen). A multivariate
analysis found past chemotherapy to be a statistically significant predictor of
poorer current QOL (p = 0.003) (Ganz et al., 2002).
Limited
information exists concerning the relationships among fatigue, other symptoms,
and QOL before, during, and after chemotherapy treatments. Learning about the
relationships will enhance the understanding of the problems faced by
survivors. The knowledge can lead to the development of management strategies
to improve long-term QOL for women living with breast cancer.
Methods
Design
The
study was longitudinal and descriptive, embedded in a pilot study that tested
an intervention designed to improve sleep and modify fatigue.
Sample
and Setting
Eligibility
criteria included women who (a) were aged 40–65 years, (b) were newly diagnosed
with stage I or II breast cancer, (c) had undergone a modified radical
mastectomy or lumpectomy, (d) were receiving a doxorubicin-based chemotherapy
regimen, (e) spoke English and were able to complete the research tools, and
(f) had a Karnofsky Performance Scale score greater
than 60. Age was restricted because of the natural changes in sleep patterns
that occur at about age 40 and the possibility that women older than 65 may
have fatigue associated with various comorbid
diseases that could threaten the validity of the results. Exclusion criteria
included women with comorbidities known to be
associated with fatigue (e.g., diagnosis of chronic insomnia, congestive heart
failure, chronic obstructive pulmonary disease, insulin-dependent diabetes,
neuromuscular disease, current steroid therapy) and jobs with rotating or
permanent shifts that result in sleep at times other than at night.
Three
oncology clinics were used to recruit the desired sample size for the pilot
study in an efficient manner. In a period of six months, 23 participants
completed the study during treatment, which included two baseline days and the
first seven days after each of four chemotherapy treatments. Twenty-one
participants completed the study after treatment ended, which included seven
days of data collection at 30, 60, and 90 days after the last treatment and one
year after the first treatment.
Measurement
of Variables
The
researchers tried to minimize participant burden and selected measurement tools
that had established reliability and validity.
Fatigue:
Three measurements
of subjective fatigue were used. The first was the total Piper Fatigue Scale
(PFS), intended to measure peak fatigue. The second was a single fatigue
intensity (FI) item (question 7 from the PFS), intended to capture
daily fatigue. The third was the fatigue items (composed of frequency,
intensity, and distress characteristics) in the Symptom Experience Scale
(SES), to describe symptoms during the previous week.
The
PFS contains 22 items that measure four dimensions of subjective fatigue:
behavioral severity (six items), sensory (five items), cognitive/mood (six
items), and affective/meaning (five items). Each item is anchored by two words
(e.g., strong/weak), and an individual circles a number from 0–10 that best
describes the current fatigue experience. Total and subscale mean scores were
obtained by summing the individual items of each subscale and dividing by the
number of items in the subscale or total score. Five open-ended questions
regarding the temporal dimension of fatigue, perceived cause, effect, and additional
symptoms complete the PFS. Content and concurrent validity have been estimated
in patients with cancer. The PFS took two to five minutes to
complete at baseline, on day 3 (peak fatigue), after each treatment, and at
each of the later times. Internal consistency reliability of the scale and
subscales ranges from alphas of 0.92–0.98 in numerous and diverse studies
(Piper et al., 1998) and was 0.94–0.98 in the current study.
The
FI item (question 7 on the PFS) was used to measure midday fatigue intensity:
“How would you describe the degree of intensity of the fatigue you are
experiencing today?” (0–10). The FI item has been
reported to be correlated with the total score on the PFS (r = 0.86–0.95, p
< 0.001) (Berger & Higginbotham, 2000). Recording a number from 0–10
that reflected midday (2–6 pm) fatigue intensity took less than one minute each
day. The FI score was obtained beginning two days before each treatment and for
seven days after each treatment and at each of the times following treatment.
The frequency, intensity, and distress characteristics of the FI were gathered
as part of the SES.
Other
physical symptoms:
The SES measures women’s symptom experiences associated with treatment for
breast cancer. The physical symptoms included in the instrument are those
directly relevant to breast cancer treatment: nausea, pain, appetite, sleep disturbances, fatigue, bowel patterns, concentration,
and appearance. The frequency, intensity, and distress of each of the eight
symptoms over the prior seven days is rated on a
five-point, descriptive Likert scale, for a total of
24 items that take approximately five minutes to complete. The scale ranges
from 0 (absence of symptoms) to 4 (most negative symptom experience). A higher
score indicates a more negative symptom experience. Alpha reliabilities for the
eight symptoms have been reported to range from 0.86–0.95 (Samarel
et al., 1996) and were 0.83–0.93 in the current study. The fatigue items were
excluded from the SES for the study to avoid multicollinearity.
