Review
Cancer-related fatigue: A critical appraisal

https://doi.org/10.1016/j.ejca.2005.11.026Get rights and content

Abstract

This aim of this systematic review was to determine the prevalence and pattern of cancer-related fatigue (CRF), and identify factors associated with its development. Relevant literature was identified through an electronic database search using specified keywords. Included studies investigated CRF in adult cancer patients using a multidimensional fatigue measure. The methodological quality was assessed using six published standards. CRF is apparent both during and after anti-cancer therapy, however, the prevalence of CRF varied between studies. The variables associated with the development and persistence of CRF remain to be identified. Inconsistencies were evident in the pattern of CRF and its associated factors. This is likely to have arisen from the inherent difficulties in the measurement of a subjective sensation, further complicated by the myriad of outcome measures used. More methodologically sound research; assessing CRF from the commencement of therapy, considering all pertinent variables is needed.

Introduction

Excessive tiredness is a common complaint of today’s society with some level of fatigue found in nearly all of the population.1 For most individuals fatigue is a protective response to physical and psychological stress2 and is easily remedied by rest. The majority of patients receiving anti-cancer therapy experience fatigue that is dissimilar from that experienced by the general population.3 Cancer-related fatigue (CRF) has a phenomenal impact on a sufferer’s life with devastating social and economical consequences, and can persist for months or even years following completion of treatment.

A lack of consensus surrounds the optimal means of assessing CRF.4 A number of CRF instruments exist that assess fatigue as a uni-dimensional construct, however, CRF can manifest itself in many domains, consequently although these instruments may appear to demonstrate satisfactory psychometric properties, they fall short in assessing the full spectrum of CRF.5 As a multidimensional experience, the most comprehensive approach would be to assess CRF using a multidimensional measure.6

A previous review conducted by Servaes and colleagues,7 concluded that fatigue was a problem for cancer patients, but the association between CRF and tumour and treatment-related variables was difficult to establish.7 It was proposed that this could be attributed to the myriad of fatigue measures used in the reviewed studies as both uni- and multidimensional measurement tools were included. In an attempt to reduce the variability in the findings, this current review only included studies that measured CRF using a multidimensional instrument. Furthermore, the body of evidence has grown substantially in recent years and an update is warranted.

In an attempt to aid clinicians in their understanding of the phenomenon as well as identifying those at most risk of developing CRF, the aims of this review were to provide clarification of the prevalence and pattern of CRF, identify factors associated with its development, and make recommendations for future research.

Section snippets

Patients and methods

Relevant literature was identified through an electronic search of Medline (1966 – September 2005), CINAHL (1982 – September 2005), AMED (1985 – September 2005), PsychINFO (1872 – September 2005), BNI (1985 – September 2005), Cochrane Library and ProQuest, using the keywords “Fatigue”[MeSH] OR “Muscle Fatigue”[MeSH] OR “Mental Fatigue”[MeSH] AND (neoplasm* OR tumor* OR tumour* OR cancer* OR Hodgkin’s OR haematolog* OR radiat* OR radioth* OR chemo* OR hormone therapy OR bone marrow transplant*).

CRF during anti-cancer therapy

Forty-four relevant publications were identified through the search strategy and are summarised in Table 1.10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53 As can be seen from Table 1, some consist of the same study sample and methodology but report on a different analysis.13, 14, 15, 24, 26, 30, 35 Consequently, 40 studies have resulted in 44 separate publications.

From

Discussion

The purpose of this review was to clarify the prevalence of CRF as measured with a multidimensional fatigue self-report questionnaire, and determine the factors associated with its occurrence. It was also proposed that the findings of this review would improve the understanding of the symptom, and guide future research.

The methodological quality of the reviewed studies was generally acceptable; however, the recruitment of an inception cohort was not well executed. Endeavouring to determine the

Conflict of interest statement

None.

Acknowledgements

G. Prue is funded by the Department of Employment and Learning, Northern Ireland. Preliminary reports of this research have been presented to the National Cancer Research Institute at ICC, Birmingham, UK in October 2005.

References (84)

  • D. Respini et al.

    The prevalence and correlates of fatigue in older cancer patients

    Crit Rev Oncol Hematol

    (2003)
  • N. De Jong et al.

    Prevalence and course of fatigue in breast cancer patients receiving adjuvant chemotherapy

    Ann Oncol

    (2004)
  • K.A. Donovan et al.

    Course of fatigue in women receiving chemotherapy and/or radiotherapy for early stage breast cancer

    J Pain Symptom Manage

    (2004)
  • P.B. Jacobsen et al.

    Relationship of haemoglobin levels to fatigue and cognitive functioning among cancer patients receiving chemotherapy

    J Pain Symptom Manage

    (2004)
  • C. Wratten et al.

