Measuring fatigue in cancer patients: a common metric for six fatigue instruments.

PURPOSE: Fatigue is one of the most disabling symptoms in cancer patients. Many instruments exist to measure fatigue. This variety impedes the comparison of data across studies or to the general population. We aimed to estimate a common metric based on six different fatigue instruments (EORTC QLQ-C30 subscale fatigue, EORTC QLQ-FA12, MFI subscale General Fatigue, BFI, Fatigue Scale, and Fatigue Diagnostic Interview Guide) to convert the patients' scores from one of the instruments to another. Additionally, we linked the common metric to the general population. METHODS: For n = 1225 cancer patients, the common metric was estimated using the Item Response Theory framework. The linking between the common metric of the patients and the general population was estimated using linear regression. RESULTS: The common metric was based on a model with acceptable fit (CFI = 0.94, SRMR = 0.06). Based on the standard error of measurement the reliability coefficients of the questionnaires ranged from 0.80 to 0.95. The common metric of the six questionnaires, also linked to the general population, is reported graphically and in supplementary crosswalk tables. CONCLUSIONS: Our study enables researchers and clinicians to directly compare results across studies using different fatigue questionnaires and to assess the degree of fatigue with respect to the general population.

The influence of self-efficacy and resilient coping on cancer patients' quality of life.

The objective of this study was to analyse whether general self-efficacy and resilient coping are negatively impacted when people are sick with cancer (compared with people from the general population), and whether these resource variables predict quality of life outcomes in that patient group. A sample of 959 patients recruited in an oncologic rehabilitation clinic was examined once while hospitalised and once again six months thereafter. The outcome variables were quality of life (EORTC QLQ-C30) and distress (PHQ-4). The resource variables were self-efficacy (General Self-Efficacy Scale) and resilient coping (Brief Resilient Coping Scale). Representative samples of the general population served as controls. Self-efficacy (d = 0.08) and resilient coping (d = 0.28) were only slightly lower in the patients' sample than in the general population. Both resource variables were associated with quality of life, but self-efficacy (and not resilient coping) was the only independent predictor of quality of life functioning scales and distress scores when the baseline values of the dependent variables were also taken into account. Strengthening patients' belief in their own ability to cope with the disease may help them retain and/or regain a higher level of quality of life.

[Selected Quality Characteristics Of Out-Patient Psychosocial Cancer Counseling Centers In Germany: A Nationwide Analysis]. / Ausgewählte Merkmale der Struktur- und Prozessqualität der psychosozialen Versorgung in ambulanten psychosozialen Krebsberatungsstellen in Deutschland. Eine Bestandsaufnahme.

OBJECTIVES: Quality assurance has become increasingly relevant in the field of outpatient psychosocial cancer counseling. At the same time, no studies are currently available that analyze outpatient psychosocial cancer counseling centers in Germany with respect to standards of service quality. Therefore, this study aimed to determine whether these centers meet selected quality criteria of outpatient psychosocial cancer counseling. METHODS: Based on quality standards of outpatient psychosocial cancer counseling previously developed by us in a Delphi study, we surveyed 106 out of 151 German psychosocial outpatient cancer counseling centers registered in a publicly accessible data base of Germany's cancer information service in Heidelberg with respect to the selected quality characteristics. Data analysis used descriptive statistical techniques. RESULTS: The centers of the sample differ in how many of them fulfill the quality standards selected for analysis here. More than 90% provide the services described by the standards as required. In contrast, in the personnel domain, there appears to be room for improvement with respect to the amount of service hours available for psychologists and the number of counselors with advanced training in psycho-oncology. Also, external supervision and case conferences turn out to be quality characteristics with room for improvement in the domain of quality assurance as do distress screening in the domain of diagnostics and using systematic documentation. CONCLUSION: Referring to recent standards of quality of outpatient psychosocial cancer counseling allowed us to delineate strength and weaknesses that may serve as starting points for quality improvement in the centers providing psychosocial cancer counseling. However, further research is necessary to arrive at a more comprehensive picture of the degree to which outpatient psychosocial cancer counseling centers in Germany comply with current standards of service quality.

Psychometric properties of the fatigue questionnaire EORTC QLQ-FA12 and proposal of a cut-off value for young adults with cancer.