Psychological
symptoms: The Hospital
Anxiety and Depression Scale (HADS) is a brief, multidimensional, 14-item,
self-reported scale that screens for anxiety and depression symptoms in
medically ill patients (Zigmond & Snaith, 1983). The seven items on each psychological
symptom are scored by intensity individually on a 0 (none) to 3 (severe)
subscale for a total score ranging from 0–21. The total scores of each subscale
are interpreted as normal (0–7), mild (8–10), moderate (11–14), or severe
(15–21). The HADS takes less than five minutes to complete. Internal
consistencies are 0.80–0.93 for anxiety and 0.81–0.90 for depression scales,
and discriminant and concurrent validity have been
established (Herrmann, 1997). The HADS was completed at baseline, treatment 4,
60 days after the last treatment, and one year after the first treatment. Alpha
reliabilities ranged from 0.72–0.89 for anxiety scales and from 0.74–0.84 for
depression scales in the current study.
Quality
of life: The Medical
Outcomes Study Short-Form General Health Survey (MOS SF-36-standard)
measures perceived health status, physical functioning, and mental health
domains of QOL. Eight scales are computed: physical, role physical, role
emotional, social, bodily pain, mental, vitality, and general health. Items are
scaled numerically in a Likert format. It takes less
than 10 minutes to complete, and scores range from 0–100, with 100 being the
most favorable score. Reliability coefficients have been reported as 0.81–0.88
(36 items). Discriminate validity was established, and the alpha coefficients
ranged from 0.734–0.813 (Ware & Sherbourne,
1992). The MOS SF-36-standard was completed at baseline, 60 days after the last
treatment, and one year after the first treatment. Alpha reliabilities in this
study were 0.68–0.94.
Data
Collection Schedule and Procedures
Following
institutional review board approval, each woman who had undergone surgery for
breast cancer and had scheduled an appointment to receive her first
chemotherapy treatment was contacted and invited to participate in the pilot
study. Further details about the pilot study and results have been reported
elsewhere (Berger et al., 2002, 2003). The 89% who agreed to participate met
with the researcher before or as close to the first treatment as possible, in a
mutually convenient place, usually the participants’ homes. After providing
written consent, participants received instructions to complete the research
tools on the scheduled days during treatment and after treatment ended, as
shown in Table 1. Subjects received standard of care
for symptoms outside of the research focus.
Data
Analysis
Descriptive
statistics (frequencies, means, standard deviations, and ranges) were obtained
for all variables at specified times. The mean of the seven FI scores recorded
daily during treatment or at times after treatment ended was calculated for
analysis. Correlations were performed to determine relationships among
variables. Random measurement analysis of variance (RM-ANOVA) was performed to
determine the patterns of fatigue, other symptoms, and QOL over time in the
pilot study. The Epi Info™ (Centers for Disease
Control and Prevention,
Results
Twenty-eight
Caucasian women were contacted, and 25 (89%) agreed to participate. No minority
women met the eligibility criteria. Participants were divided evenly between
stage I and II disease; most were married, employed full- or part-time,
postmenopausal, and high school graduates (see Table 2).
Fatigue
Participants
reported moderate-intensity fatigue as measured by the PFS on day 3 after each
treatment, and the level of fatigue remained relatively stable during
treatment. Subjects reported reduced levels of fatigue after treatments ended,
with the lowest level reported one year after the first chemotherapy treatment.
Fatigue scores changed significantly over time per RM-ANOVA. Mean daily fatigue
intensity scores measured by the FI item decreased from treatment 1 but
rebounded at the fourth treatment before decreasing after treatment ended. FI
scores per RM-ANOVA significantly changed over time in a pattern similar to PFS
scores. Participants reported stable levels of fatigue distress on the SES
during treatment and lower levels after treatment ended (see Table 3).
Frequency,
Intensity, and Distress of Other Physical and Psychological Symptoms
Descriptive
statistics were run to determine the means, ranges, and standard deviations for
the frequency, intensity, and distress scores of the other physical symptoms.
Seven symptoms were included (fatigue was excluded). Descriptive statistics of
psychological symptoms (anxiety and depression) were run to determine the means
and standard deviations.
Prior
to the first chemotherapy treatment, the symptoms reported most frequently were
sleep disturbances and pain. At the time of subsequent treatments, women consistently
reported sleep disturbances. Gastrointestinal symptoms also occurred
frequently, with nausea reported more frequently at later treatments. At all times after treatments ended, women reported that sleep
disturbances and pain persisted, that nausea abated, and that difficulty
concentrating occurred. Prior to the initiation of chemotherapy, the
most intense symptoms reported were sleep disturbances, pain, and concentration
disturbances. After treatment 1, sleep disturbances were reported as intense prior
to and following later treatments. After treatment ended, sleep disturbances
and pain persisted as the most intense symptoms; difficulty concentrating also
was one of the most intense symptoms.
