To Peter, and Ed and all those others who fed my spirit

Purpose of the articleMagnan, M.A, and Mood, D.W. (2003). The

effects of health state, hemoglobin, global symptom distress, mood disturbance, and treatment site on fatigue onset, duration and distress in patient receiving radiation therapy. Oncology Nursing Forum 30(2).

Purpose was to seek out correlates of early onset, long-lasting duration, and severe fatigue-related distress in persons receiving radiation for treatment of cancer.

Introduction

• How does cancer-related fatigue differ from general fatigue

• Scope of the problem

• Purpose of the article reviewed

• Significance to nursing

Faces of FatigueEnergy CrisisAt first I was energizedThe diagnosis shocked me into actionThe clutching fear galvanized me The details demanded attentionThe family’s tears called for comfortThe decisions were madeThe adrenaline flowed and I was energized

But one day all the energy was gone-Physical, psychic, emotional –

The days turned into weeksAnd the weeks into monthsNow I search Each cell of my bodyEach corner of my mindFor one tiny spark

Faces of Fatigue

Energy CrisisAt first I was energizedThe diagnosis shocked me into actionThe clutching fear galvanized me The details demanded attentionThe family’s tears called for comfort

The decisions were madeThe adrenaline flowed and I was energized

But one day all the energy was gone-Physical, psychic, emotional –

The days turned into weeksAnd the weeks into monthsNow I search Each cell of my bodyEach corner of my mindFor one tiny spark

Faces of FatigueMental fatigue often

results from the intensive mental effort and excessive attention that is necessary when coping with a serious illness.

A woman with newly diagnosed breast cancer must absorb the impact of the diagnosis as well as make treatment decisions to go on with her life

• Before I joined the “Cancer Club”, I shared similar thinking with many people that cancer is a death sentence and something to fear. After diagnosis, I realized it was really a gift that provided clarity and direction for the second half of my life.

•I no longer wait for "someday". I make sure every day is as fulfilling as possible. I value every single interaction I have with people. And I live every day fully and with dignity. Survivorship is really the power to face something so scary with fortitude and tenacity of being. I can't say I am positive every day, but I can firmly say I am thankful for the warning to slow down and smell the flowers.

Cancer-Related Fatigue

• CRF is more rapid in onset, more energy draining, more intense, longer lasting, more severe, and more unrelenting when compared with "typical" fatigue.

• CRF causes distress in the physical, social, spiritual, psychological, and cognitive domains.

• CRF is different than the typical fatigue of everyday life.

Scope of the Problem

• 8,000,000 persons are living with cancer in the US.

• 60-96% of cancer patients experience fatigue at some point during their treatment

• Cancer fatigue is a major troubling symptom and the primary cause of distress as persons try to contend with the illness and treatment regimen

Significance to Nursing:

Significance to nursing: Improve the timing of education and the content of what is being presented.

Currently little significance is given to baseline measurements when assessing for fatigue from radiation. If correlates point to initial levels of hemoglobin, or health state, then particularly vulnerable patients can be more carefully counseled.Complexity of nursing care increases with patients who suffer with the worst symptoms so these high risk patients should be identified

Overview of the article reviewed

• Quantitative: descriptive quasi-experimental correlational study utilizing secondary data from a large data bank.

General Reading

Burns, N. & Groves, S.K. (2007).Understanding Nursing Research (4th ed.). St. Louis:

Saunders.

Hanna, A., Sledge, G., Mayer, M.L., Hanna, N., Einhorn, L., Monahan, P., Daggy, J., and Bhatia, S. (2006). A phase II study of methylphenidate for the treatment of fatigue. Support Care Cancer 14: 210-215.

Holley, S. (2000). Cancer-related fatigue. Suffering a different fatigue. Cancer Practice 8(2) 87-95.

Highlight the findings

• Literature review:– Very nice review of the current literature on

fatigue associated with radiation treatment of cancer

– Persons fatigue can persist 6-months to a year after last radiation treatment

– 37 primary sources and 4 secondary sources cited. All primary sources from peer-reviewed literature

Overview of article reviewed

• 2 Clear research questions – Correlation between site and 3 outcome variables– Correlation between baseline characteristics and 3

outcome variables

• Methods• Sample: 384 subjects from 2 clinics

• Inclusions – age, language, number of treatments scheduled

• Exclusions (extraneous variables)– brain radiation, extremities as sole site, any cognitive compromise

Methods (cont’d)Dependent and independent variables

Dependent: onset of fatigue, duration of fatigue, and fatigue-related distressIndependent: site of radiation, hemoglobin level, health state, global symptom disturbance, mood disturbance