BACKGROUND: Young adult patients with cancer have to deal with their disease in an eventful phase of life. A common side effect of cancer and its treatment is cancer-related fatigue (CRF), a phenomenon which can thwart successful coping with developmental tasks. The aims of this study were to assess the psychometric properties of the EORTC QLQ-FA12, a new instrument for assessing physical, emotional and cognitive fatigue, in young adults with cancer, and to propose a cut-off value that indicates a need for further more specific diagnostics. METHODS: In a sample of young adults who were first diagnosed with cancer between the ages of 18 and 39 years old, we assess the composite and item reliabilities as well as discriminant validity of the subscales for the EORTC QLQ-FA12. We also discuss two possible ways to calculate a summarizing score when conducting a receiver operating characteristic (ROC) analysis to find the cut-off value. RESULTS: The EORTC QLQ-FA12 fit the sample (CFI = 0.96, SRMR = 0.04), had discriminant validity regarding its subscales and every subscale showed convergent validity (composite reliabilities were 0.92 for physical, 0.89 for emotional and 0.74 for cognitive fatigue). The sum of the first ten items with a range of 0 to 30 revealed a cut-off value of twelve or more with 91% sensitivity and 77% specificity. CONCLUSION: The new instrument EORTC QLQ-FA12 is able to distinguish between physical, emotional, and cognitive fatigue in young adult patients. It enables us to study different concepts of general fatigue without the need for additional items, and can be used as a screening instrument for young adults. Future research should investigate the multidimensional character of CRF.

[Cancer Related Fatigue in Rehabilitation Care]. / Tumorassoziierte Fatigue in der onkologischen Rehabilitation.

Aim of the study was to provide information about the prevalence of cancer related fatigue and the association between treatment-related factors and fatigue in cancer patients during the rehabilitation care. In a multicenter study 693 cancer patients (27% breast cancer, 17% prostate cancer etc.) completed the Multidimensional Fatigue Inventory (MFI-20) and sociodemographic and treatment information was noted. 51% of the patients suffer from fatigue (n=356). Fatigue prevalence differed according to tumour localization (p≤0.001). There was a substantial association between fatigue and treatment condition in terms of the combination of surgery and radiation (p≤0.05). Fatigue was high prevalent in patients in the rehabilitation care. Thus, fatigue should be routinely screened and after differentiated diagnostics be considered in rehabilitation care plans.

Twelve-Month and Lifetime Prevalence of Mental Disorders in Cancer Patients.

BACKGROUND: Psychological problems are common in cancer patients. For the purpose of planning psycho-oncological interventions and services tailored to the specific needs of different cancer patient populations, it is necessary to know to what extent psychological problems meet the criteria of mental disorders. The purpose of this study was to estimate the 12-month and lifetime prevalence rates of mental disorders in cancer patients. METHODS: A representative sample of patients with different tumour entities and tumour stages (n = 2,141) in outpatient, inpatient and rehabilitation settings underwent the standardized computer-assisted Composite International Diagnostic Interview for mental disorders adapted for cancer patients (CIDI-O). RESULTS: The overall 12-month prevalence for any mental disorder was 39.4% (95% CI: 37.3-41.5), that for anxiety disorders was 15.8% (95% CI: 14.4-17.4), 12.5% (95% CI: 11.3-14.0) for mood disorders, 9.5% (95% CI: 8.3-10.9) for somatoform disorders, 7.3% (95% CI: 6.2-8.5) for nicotine dependence, 3.7% (95% CI: 3.0-4.6) for disorders due to general medical condition, and 1.1% (95% CI: 0.7-1.6) for alcohol abuse or dependence. Lifetime prevalence for any mental disorder was 56.3% (95% CI 54.1-58.6), that for anxiety disorders was 24.1% (95% CI: 22.3-25.9), 20.5% (95% CI: 18.9-22.3) for mood disorders, 19.9% (95% CI: 18.3-21.7) for somatoform disorders, 18.2% (95% CI: 16.6-20.0) for nicotine dependence, 6.4% (95% CI: 5.4-7.6) for alcohol abuse or dependence, 4.6% (95% CI: 3.8-5.6) for disorders due to general medical condition, and 0.2% (95% CI: 0.1-0.6) for eating disorders. CONCLUSIONS: Mental disorders are highly prevalent in cancer patients, indicating the need for provision of continuous psycho-oncological support from inpatient to outpatient care, leading to an appropriate allocation of direct personnel and other resources.

