Exploratory Factor Analysis of the Strength of the Cultural Affiliation Scale.

BACKGROUND: Within the United States, there are individuals who retain the traditions and beliefs of cultural groups that vary from the general majority population. Both healthcare providers and researchers have reported that many individuals who live in but are less affiliated with the dominant culture tend to have less positive health outcomes. OBJECTIVE: The purpose of this study is to use factor analysis to assess the psychometric properties of Mood's 18-item Strength of Cultural Affiliation Scale (SCAS). METHODS: The SCAS was administered to 604 participants from a randomized clinical trial of cancer patients who were treated with radiotherapy at a large central city hospital located in the Midwest. RESULTS: Confirmatory Factor Analyses using Principal Component Analysis with Oblimin Rotation indicated a 16-item, 4-factor final solution with the following subscales: factor 1, lifestyle (7 items); factor 2, language and cultural-specific holidays (3 items); factor 3, relationships (4 items); and factor 4, cultural health practices (2 items). CONCLUSION: The SCAS demonstrated high reliability and content, construct, discriminant, convergent, divergent, and predictive validity. IMPLICATIONS FOR PRACTICE: The SCAS seems to be a reliable and valid tool for practitioners to use to assess a patient's strength of cultural affiliation to provide the best culturally sensitive care possible for the patient.

Randomized clinical trial of a brief and extensive dyadic intervention for advanced cancer patients and their family caregivers.

BACKGROUND: Few intervention programs assist patients and their family caregivers to manage advanced cancer and maintain their quality of life (QOL). This study examined (i) whether patient-caregiver dyads (i.e., pairs) randomly assigned to a brief or extensive dyadic intervention (the FOCUS Program) had better outcomes than dyads randomly assigned to usual care and (ii) whether patients' risk for distress and other factors moderated the effect of the brief or extensive program on outcomes. METHODS: Advanced cancer patients and their caregivers (N = 484 dyads) were stratified by patients' baseline risk for distress (high versus low), cancer type (lung, colorectal, breast, or prostate), and research site and then randomly assigned to a brief (three-session) or extensive (six-session) intervention or control. The interventions offered dyads information and support. Intermediary outcomes were appraisals (i.e., appraisal of illness/caregiving, uncertainty, and hopelessness) and resources (i.e., coping, interpersonal relationships, and self-efficacy). The primary outcome was QOL. Data were collected prior to intervention and post-intervention (3 and 6 months from baseline). The final sample was 302 dyads. Repeated measures MANCOVA was used to evaluate outcomes. RESULTS: Significant group by time interactions showed that there was an improvement in dyads' coping (p < 0.05), self-efficacy (p < 0.05), and social QOL (p < 0.01) and in caregivers' emotional QOL (p < 0.05). Effects varied by intervention dose. Most effects were found at 3 months only. Risk for distress accounted for very few moderation effects. CONCLUSIONS: Both brief and extensive programs had positive outcomes for patient-caregiver dyads, but few sustained effects. Patient-caregiver dyads benefit when viewed as the 'unit of care'.

Study of dyadic communication in couples managing prostate cancer: a longitudinal perspective.

OBJECTIVE: Cancer patients and partners often report inadequate communication about illness-related issues, although it is essential for mutual support and informal caregiving. This study examined the patterns of change in dyadic communication between patients with prostate cancer and their partners, and also determined if certain factors affected their communication over time. METHOD: Using multilevel modeling, this study analyzed longitudinal data obtained from a randomized clinical trial with prostate cancer patients and their partners, to examine their communication over time. Patients and partners (N=134 pairs) from the usual-care control group independently completed baseline demographic assessment and measures of social support, uncertainty, symptom distress, and dyadic communication at baseline, and 4-, 8-, and 12-month follow-ups. RESULTS: The results indicated that (1) patients and partners reported similar levels of open communication at the time of diagnosis. Communication reported by patients and partners decreased over time in a similar trend, regardless of phase of illness; (2) phase of illness affected couples' open communication at diagnosis but not patterns of change over time; and (3) couples' perceived communication increased as they reported more social support, less uncertainty, and fewer hormonal symptoms in patients. Couples' demographic factors and general symptoms, and patients' prostate cancer-specific symptoms did not affect their levels of open communication. CONCLUSIONS: Perceived open communication between prostate cancer patients and partners over time is affected by certain baseline and time-varying psychosocial and cancer-related factors. The results provide empirical evidence that may guide the development of strategies to facilitate couples' interaction and mutual support during survivorship.