Potential confounding variablesAmount and type of radiationPrior or concurrent treatmentNutrition, self-care

Demographic variables: sex, age, marital status,

education, ethnicity, education, location of cancer, cancer stage, income, socioeconomic class

Methods (cont’d)

• Instruments – reliability and validity

• This is where things either come together or fall apart! Was there a choice? Big data bank from parent study– They did have trained research assistants administer

the questionnaires– They did measure hemoglobin and used a standard

tool for health state and mood disturbance. Health state tool is well established in cancer (alpha .93-.95)

Functional Assessment of Cancer Therapy 5-point Likert

Functional Well-Being• My work (including housework) is fulfilling• I am able to enjoy life “in the moment”• I have been able to work (including

housework)• I have accepted my illness• I am sleeping well• I am enjoying my usual leisure pursuits• I am content with the quality of my life right

now

Physical Well-Being• I have nausea• I have trouble meeting the needs of my

family• I have pain• I am bothered by side effects of treatment• In general I feel sick• I am forced to spend time in bed

Emotional Well-Being• I feel sad• I am proud of how I’m coping with my

illness• I am losing hope in the fight against my

illness• I feel nervous• I worry about dying• I worry that my condition will get worse

Social Well-Being• I feel distant from my friends• I get emotional support from my family• I get support from my friends and

neighbors• My family has accepted my illness• Family communication about my illness

is poor• I feel close to my partner (or main

support)• I am satisfied with my sex life

Methods (cont’d)

• Mood State – POMS modified – unclear as to whether this is a standard tool in cancer research but it is used in at least one other cancer study

• Global Symptom Distress – use in cancer is unclear

• Attributes of Fatigue – patient self-report ofdate of onset and duration. Fatigue distress 5-point

Likert scale of unestablished and unpublished origin (a better tool is on the next slide).

Data Analysis

• Multivariate data – standard SPSS PC9

• Paired sample t tests (to assess significance of change from baseline at different time intervals), analysis of variance Statistical significance set at 0.05

Power test at a level .97

Results – Did Address the Purpose

• Sample Characteristics – 2 outpatient clinics in Midwest, sex, age (24-87), ethnic, socioeconomic, education, etc.– Half African-American, half European-American, middle-class– All 20 radiation treatments – none to extremities only, nor to

brain, or otherwise cognitively compromised– Stage: 265 0-II, 161 III-IV– Site: 37% breast, 32% prostate

• Fatigue onset, duration, distressOnset average 8 days, but 20% reported onset at

day 1Duration 1 to 78 days – avg 32 daysDistress worst at the end of treatment

Results cont’d

• Correlates– Health state, hemoglobin, = delayed onset, less

distress, shorter duration– Global distress, Low mood = earlier onset, more

fatigue distress, longer duration– Site = prostate cancer: shorter duration

Gynecologic, and lung cancer: most severe distress

(concern regarding stage and site – confounding )

Limitations

• A better psychometric tool for fatigue is needed – BIF .96 alpha to support reliability

• Karnofsky scale would have been beneficial

• Concern about the 20% fatigue reported on the first day needed to be more clearly identified.

Limitations cont’d

• Confounding variables.– Unclear how persons with stage 0 (carcinoma

in-situ or precancerous) to stage I can be scheduled for 20 courses of radiation

– Type and amount of radiation

Implications for Nursing

• Preassessment of baseline Hgb, Health Status, Mood, Distress is important because it can guide timing of educational interventions

• Patients need to understand fatigue is an individualized experience and they should not compare their experiences with those of others.

Significance to nursing:

Sit down to bathe: instead of wasting energy drying off, wear a terrycloth robe that does the job for you.

When bathing or dressing, minimize leaning down or reaching. There are many helpful gadgets that can help you with washing yourself, getting dressed or reaching objects

Do housework sitting down when possible, and delegate heavier tasks to others. Take frequent rest breaks, and stop working before you become tired.

Use convenience foods that can be prepared in a microwave Prepare double portions of food and freeze half.

When shopping, make a list by grocery aisle to eliminate unnecessary walking. Let a grocery store worker carry your bags to the car.

Avoid lifting your children whenever possible. When playing with them, choose activities that allow you to sit down.

Use a wheelchair or cane

Future research/ Frustration

Assess fatigue with respect to the stage of cancer

Examine data sets from other institutions

“Mantras in the literature” delay progress

Common Lexicon is essential for integrative studies