Dr Sahil Suleman

Guy’s & St Thomas’ NHS Foundation Trust

& Institute of Psychiatry

CANCER Increasingly viewed as an LTC Survivorship = Symptoms & Side

Effects from treatment

Pain Swelling Lymphoedema Hair Loss Dry mouth Infection Cognitive Impairment Nausea Hormonal Changes FATIGUE

“CANCER-RELATED FATIGUE” (CRF) “a distressing, persistent, subjective

sense of physical, emotional, and/or cognitive tiredness, or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning”

National Comprehensive Cancer Network (2011)

Lack of consensus over definition ICD-10 Criteria for Cancer Related

Fatigue Syndrome

WHY FOCUS ON CANCER-RELATED FATIGUE? 39% - 90+% of those in treatment

(Prue et al., 2006)

Significant impact on the ability to function and quality of life

Most important and distressing symptom (Curt et al., 2000)

Curt (2000) - Prevented “normal life” (91%) and changed daily routine (88%)

Carers – for 65%, fatigue had resulted in partners having taken at least one day (and a mean of four and a half days) off work

(Curt, 2000)

UNIQUENESS OF CANCER-RELATED FATIGUE EXPERIENCE VS. FATIGUE More severe and distressing than

fatigue (Andrykowski et al., 2010; Jacobsen et al., 1999)

Less frequently relieved by adequate sleep or rest than fatigue

(Poulson, 2001; Stone et al., 1999)

FACTORS ASSOCIATED WITH CANCER-RELATED FATIGUE Disease-related Treatment-related Other Physiological Markers Demographic Behavioural & Symptom

PsychologicalFound to supersede physiological and

demographic data in their ability to predict CRF (Hwang et al., 2003)

PSYCHOLOGICAL FACTORS ASSOCIATED WITH CANCER-RELATED FATIGUE

Depression & Anxiety Personality Traits

Trait AnxietyNeuroticismExtraversion

Maladaptive Coping StylesHigher order coping stylesBeliefs/Cognitions about experience and

management of CRF

INTERVENTIONS TARGETING CANCER-RELATED FATIGUE

Pharmacological Exercise & Activity Complementary & Lifestyle

PsychologicalWider Psychosocial Approaches

○ education, social support, relaxation, self-careCognitive Behavioural Approaches

SO WHERE DOES THIS LEAVE US… Range of factors contributing to CRF Psychological factors are important Targeting psychological factors has been

successful in reducing CRF

CBT works in CFS CBT works for other physical health conditions and

for specific symptoms Limited evidence that CBT works in CRF…

But how/why does it work?

SULEMAN, S., RIMES, K. & CHALDER, T. (2011) Cross-sectional investigation of the role of

range of psychological variables in a sample of women undergoing chemotherapy for breast cancerRelationship between these variables and Fatigue

and Functional ImpairmentAlso considered demographic and clinical variables

Prospective exploratory investigation of the role of psychological (and other) variables identified at commencement of chemotherapy in predicting Fatigue and Functional Impairment after 3 cycles of chemotherapy

METHODOLOGY

Questionnaire Study 100 Female Patients from Breast Care

Clinic at King’s College Hospital, London3 groups - pre-chemotherapy, in

chemotherapy or post-chemotherapy

33 pre-chemotherapy participants followed up after 3 cycles of chemotherapy

FEC-T Chemotherapy Regimen

MEASURES Fatigue - Chalder Fatigue Questionnaire (Chalder et al., 1993) & Visual Analogue

Scale – Fatigue (VAS-F) Physical Functioning - European Organisation for Research and Treatment of

Cancer Quality of Life Questionnaire Core 30, Version 3 (EORTC QLQ-C30; Aaronson et al., 1993)

Social Functioning - Work and Social Adjustment Scale (Marks, 1986)

Cognitive and Behavioural Responses to Symptoms Questionnaire (CBRSQ; Moss-Morris et al., in preparation)

Beliefs about Emotions Scale (BES; Rimes & Chalder, 2010) West Haven-Yale Multidimensional Pain Inventory – Part II - Significant Other

Response Scales (WHYMPI; Kerns et al., 1985) Short Health Anxiety Inventory - Retrospective (SHAI-R; Salkovskis et al., 2002) Very Short Health Anxiety Inventory (Salkovskis, correspondence) Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) State Trait Anxiety Inventory – Trait (STAI-T; Spielberger et al., 1970) Jenkins Sleep Scale (Jenkins et al., 1988) Visual Analogue Scale – Expected Fatigue (VAS-E) Cancer-specific Cognitions (exploratory) Use of Coping Strategies (exploratory) Demographic & Clinical Information

MEASURES (CONTINUED) Cognitive and Behavioural Responses to

Symptoms Questionnaire6 subscales

○ catastrophising, symptom-focusing, fear avoidance, embarrassment avoidance, avoidance behaviour, all-or-nothing behaviour

1 new scale – ‘embarrassment avoidance (cancer-related)’

Beliefs about Emotions Scale West Haven-Yale Multidimensional Pain

Inventory – Part II - Significant Other Response ScalesPerceived punishing, distracting and over-

solicitous responses

PRELIMINARY RESULTS Comparison between sample and population norms

(Fayers et al., 2001; Loge et al., 1998)

Comparison of 3 groups – One way ANOVA No difference between pre-chemotherapy, in

chemotherapy and post-chemotherapy groups on fatigue, social adjustment or physical functioning scores