Assessing longitudinal quality of life in prostate cancer patients and their spouses: a multilevel modeling approach.

PURPOSE: This study aimed at examining the relationship between quality of life (QOL) in prostate cancer (PCa) patients and partners and how baseline demographics, cancer-related factors, and time-varying psychosocial and symptom covariates affect their QOL over time. METHODS: Guided by a modified Stress-Coping Model, this study used multilevel modeling to analyze longitudinal data from a randomized clinical trial that tested a family-based intervention to improve QOL in couples managing PCa. Patients and partners from the usual-care control group (N = 134 dyads) independently completed the measurements at baseline, and at 4-, 8-, and 12-month follow-ups. RESULTS: Correlations of QOL between patients and partners over time were small to moderate. Patients' lower education level, partners' older age, higher family income, and localized cancer at baseline were associated with better QOL in couples. Over time, couples' QOL improved as their social support and cancer-related dyadic communication increased and as couples' uncertainty, general symptoms, and patients' prostate cancer-related sexual and hormonal symptoms decreased. CONCLUSIONS: Evidence indicates that couples' QOL during cancer survivorship is affected by multiple contextual factors (e.g., baseline demographics and time-varying psychosocial factors and symptoms). Intervention research is needed to explore comprehensive strategies to improve couples' QOL during the continuum of PCa survivorship.

The influence of easy-to-read pamphlets about self-care management of radiation side effects on patients' knowledge.

PURPOSE/OBJECTIVES: To test patients' knowledge of side effects after they review six easy-to-read pamphlets on radiation side effects. DESIGN: Nonexperimental. SETTING: Urban radiation oncology clinic. SAMPLE: 47 patients receiving radiation treatment. METHODS: The Knowledge of Radiation Side Effects Test was administered. MAIN RESEARCH VARIABLES: Patient literacy and knowledge level. FINDINGS: The self-report of highest grade completed in school was 10th grade; however, the actual reading level was 4th-6th grade. Scores for each knowledge test increased with literacy level, with statistically significant correlations for pamphlets on fatigue, skin problems for women, and skin problems for men. Participants who read at the 4th-6th-grade level scored higher than expected. CONCLUSIONS: Although the pamphlets were deemed easy to read, patients who had the lowest reading levels still had difficulty understanding them. IMPLICATIONS FOR NURSING: In addition to written patient information, oncology nurses should use innovative teaching strategies to improve patient understanding and self-care behaviors. A need exists for continued nursing inquiry that will focus on self-care behaviors to manage radiation side effects, particularly for patients with low literacy.

The effect of low literacy on the self-care behaviors of men receiving radiation therapy.

Using Orem's theory as the framework, two purposes guided the study: (a) to test the effectiveness of an audio-visual education program and behavioral contracting to promote self-care behaviors in managing radiation side effects and (b) to determine the extent to which low literacy affects self-care abilities. Seventy men diagnosed with prostate cancer participated in this experimental study. The nursing interventions of education and behavioral contracting significantly increased the self-care behaviors of men in managing radiation side effects. An increase in self-care behaviors was especially shown in men with low-literacy skills.

Interventions with family caregivers of cancer patients: meta-analysis of randomized trials.

Family caregivers of cancer patients receive little preparation, information, or support to perform their caregiving role. However, their psychosocial needs must be addressed so they can maintain their own health and provide the best possible care to the patient. The purpose of this article is to analyze the types of interventions offered to family caregivers of cancer patients, and to determine the effect of these interventions on various caregiver outcomes. Meta-analysis was used to analyze data obtained from 29 randomized clinical trials published from 1983 through March 2009. Three types of interventions were offered to caregivers: psychoeducational, skills training, and therapeutic counseling. Most interventions were delivered jointly to patients and caregivers, but they varied considerably with regard to dose and duration. The majority of caregivers were female (64%) and Caucasian (84%), and ranged in age from 18 to 92 years (mean age, 55 years). Meta-analysis indicated that although these interventions had small to medium effects, they significantly reduced caregiver burden, improved caregivers' ability to cope, increased their self-efficacy, and improved aspects of their quality of life. Various intervention characteristics were also examined as potential moderators. Clinicians need to deliver research-tested interventions to help caregivers and patients cope effectively and maintain their quality of life.