    Fatigue during breast radiotherapy and its relationship to biological factors

    Int J Radiat Oncol Biol Phys

    (2004)
  • K. Ahlberg et al.

    The experience of fatigue, other symptoms and global quality of life during radiotherapy for uterine cancer

    Int J Nurs Stud

    (2005)
  • N. De Jong et al.

    Course of mental fatigue and motivation in breast cancer patients receiving adjuvant chemotherapy

    Ann Oncol

    (2005)
  • P.J. Mills et al.

    The relationship between fatigue and inflammation during anthracycline-based chemotherapy in breast cancer

    Biol Psychol

    (2005)
  • A. Lucia et al.

    Cancer-related fatigue: can exercise physiology assist oncologists?

    Lancet Oncol

    (2003)
  • P. Stone et al.

    Fatigue in patients with cancer

    Eur J Cancer

    (1998)
  • J.H. Loge et al.

    Fatigue and psychiatric morbidity among Hodgkin’s Disease Survivors

    J Pain Symptom Manage

    (2000)
  • T. Okuyama et al.

    Fatigue in ambulatory patients with advanced lung cancer: prevalence, correlated factors, and screening

    J Pain Symptom Manage

    (2001)
  • P. Servaes et al.

    Fatigue after treatment for malignant and benign bone and soft tissue tumors

    J Pain Symptom Manage

    (2003)
  • F. Dimeo et al.

    Physical performance, depression, immune status and fatigue in patients with haematological malignancies after treatment

    Ann Oncol

    (2004)
  • M. Egger et al.

    Language bias in randomised controlled trials published in English and German

    Lancet

    (1997)
  • U. Bultmann et al.

    The relationship between psychosocial work characteristics and fatigue and psychological distress

    Int Arch Occup Environ Heath

    (2002)
  • A. Romanelli et al.

    Cancer-related fatigue: evaluation and treatment

    Rays

    (2004)
  • P.B. Jacobsen

    Assessment of fatigue in cancer patients

    J Natl Cancer Inst Monogr

    (2004)
  • K.D. Stein et al.

    A multidimensional measure of fatigue for use with cancer patients

    Cancer Pract

    (1998)
  • Department of Clinical Epidemiology and Biostatistics

    How to read clinical journals? III. To learn the clinical course and prognosis of disease

    Can Med Assoc J

    (1981)
  • D.M. Irvine et al.

    A critical appraisal of the research literature investigating fatigue in the individual with cancer

    Cancer Nurs

    (1991)
  • G.E. Dean et al.

    Fatigue in patients with cancer receiving interferon alpha

    Cancer Pract

    (1995)
  • A.M. Berger

    Patterns of fatigue and activity and rest during adjuvant breast cancer chemotherapy

    Oncol Nurs Forum

    (1998)
  • E.M.A. Smets et al.

    Fatigue and radiotherapy: (A) experience in patients undergoing treatment

    Br J Cancer

    (1998)
  • M.R.M. Visser et al.

    Fatigue, depression and quality of life in cancer patients: how are they related?

    Support Care Cancer

    (1998)
  • A.M. Berger et al.

    The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue

    Oncol Nurs Forum

    (1999)
  • F. Gaston-Johansson et al.

    Fatigue, pain and depression in pre-autologous breast cancer patients

    Cancer Pract

    (1999)
  • D.M. Hann et al.

    Fatigue and quality of life in breast cancer patients undergoing autologous stem cell transplantation: a longitudinal comparative study

    J Pain Symptom Manage

    (1999)
  • P.B. Jacobsen et al.

    Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course and correlates

    J Pain Symptom Manage

    (1999)
  • U. Monga et al.

    Prospective study of fatigue in localised prostate cancer patients undergoing radiotherapy

    Radiat Oncol Investig

    (1999)
  • A.M. Berger et al.

    Correlates of fatigue during and following adjuvant breast cancer chemotherapy: a pilot study

    Oncol Nurs Forum

    (2000)
  • P. Stone et al.

    Cancer-related fatigue: inevitable, unimportant and untreatable? Results of a multi-centre patient survey

    Ann Oncol

    (2000)
  • Cited by (316)

    • A neuro-metabolic account of why daylong cognitive work alters the control of economic decisions

      2022, Current Biology
      Citation Excerpt :

      A choice bias for low-cost (LC) options would thus represent an objective marker of cognitive fatigue, even in the absence of a conscious fatigue sensation that could be reported on a psychometric scale. Indeed, subjective fatigue reports are notoriously unreliable, due to limitation of insight, social desirability bias, and variability in the mapping from sensations to rating scales.19–23 In a previous study,24 we developed a daylong protocol mixing cognitive control tasks meant to induce cognitive fatigue and intertemporal choices to reveal cognitive fatigue.

    View all citing articles on Scopus
    View full text