Before
chemotherapy started, pain and sleep disturbances were ranked as the most
distressing symptoms. Following treatments 1, 3, and 4, nausea was reported as
the most distressing symptom. Distress associated with concentration
disturbances increased during later treatments. After treatment ended, sleep
disturbances and pain were the most distressing symptoms.
The
frequency, intensity, and distress scores then were combined, as instructed by
the developer of the SES instrument, to create a mean score and standard
deviation for each of the other physical symptoms at each time. Figure 1 illustrates the trajectory of each symptom over
time. As shown in Table 3, physical symptom frequency, intensity, and distress
changed significantly over time as determined by RM-ANOVA. Other physical symptom
levels were mild and stable during treatment and significantly declined after
treatment ended.
Mean
scores for anxiety and depression were within normal limits at measured times,
ranging from 1–20 for anxiety and 1–14 for depression. Women reported anxiety
more frequently than depression at all times except at treatment 4. Perceived
anxiety did not change significantly over time. Depression was lower at
baseline, peaked at treatment 4, and then returned close to baseline after
treatment ended.
Relationships
of Fatigue to Other Physical and Psychological Symptoms
Pairwise correlations were performed between fatigue and the two
psychological symptoms (anxiety and depression) and the seven other physical
symptoms (see Table 4). At baseline, fatigue was not
related to anxiety, depression, or other physical symptoms. In the seven-day
periods after each chemotherapy treatment, significant relationships of fatigue
to anxiety, depression, and other physical symptoms were noted at several
times. The relationship of fatigue to baseline anxiety and depression was
inconsistent during treatments. After treatment ended, fatigue was consistently
and significantly correlated with the two psychological and the seven other
physical symptoms.
Relationship
Between Fatigue and Quality of Life
At
baseline, the means of the six QOL domains (all except mental and general
health) examined by t test analyses were significantly (p = 0.01) lower than
the population group norms established by Ware (1993). Pearson correlations
were used to examine the relationships between levels of eight QOL domains and
daily FI at specific times (see Table 5). At baseline,
women who were reporting higher levels of daytime fatigue experienced lower
levels of QOL in four domains: physical, role emotional, mental, and vitality.
At 60 days after completing chemotherapy, women experiencing higher levels of
daytime fatigue reported lower QOL in seven of the eight domains (all except
bodily pain). At one year after the initiation of chemotherapy, women
experiencing more intense fatigue reported lower levels of QOL in all domains
except physical and emotional roles.
Discussion
No
previous study has provided such an in-depth description of the impact of
adjuvant breast cancer chemotherapy on fatigue, other symptoms, and QOL in
women during and after treatment. The findings are important to researchers
developing interventions to modify fatigue and to clinicians who support and
teach patients with breast cancer.
Fatigue
was found to be a moderately intense symptom during chemotherapy treatments,
consistent with findings of previous studies (Berger, 1998; Boehmke,
2004; Knobf, 2000). Fatigue increased from baseline
to the first treatment but did not rise with subsequent treatments, also
consistent with previous findings (Berger; de Jong et
al., 2002; Jacobsen et al., 1999). After completion of treatment, mean fatigue
decreased but was not gone for all women. The results reinforce previous
findings that fatigue persists beyond active treatment for about one-third of
breast cancer survivors (Bower et al., 2000; Cella et
al., 2001).
Other
frequent and problematic symptoms were pain, sleep disturbances, nausea,
concentration, anxiety, and depression. The trajectories of pain, sleep, and
concentration did not follow the bell curve pattern of appearance and
gastrointestinal symptoms. Gastrointestinal complaints were much lower
following treatment than psychoneurologic symptoms
and may be related to faster recovery time for cells in the gastrointestinal
tract than for the central nervous system.
Pain
was one of the most problematic symptoms (Eversley et
al., 2005; Given, Given, Azzouz, Kozachik,
& Stommel, 2001). Various etiologies for
post-treatment pain have been identified, including postsurgical
pain, neuropathies, mucositis, lymphedema,
metastasis, and postherpetic neuralgias (Longman et
al., 1999; Shapiro & Recht, 2001). Sleep
disturbances continued after completion of chemotherapy, a time when most
participants were taking 20 mg tamoxifen daily and
many had hot flashes. Although the majority of women treated
with chemotherapy have mild or moderate nausea and vomiting, the symptoms
previously have been reported as severe in about 5% of women (Shapiro & Recht). Distress related to nausea was prevalent in
the women in the current study. Cognitive disturbances increasingly have been
observed to be a problem in women during and after adjuvant breast cancer
chemotherapy and to be associated with fatigue and menopausal symptoms (Tchen et al., 2003). Anxiety was highest at baseline,
consistent with reports that it is highest at the time of diagnosis (Williams
& Schreier, 2004).