Factors associated with prostate cancer patients' and their spouses' satisfaction with a family-based intervention.

Only a few programs are designed to help couples cope with the effects of prostate cancer, and typically, only their intervention outcomes are reported. The purpose of this study was to assess prostate cancer patients' and their spouses' satisfaction with an efficacious supportive-educative, family-based intervention, and factors associated with their satisfaction. We assessed the relationship of overall satisfaction with the intervention to (1) the patients' and spouses' appraisal and the resource and quality-of-life baseline scores and (2) changes in those scores after completing the intervention. Results showed that participants were very satisfied with the program. Patients who had higher scores on baseline measures, indicating more positive appraisal of their illness, better use of resources (eg, coping, self-efficacy), and higher overall quality of life, reported more satisfaction with the intervention. For spouses, few baseline measures were related to their satisfaction; however, spouses who reported positive changes after intervention (less negative appraisal and uncertainty, better communication) reported higher satisfaction with the program. Although satisfied with the program, factors associated with patients' and spouses' satisfaction differed. To translate effective interventions to clinical practice settings, it is important to assess participants' satisfaction with program content and delivery, as well as program outcomes.

An educational video to increase clinical trials enrollment among breast cancer patients.

Only 3% of women with breast cancer participate in cancer clinical trials nationwide. The lack of awareness about clinical trials is a significant barrier towards clinical trials participation. A study was conducted at a large urban Comprehensive Cancer Center to test (1) the effectiveness of an 18-min educational video on improving attitudes toward clinical trials and trials enrollment among new breast cancer patients seen at the Karmanos Cancer Institute, and (2) to assess racial differences in attitudes regarding clinical trials. Participants were randomized to either the educational intervention prior to their first oncology clinic appointment or to standard care. A baseline and 2-week post-intervention survey to assess attitudes toward clinical trials participation was completed by participants. Of 218 subjects recruited, 196 (55% white vs. 45% African American (AA)) eligible patients were included in the analysis. A small increase in therapeutic clinical trial enrollment was observed in the intervention arm but was not statistically significant (10.4% vs. 6.1%; P = 0.277). The intervention also did not result in a clear improvement in patients' attitudes toward clinical trials at posttest. However, a lower enrollment rate for the AA women was noted after adjusting for stage (OR = 0.282, P = 0.049). Significantly more negative scores were noted in 3 out of the 5 baseline attitudinal scales for AA women. The educational video did not significantly increase enrollment in breast cancer clinical trials. The findings that AA women had significantly more negative attitudes toward clinical trials than white women may partially explain the racial disparity in enrollment. An educational video remains a simple and cost-effective way to educate patients. Future studies should focus on designing a new educational video to specifically target cultural and attitudinal barriers in the AA population to more effectively change attitudes and increase trial enrollment.

Longitudinal analysis of a model to predict quality of life in prostate cancer patients and their spouses.

BACKGROUND/PURPOSE: This study examined a stress-coping model to assess whether baseline antecedent variables predicted subsequent appraisal and how that appraisal predicted coping and quality of life for prostate cancer patients and their spouses. METHODS: In a sample of 121 prostate cancer patient/spouse dyads, we assessed baseline antecedent variables (self-efficacy, current concerns, age, socioeconomic status, social support, communication, symptoms, phase of illness), 4-month follow-up appraisal (negative appraisal, hopelessness, uncertainty), and 8-month follow-up coping and mental and physical quality of life. Patients and spouses were assessed in a single integrated path model using structural equation modeling. RESULTS: The stress-coping model accounted for a significant amount of variance in mental and physical quality of life at 8 months for patients (40% and 34%, respectively) and spouses (43% and 24%, respectively). Appraisal mediated the effect of several antecedent variables on quality of life. In addition, several partner effects (e.g., spouse variables influencing patient outcomes) were found. CONCLUSIONS: Prostate cancer patients need interventions that assist them to manage the effects of their disease. The stress-coping model suggests skills in several areas that could be improved. Programs need to include spouses because they also are negatively affected by the disease and can influence patient outcomes.

An educational video to increase clinical trials enrollment among lung cancer patients.