Does psychodynamic short-term psychotherapy for depressed breast cancer patients also improve fatigue? Results from a randomized controlled trial.

The purpose of this study was to determine (a) the course of fatigue in depressed breast cancer patients, (b) the effect of a depression-focused individual psychodynamic psychotherapy on fatigue, and (c) the associations of fatigue with depression, quality of life and treatment-related variables. In a German multicentre randomized controlled trial in Leipzig and Mainz, depressed early breast cancer patients (UICC stage 0-III, age 18-70 years) were randomly assigned to a short-term psychodynamic psychotherapy (STPP, an adaptation of the Supportive-Expressive psychotherapy by Luborsky for cancer patients) or treatment as usual (TAU) and completed data assessment pre- and post-treatment. Fatigue was assessed with the Multidimensional Fatigue Inventory (MFI-20). All analyses were conducted as complete case analyses including 52 STPP and 54 TAU completers (n = 106). The trial is registered at http://www.controlled-trials.com , number ISRCTN96793588. Fatigue declined significantly from a high level pre-treatment to post-treatment, but remained significantly higher than among population-based controls and a mixed sample of cancer patients. Significant time by group interactions favoured STPP for the subscales reduced activity and physical fatigue and the total scale. The strength of the associations between total fatigue and depression increased from 0.49 pre-treatment to 0.63 (Quality of life -0.52 to -0.63) at follow-up. STPP is beneficial for reducing dimensions of fatigue (particularly reduced activity and physical fatigue) in depressed breast cancer patients. Chronic fatigue needs more clinical attention in this vulnerable group.

[Out-Patient Psychosocial Cancer Counseling Centers and their Clients - Services Provided and Service Utilization by Patients and Patients' Relatives]. / Ambulante psychoonkologische Versorgung durch Krebsberatungsstellen - Leistungsspektrum und Inanspruchnahme durch Patienten und Angehörige.

Psychosocial cancer counseling centers represent an increasingly important part of comprehensive psychosocial cancer care. Research on the services provided by those centers is sparse, however, as is research on person-, disease-, and treatment-related characteristics of their clients. Therefore, the present study analyzes the services provided by 26 psychosocial cancer counseling centers temporarily being funded by the German Cancer Aid as well as selected characteristics of their clients. Analyses are based on data collected during 2011 by means of a documentation system specifically designed for the purposes of psychosocial cancer counseling. Testing focuses on whether cancer patients and cancer patients' relatives differ with respect to various characteristics and the services used. The results show that psychosocial and benefit counseling represent a major part of counseling services, followed by giving information and employing relaxation techniques. Clients seek counseling primarily in early phases of disease and treatment. Women with breast cancer are over-represented among clients. Analyses also reveal significant differences between cancer patients and patients' relatives. Psychotherapeutic interventions and grief-counseling are more frequent in counseling relatives, whereas benefit counseling is more frequent in working with patients. The results emphasize the relevance of outpatient psychosocial cancer counseling. They may also help support initiatives aiming at establishing psychosocial cancer counseling targeted to the needs of each individual client.

[Outpatient psychosocial counseling--results of a user-based cross-sectional study about patient reported needs and its consideration]. / Ambulante psychosoziale Krebsberatung - Ergebnisse einer nutzerbasierten Studie zu Beratungsanliegen und Zufriedenheit mit der Beratung.

BACKGROUND: This article presents results of a user-based cross-sectional study about patient reported needs and its consideration in the course of outpatient psychosocial counseling. In addition, patient satisfaction with consultations was evaluated. METHOD: A sample of 1 930 cancer patients or family caregivers who consulted one of 26 psychosocial counseling units funded by German Cancer Aid completed a questionnaire sent by mail. RESULTS: Younger and female patients/care-givers, and those with ovarian, pancreatic and cns tumours were more likely to seek counseling. Overall, patient reported needs were met to a high degree. The majority of the participants was very satisfied with different aspects of counseling. However, 16% of participants reported unmet needs and had suggestions for improvements primarily with regard to the counselor (4% of the participants) and time management (2% of the participants). In addition, 10% of the participants suggested optimizing the counseling location and setting as well as the accessibility, time scheduling and the work approach of the staff (1-5%). DISCUSSION: Our findings represent a part of the core evaluation of psychosocial counseling for cancer patients. Overall, it can be highlighted that cancer patients are very satisfied with outpatient psychosocial counseling offers. However, few critical aspects could be identified from the clients' perspective. Our results are discussed in the context of methodological aspects of the study.