The
findings also concur with previous findings that fatigue is associated with other
physical and psychological symptoms during and after chemotherapy (Badger et
al., 2001). Depression and fatigue at the time of the fourth treatment were
linked, consistent with prior findings (Badger et al., 2001). Women who
reported elevated depressive symptoms had more physical symptom distress and
more impaired functioning (both p < 0.001) (Pasacreta,
1997). Findings also are consistent with literature that reported
that women’s higher fatigue is related to lower QOL in most domains during and
after adjuvant breast cancer chemotherapy (Bower et al., 2000; Broeckel et al., 2000; Ganz et
al., 2002).
Strengths
of the current study are the demographic and diagnostic homogeneity of the
sample, the use of well-established self-report instruments, and the
longitudinal design. Measuring the level of fatigue at a set time of day and
completing tools in the home setting strengthen the reliability of the
findings. Limitations are the small sample size, missing data, and a
convenience sample that included only Caucasians, which affect the generalizability of the findings. The results may not
reflect the natural progression of symptoms that would have occurred without
the sleep intervention. However, the intervention focused on improving sleep
and did not directly address other symptoms. The participants might have
reported more frequent, intense, and distressing sleep disturbances because the
intervention focused on that symptom.
Care
should be taken when generalizing information collected from a sample without a
true baseline because surgical procedures and radiation therapy treatments were
not identical for the sample. A limitation of many of the instruments is that
they were used to measure fluctuating symptoms, and the time of day for
completing written tools could not be controlled. A limitation of the SES is
that it does not include measurement of menopausal symptoms (hot flashes and
weight gain) reported by women taking tamoxifen (Boehmke, 2004).
Implications for Research and Practice
A great
deal of work must to be done by researchers and clinicians in regard to
fatigue, other symptoms, and QOL in women receiving adjuvant therapy for breast
cancer. Many variations exist in the definition and measurement of the concepts
in the literature. Continued methodologic work may
result in a handful of tools with established reliability and validity that can
be used consistently in research studies and practice settings. Interventions
must be developed and tested to modify clusters of fatigue and psychoneurologic symptoms (e.g., pain, sleep disturbances,
depression, impaired cognitive functioning, menopause).
The
study’s findings point out the need for clinicians to routinely screen and
perform further assessments of the frequency, intensity, and distress of other
physical and psychological symptoms and their impact on QOL in patients with
breast cancer. Evidence-based antiemesis, distress,
and pain guidelines and fatigue assessment and management should be integrated
into practice. Aggressive management and referrals for control of the most
common side effects may assist in relieving acute and chronic
chemotherapy-related fatigue (Jacobsen et al., 1999).
Screening
currently is not systematic or effective in practice settings for many reasons,
including patient and healthcare provider issues. Patient barriers to fatigue
assessment and treatment include not wanting to bother their healthcare
providers, fear that their treatments may be altered if they bring up their
fatigue, and the assumption that they will just have to live with it. Women
experiencing fatigue, depression, pain, or sleep disturbances should be
identified early, assessed frequently, and encouraged to participate in
physical and psychosocial rehabilitation programs.
Interventions
to reduce fatigue and other symptoms and improve QOL during and after
chemotherapy are being developed and tested for effectiveness. Targeting
primary or cluster symptoms and delivering effective interventions may reduce
the impact of adjuvant breast cancer chemotherapy on fatigue, other symptoms,
and QOL.
The
authors would like to thank Patti Higginbotham, MS, RN, AOCN®,
research nurse, and Sangeeta Agrawal,
MSc, research analyst, both at the University of
Nebraska Medical Center at the time of the study, for their assistance in data
collection and analysis. They also would like to thank the physicians, nurses,
support staff, and patients who participated in the study.
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Katherine
L. Byar, MSN, APRN, BC, is a hematologic
nurse practitioner in the Department of Internal Medicine–Oncology/Hematology
Section, and Ann M. Berger, PhD, RN, AOCN®, FAAN, is an associate
professor, advanced practice nurse, and the Niedfeld
Nursing Professor in the College of Nursing, both at the University of Nebraska
Medical Center in Omaha; Suzanne L. Bakken, MSN,
APRN, is a certified nurse practitioner at Sioux Valley Clinic–Occupational
Medicine in Sioux Falls, SD; and Melissa A. Cetak,
MSN, APRN, BC, OCN®, is a nurse practitioner at Southeast Nebraska
Oncology/Hematology in Lincoln. This study was funded by an ONS Foundation
research grant supported by Ortho Biotech Products, L.P., and a scholarship
from the American Cancer Society. (Submitted May 2005.
Accepted for publication August 6, 2005.)
Author
Contact: Katherine
L. Byar, MSN,
Digital
Object Identifier: 10.1188/06.ONF.E18-E26