INTRODUCTION: Only 3 to 5% of new adult cancer patients participate in clinical trials nationwide. The lack of knowledge and awareness about clinical trials is a significant barrier to clinical trials participation. A randomized trial was conducted to test the effect of an educational video on positively changing patients' knowledge and attitudes regarding clinical trials and thereby increasing enrollment rates. METHODS: Lung cancer patients were randomized to viewing either an 18-minute video about clinical trials before first clinic appointment or to standard care. Participants completed a baseline and 2-week postintervention survey to assess their knowledge and attitudes toward trials participation. Fisher's exact test tests, t tests, and regression were used to compare patient characteristics and outcomes between arms. RESULTS: Of 145 subjects randomized, 126 (63/arm) satisfied all inclusion criteria and were included in the analysis. A linear regression showed that the video intervention was significantly associated with patients' self-assessed likelihood to enroll score measured at 2-week follow-up (p = 0.019). Although statistically insignificant, enrollment rates were found to be higher in the intervention arm for therapeutic trials alone (17.5% versus 11.1%) and for therapeutic and nontherapeutic trials combined (25.4% versus 15.9%). CONCLUSIONS: The brief educational video seems to be effective in positively changing lung cancer patients' attitudes about participation in clinical trials. Higher enrollment rates were also observed in the intervention group but the differences did not reach statistical significance. These findings suggest a potential impact of the educational video on clinical trial enrollment; however, larger studies are needed to confirm these findings.

Randomized clinical trial of a family intervention for prostate cancer patients and their spouses.

BACKGROUND: Few intervention studies have been conducted to help couples manage the effects of prostate cancer and maintain their quality of life. The objective of this study was to determine whether a family-based intervention could improve appraisal variables (appraisal of illness or caregiving, uncertainty, hopelessness), coping resources (coping strategies, self-efficacy, communication), symptom distress, and quality of life in men with prostate cancer and their spouses. METHODS: For this clinical trial, 263 patient-spouse dyads were stratified by research site, phase of illness, and treatment; then, they were randomized to the control group (standard care) or the experimental group (standard care plus a 5-session family intervention). The intervention targeted couples' communication, hope, coping, uncertainty, and symptom management. The final sample consisted of 235 couples: 123 couples in the control group and 112 couples in the experimental group. Data collection occurred at baseline before randomization and at 4 months, 8 months, and 12 months. RESULTS: At 4-month follow-up, intervention patients reported less uncertainty and better communication with spouses than control patients, but they reported no other effects. Intervention spouses reported higher quality of life, more self-efficacy, better communication, and less negative appraisal of caregiving, uncertainty, hopelessness, and symptom distress at 4 months compared with controls, and some effects were sustained to 8 months and 12 months. CONCLUSIONS: Men with prostate cancer and their spouses reported positive outcomes from a family intervention that offered them information and support. Programs of care need to be extended to spouses who likely will experience multiple benefits from intervention.

Living with prostate cancer: patients' and spouses' psychosocial status and quality of life.

PURPOSE: Despite the high prevalence of prostate cancer, little information is available on the quality of life of men and their spouses during the phases of illness. This study assessed patients' and spouses' quality of life, appraisal of illness, resources, symptoms, and risk for distress across three phases of prostate cancer: newly diagnosed, biochemical recurrence, and advanced. PATIENTS AND METHODS: The sample consisted of 263 patient/spouse dyads. A stress-appraisal conceptual model guided the selection of variables which were then assessed with established instruments. Study variables were examined for phase effects (differences in dyads across three phases), role effects (patients v spouses), and phase-by-role interactions (differences within dyads across phases) using analysis of variance (ANOVA). RESULTS: More phase effects than role effects were found, indicating that the psychosocial experiences of patients and their spouses were similar, but differed from dyads in other phases. Dyads in the advanced phase were at highest risk for distress. These patients had the lowest physical quality of life, and their spouses had the lowest emotional quality of life of all participants. Dyads in the biochemical recurrence and advanced phases had more negative appraisals of illness and caregiving, greater uncertainty, and more hopelessness compared with dyads in the newly diagnosed phase. Spouses, in contrast to patients, had less confidence in their ability to manage the illness and perceived less support across all phases of illness. CONCLUSION: Phase-specific programs of care are needed to assist both men with prostate cancer and their spouses to manage the effects of illness.

Quality of life as a predictor of weight loss in obese, early-stage breast cancer survivors.