Construct validity of the EORTC quality of life questionnaire information module.

PURPOSE: Providing sufficient information about diagnosis and treatment is an important feature of high-quality patient care in oncology. To measure patient satisfaction with information received, the European Organisation for Research and Treatment of Cancer Quality of Life Group has recently developed a new tool, the information module (INFO25). The aim of this study was to evaluate the scale structure of the INFO25. METHODS: A total of n = 423 patients completed the INFO25 after finishing cancer therapy. The internal consistency of multi-item subscales was calculated using Cronbach's Alpha. The scale structure was evaluated using multi-trait methods and confirmatory factor analysis. RESULTS: Cronbach's Alpha of the multi-item scales ranged from 0.79 to 0.88. Only two items correlated somewhat higher with another scale than with their own, indicating a good scale structure. Construct validity with latent variable models, including a general information factor and four multi-item scales, resulted in the following fit indices CFI = 0.96, RMSEA = 0.08, TLI = 0.99 and WRMR = 1.03. CONCLUSION: The suggested construct of the INFO25 with a total score (general factor) in addition to the subscales is valid.

[KoMPASS--design, implementation and experiences concerning a structured communication skills training for physicians dealing with oncology]. / KoMPASS - Konzeption, Implementierung und Erfahrungen mit einem strukturierten Kommunikationstraining für onkologisch tätige Ärzte.

Goal of the KoMPASS project is to develop and test a training program that effectively improves oncologists' communication skills. The training draws with regard to concept, content and didactic methods to the specific challenges arising in interactions with cancer patients. Concept and didactical methods for an intensive training (KoMPASS Training) are being presented and complemented with experiences gathered during 39 trainings with 335 physicians, as well as findings from the training evaluation by participants. The participants' feedback after 4 months indicates successful transfer into clinical practice along with personal relief, improved self-efficacy, and communicative competencies. Even experienced practitioners ascribe high practical usefulness, and personal learning achievements to the KoMPASS training. The results of the concomitant study concerning self-efficacy, empathy, work-related stress and communicative competence will be published later.

Efficacy of psychodynamic short-term psychotherapy for depressed breast cancer patients: study protocol for a randomized controlled trial.

BACKGROUND: There is a lack of psychotherapeutic trials of treatments of comorbid depression in cancer patients. Our study determines the efficacy of a manualized short-term psychodynamic psychotherapy and predictors of outcome by personality and quality of the therapeutic relationship. METHODS/DESIGN: Eligible breast cancer patients with comorbid depression are assigned to short-term psychodynamic psychotherapy (up to 20 + 5 sessions) or to treatment as usual (augmented by recommendation for counseling center and physician information). We plan to recruit a total of 180 patients (90 per arm) in two centers. Assessments are conducted pretreatment, after 6 (treatment termination) and 12 months (follow-up). The primary outcome measures are reduction of the depression score in the Hospital Anxiety and Depression Scale and remission of depression as assessed by means of the Structured Clinical Interview for DSM IV Disorders by independent, blinded assessors at treatment termination. Secondary outcomes refer to quality of life. DISCUSSION: We investigate the efficacy of short-term psychodynamic psychotherapy in acute care and we aim to identify predictors for acceptance and success of treatment. TRIAL REGISTRATION: ISRCTN96793588.

The desire for shared decision making among patients with solid and hematological cancer.