Treated as 1 group for subsequent analyses

CROSS-SECTIONAL CORRELATIONSFatigue Social

AdjustmentPhysical

Functioning

Cognitive Behavioural Variables

Symptom focusing ** **

Catastrophising ** *

Fear avoidance ** **

Embarrassment avoidance ** * *

Embarrassment avoidance (cancer-related)

** ** **

Avoidance behaviour ** *** ***

All-or-nothing behaviour ** ** **

Punishing responses from significant other

** ** **

Solicitous responses from significant other

Distracting responses from significant other

Beliefs about negative emotions * **

Current health anxiety * *** **

Past health anxiety

Significance* = .05 level** = .01 level*** = .001 level

CROSS-SECTIONAL CORRELATIONS (CONT’D)

Fatigue Social Adjustment

Physical Functioning

Wider Psychological, Behavioural & Personality Variables

Anxiety (HADS) ** *** **

Depression (HADS) ** *** ***

Sleep ** *** *

Trait Anxiety

Exploratory Variables

Use of coping strategies * * **

Expectation of future fatigue ** ** **

Cancer-specific cognitions ** ** *

Significance* = .05 level** = .01 level*** = .001 level

Fatigue Social Adjustment

Physical Functioning

Demographic & Clinical Variables

Ethnicity (being non-white) ** **

Marital status (not being married or living with a partner)

*

Further education (none or school only)

** **

Employment status (unemployed) ** **

Help sought previously - fatigue ** ** **

Help sought previously - mood * ** *

Help sought previously - anxiety *

Stage of cancer * *

Number of comorbidities *

Significance* = .05 level** = .01 level*** = .001 level

CROSS-SECTIONAL CORRELATIONS (CONT’D)

Point bi-serial correlations of dichotomised demographic and clinical variables OR Spearman’s rank correlation coefficients

No significant correlations found for age, having sought help for other psychiatric problems, 5 comorbidity variables and 6 medication variables

CROSS-SECTIONAL PREDICTORS – MULTIPLE REGRESSION Psychological Predictors

- Hierarchical stepwise multiple regressionStep 1 – cognitive behavioural variablesStep 2 – wider psychological and behavioural

variables

Psychological & Demographic/Clinical Predictors- Hierarchical forced entry multiple regressionStep 1 – demographic/clinical variablesStep 2 – psychological predictors from previous

model

CROSS-SECTIONAL PREDICTORS OF FATIGUE

Model

Psychological Predictors of Fatigue

Embarrassment avoidance (cancer-related)

F(4,85) = 8.19; p<.001

Total R2 = 0.28

All-or-nothing behaviour

Punishing responses from significant other

Sleep

Demographic / Clinical predictors in final model Further education vs. no further education Help sought for fatigue previously

Exploratory predictors Expectation of future fatigue

CROSS-SECTIONAL PREDICTORS OF SOCIAL ADJUSTMENT

Model

Psychological Predictors of Social Adjustment

Avoidance behaviour

F(3,85) = 29.56; p<.001

Total R2 = 0.51 Health anxiety

Depression

Demographic / Clinical predictors in final model White vs. non-white Help sought for fatigue previously

Exploratory predictors Expectation of future fatigue (minimally significant)

CROSS-SECTIONAL PREDICTORS OF PHYSICAL FUNCTIONING

Demographic / Clinical predictors in final model Further education vs. no further education White vs. non-white Working vs. not working Help sought for fatigue previously

Exploratory predictors Expectation of future fatigue

Model

Psychological Predictors of Physical Functioning

Avoidance behaviour

F(3,85) = 26.42; p<.001

Total R2 = 0.48 Beliefs about negative emotions

Depression

PROSPECTIVE PREDICTORS – AN EXPLORATORY ANALYSIS

Model

Pre-chemotherapy Predictors of Fatigue after 3 cycles of chemotherapy

Embarrassment avoidance (cancer-related)F(1,32) = 8.76; p=.006

R2 = 0.22 Model

Pre-chemotherapy Predictors of Social Adjustment after 3 cycles of chemotherapy

Avoidance behaviourF(1,31) = 7.13; p=.012

R2 = 0.19 Model

Pre-chemotherapy Predictors of Physical Functioning after 3 cycles of chemotherapy

DepressionF(1,31) = 8.73; p=.006

R2 = 0.22

KEY FINDINGS More detailed picture of cognitions, behaviours and

other psychological factors playing a part in CRF Beyond umbrella terms e.g. ‘depression’ Preliminary evidence of presence of maladaptive cognitions and

behaviours prior to chemotherapy impacting on CRF over course of chemotherapy i.e. predictive role

Corroborates evidence from chronic fatigue syndrome and comparable health conditions Wide range of patterns of cognition and behaviour Unique aspects of CRF e.g. embarrassment avoidance (cancer-

related), perceived punishing responses of significant others

Preliminary evidence for psychometric properties of new ‘embarrassment avoidance (cancer-related)’ scale

CLINICAL IMPLICATIONS Development of targeted CBT interventions for CRF

Particular prominence to cognitive and behavioural aspects of avoidance behaviour and embarrassment avoidance in cancer

Screening and early intervention Informing staff and validating patients Carers

Staff training Stepped care approach

Limitations

Future Research

THANK YOU FOR LISTENING