PURPOSE/OBJECTIVES: To investigate whether quality of life (QOL) assessed before weight loss intervention predicts weight loss and, in turn, what the effect of weight loss is on QOL measures after 12 months in early-stage breast cancer survivors. DESIGN: A clinical trial of a weight loss intervention in breast cancer survivors. SETTING: Community-wide recruitment in Detroit, MI. SAMPLE: 39 breast cancer survivors (body mass index = 30-44 kg/m2), within three years of initial diagnosis and at least three months after chemotherapy or radiation therapy. METHODS: Participants were randomized to one of three weight loss methods or a control group. The Functional Assessment of Cancer Therapy-Anemia (FACT-An) QOL questionnaire was administered at baseline and after the intervention. MAIN RESEARCH VARIABLES: Six subscales of the FACT-An and weight change. FINDINGS: Modest but statistically significant associations were found for the physical and functional subscales of the FACT-An with weight loss for 39 subjects who completed 12 months of the study. Those reporting relatively impaired physical or functional QOL at baseline lost more weight, which accounted for 8%-9% of the weight loss variance beyond that resulting from the diet arm assignment. At 12 months, greater weight loss was associated with significant improvements in overall FACT-An score and in the physical, functional, fatigue, and anemia subscales (p < 0.05). CONCLUSIONS: Relatively low physical function at baseline was not a barrier to weight loss; indeed, it may have been a motivating factor in adherence to the weight loss intervention. Weight loss was associated with improvement in several QOL subscale measures in breast cancer survivors, but the emotional and social subscales were not affected. IMPLICATIONS FOR NURSING: Counseling for weight loss that includes recommendations for exercise should not be withheld for patients with relatively low physical functioning.

Qualitative analysis of couples' experience with prostate cancer by age cohort.

Prostate cancer is a significant cause of morbidity and mortality in men in all adult life stages. Normative developmental tasks of aging combined with disease-related stressors may negatively affect adjustment to prostate cancer and, consequently, affect the quality of life of both the man and his spouse. The purpose of this study was to examine the experiences of men with prostate cancer and their partners according to their life cycle cohort: 50-64 (late middle age), 65-74 (young-old), and 75-84 (old-old). Qualitative interviews with 15 couples were used to provide information about the dyad's experiences with prostate cancer. Interview data were analyzed to identify preliminary coding schemas, which were subsequently refined and modified into themes. Three major themes were identified from the data. Across all age groups, prostate cancer had a significant effect on: (1) couples' daily lives, (2) their dyadic and family relationships, and (3) their developmental stage. There were also differences in age groups. Couples in the late middle age group reported greater disappointment and anger at their inability to reach life goals and establish financial security. Couples in the young-old group made more spontaneous comments about being satisfied with their life than the couples in the other 2 groups. Couples in the old-old group reported slower recovery from the illness than the younger couples. Results indicate that although prostate cancer may have some universal effects on couples, it also may have differential effects by age cohort. Hence, targeted interventions by age cohort may be warranted.

Research with families facing cancer: the challenges of accrual and retention.

The purposes of this article are: (a) to describe and analyze the accrual and retention patterns in a longitudinal randomized clinical trial with prostate cancer patients and their partners, and (b) to discuss strategies that were used to overcome challenges in conducting this family-based study. Initially, 429 dyads were referred to the study. Of these, 166 were not enrolled due to refusal (n = 120) or ineligibility (n = 46), 21 of whom did not meet one or more of the inclusion criteria, and 25 of whom could not be reached within the 2-month window of eligibility. Of the 383 eligible dyads, 263 dyads were enrolled (enrollment rate of 68.7%). Accrual and retention patterns differed by research site, referral procedures, and phase of prostate cancer. The retention rate was very good with the majority of dyads (n = 218) completing all three follow-up assessments at 4, 8, and 12 months (82.9%).

HIV health care access issues for women living with HIV, mental illness, and substance abuse.