GOAL: The desire for shared decision making arises especially for frequently occurring cases of solid cancer. For hematological cancer conditions, there are no analogous results. This study compares the participation patients' desires concerning medical decisions dealing with their solid and hematological tumors. PATIENTS AND METHODS: The 533 inpatients with solid cancer (age<65: 61.0%; female: 39.6 %) and 177 patients with hematological cancer (inpatient: 62.1%, outpatient: 37.9%; age<65: 63.3%; female: 42.4%) were given a questionnaire after admission to a hospital or medical practice. The dependent variable was patient preference for control in decision making for eight different medical areas of decision. RESULTS: Descriptive results showed that patients with solid cancer had a stronger desire to participate in the decisions in six of a total of eight survey fields (p<0.01). When considering medical and socio-demographic control variables, the multivariate regression shows that the differences between the patient groups remain in all areas (p<0.01). Further predictor variables are educational background and age (p<0.05). No influence resulted from the factors of gender, medical or treatment characteristics. CONCLUSION: The results show differences between patients with hematological cancer and patients with solid tumors, and these differences concern the preference to participate in medical decisions. Hemato-oncological patients desire less active participation and prefer a more dominant role of the physician in the various areas requiring decisions. Physicians should respect this in the course of the treatment.

Patients' acceptance and psychometric properties of the EORTC QLQ-CX24 after surgery.

OBJECTIVE: The aim of this study was to evaluate patients' acceptance and the reliability and validity of a recently developed instrument to assess quality of life among cervical cancer patients, the European Organization for Research and Treatment of Cancer Cervical Cancer Module (EORTC QLQ-CX24), in surgically treated patients after primary surgery. METHODS: The EORTC QLQ-CX24 was administered to 134 cervical cancer patients who had undergone pelvic surgery. Additional questionnaires completed were the EORTC QLQ-C30, and the Hospital Anxiety and Depression Scale. Sociodemographic and medical data were recorded. RESULTS: Missing values occurred in 4.5% of all non-optional items. Internal consistencies (Cronbach's alpha coefficients) for the three multi-item scales ranged from 0.70 to 0.87 (Symptom Experience 0.70, Body Image 0.87, Sexual/Vaginal Functioning 0.76), whereas scaling errors occurred in 6.8%, 0.0%, and 6.3% of the cases. In all domains, the entire range of the scale was used by patients. The scales were able to discriminate between different subgroups of patients. CONCLUSION: These psychometric analyses confirm that the EORTC QLQ-CX24 is a useful tool for the assessment of quality of life in cervical cancer patients after surgery.

Fatigue in cancer survivors--prevalence and correlates.

BACKGROUND: The aim of this study was to determine the prevalence and influencing factors of fatigue in cancer survivors. PATIENTS AND METHODS: 646 cancer survivors completed the Multidimensional Fatigue Inventory (MFI-20), in addition to the Hospital Anxiety and Depression Scale (HADS), the Quality Of Life questionnaire EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer QLQ-C30), the subscale 'social support' of the Functional Assessment of Cancer Therapy Scale (FACT), the Perceived Adjustment to Chronic Illness Scale (PACIS), and a questionnaire containing items on demographic and clinical data. RESULTS: 36% of cancer survivors suffer from moderate, 12% from severe fatigue. Fatigue was significantly associated with depression, anxiety, sleep difficulties, adjustment to the illness, pain, dyspnoea, age, lacking social support, and sex. Other socio-demographic, cancer-related, and treatment-related factors had no influence on fatigue. CONCLUSION: Fatigue in cancer survivors is strongly linked to physical and psychological aspects.

Screening Properties of the Diagnostic Criteria for Cancer-Related Fatigue.

BACKGROUND: Within the theoretical framework of the ICD diagnostic criteria of cancer-related fatigue, we aim to investigate how those criteria can be used for screening purposes. METHODS: Fatigue was assessed in a mixed sample of 1,225 cancer patients during their stay in a rehabilitation clinic using four different fatigue measures and the diagnostic criteria (Criterion A; DC-A). Psychometric evaluations (e.g., acceptance, reliability, validity, item analyses) were conducted for the sum score and for all items of the diagnostic criteria. RESULTS: A total of 678 (57.1%) patients tested positive according to the DC-A. The sum score of the DC-A had good reliability (Cronbach's alpha = 0.87) and validity, corresponded closely with other fatigue scales, and, with less than 1% missing values, showed a high degree of patients' acceptance. The highest accuracy (approx. 0.80) and Youden indices (>0.55) were found for the items "Difficulties completing daily tasks" (A9), "Struggle to overcome inactivity" (A7), "Decreased motivation or interests" (A4), and "Unrefreshing sleep" (A6). CONCLUSION: The DC-A proved to be a well-accepted, easy to use, and reliable tool for measuring the severity of fatigue. In this paper, we make suggestions for the use of single items of the DC-A as a short and economical screening tool.