Nurses at the Well-Being Institute, a community-based nursing outreach clinic in Detroit, Michigan, located 75 women living with HIV, mental illness, and substance abuse who were lost to follow-up at their HIV medical clinic as part of a nursing research study. Women who had been scheduled for an appointment in the last 4 months but who had missed that appointment were considered "lost to follow-up" in the HIV clinic. The purpose of the research was to study factors related to health care access in women not participating in regular health care for their HIV infection. Women were randomly assigned to two study groups. Women assigned to "care as usual" study group (n = 37) received no additional services beyond study interviews for 1 year. Women assigned to the "nursing intervention" group (n = 38) were provided with nursing services designed to facilitate their return to and continued connection with their HIV clinic. Findings showed that factors related to the women's vulnerability, such as mental illness and drug use, were more related to their use of expensive health care services such as hospital emergency departments or hospital inpatient admissions than was assignment to either the "nursing intervention" or "care as usual" study groups. Two case studies describing the cost of care for 2 of the multiply diagnosed women in the study is presented. The women differed on whether they had stable housing and were accessing care for their mental illness.

Cultural affiliation and mammography screening of Chinese women in an urban county of Michigan.

The aim of this study is to explore the relationship of culturally based attitudes on breast cancer screening behavior of Chinese women currently residing in the United States. This cross-sectional study used a survey instrument that was administered to a consecutive nonprobability sample of 202 Chinese women residing in an urban Michigan county. Mood's strength of cultural affiliation scale (SCAS) was modified for cultural appropriateness prior to being translated into Chinese, back-translated, and pretested prior to use for this study. Data were analyzed using descriptive, correlational, and multivariate analysis techniques. Statistical analyses revealed that cultural diversity within the Chinese sample was associated with differing health behaviors and that the SCAS had indirect effects, through access to health care, on women's mammography screening use (R2 = 28.3%). These study's findings reveal that cultural affiliation and beliefs are related to the breast cancer screening behavior of immigrant Chinese women.

Effects of a family intervention on the quality of life of women with recurrent breast cancer and their family caregivers.

BACKGROUND: The purpose of this study was to determine if patients with advanced breast cancer and their family caregivers, who participated in a family based intervention, report better quality of life and other psychosocial outcomes than dyads who received standard care alone. METHODS: Using a randomized clinical trial, 134 patients and their family caregivers were assigned to usual care (control) or to usual care plus the family intervention (experimental condition). Dyads were assessed at baseline, three- and six-months later. The intervention consisted of five sessions and addressed family involvement, optimistic attitude, coping effectiveness, uncertainty reduction, and symptom management. RESULTS: Patients in the family intervention reported significantly less hopelessness and less negative appraisal of illness than controls; their family caregivers reported significantly less negative appraisal of caregiving. Intervention effects were evident at three-months, but were not sustained at six-months. No difference was found in the quality of life of dyads in experimental or control conditions. CONCLUSIONS: Although the family intervention had positive effects initially, these effects were not sustained over time. Future studies need to consider program dose and duration of effect, outcome measures that are more sensitive to change, and realistic end-points for patients with advanced cancer.

The effects of health state, hemoglobin, global symptom distress, mood disturbance, and treatment site on fatigue onset, duration, and distress in patients receiving radiation therapy.

PURPOSE/OBJECTIVES: To describe the fatigue experience of patients with cancer receiving radiation therapy and determine to what extent diverse correlates of fatigue affect fatigue onset, duration, and distress. DESIGN: Descriptive correlational study completed by secondary data analysis. SAMPLE/SETTING: Data were obtained from 384 subjects recruited from two urban, university-affiliated, radiation oncology clinics located in a large, Midwestern city. METHODS: The effects of health indicators and treatment site on fatigue onset, duration, and distress were examined using correlational analyses and analyses of variance. MAIN RESEARCH VARIABLES: Hemoglobin, health status, global symptom distress, mood disturbance, treatment site, and fatigue onset, duration, and distress. FINDINGS: Fatigue started near the middle of the second week of treatment, was moderately distressing, and lasted approximately 32 days. Higher levels of health and hemoglobin at the start of therapy were associated with a delayed onset, shorter duration, and lower levels of fatigue distress. In contrast, higher pretreatment levels of global symptom distress and mood disturbance were associated with an earlier onset, longer duration, and greater severity of fatigue distress. CONCLUSION: The fatigue experience in patients undergoing radiation therapy is highly individualized. Variations in the health states of patients as well as the area of the body being treated can influence fatigue onset, duration, and distress. IMPLICATIONS FOR NURSING: Pretreatment screening for fatigue and its correlates is needed to identify patients at risk for an earlier onset, longer duration, and more distressing levels of fatigue.