The efficacy of Internet-based cognitive behavioral therapy for severely fatigued survivors of breast cancer compared with care as usual: A randomized controlled trial.

BACKGROUND: Severe fatigue is a common and distressing symptom affecting approximately one in four survivors of breast cancer. The current study examined the efficacy of Internet-based cognitive behavioral therapy (ICBT) for severe fatigue in survivors of breast cancer compared with care as usual (CAU). METHODS: The authors conducted a parallel-group randomized controlled trial. Severely fatigued, disease-free survivors of breast cancer who had completed cancer treatment at least 3 months previously were eligible. Participants were randomly allocated to ICBT or CAU using computer-generated stratified block randomization. The primary outcome of fatigue severity was assessed at baseline and after 6 months, as were the secondary outcomes of functional impairment, psychological distress, and quality of life. Statistical effects were tested with analyses of covariance (intention-to-treat analysis). RESULTS: Participants were recruited between January 2014 and March 2016 and assigned to ICBT (66 patients) or CAU (66 patients). Compared with the participants who had received CAU, those who had received ICBT reported lower fatigue scores at 6 months (mean difference [Δ], 11.5; 95% confidence interval [95% CI], 7.7-15.3) and a large effect size (Cohen d = 1.0), with the majority of patients (73%) demonstrating clinically significant improvement. ICBT also was found to lead to lower functional impairment (Δ, 297.8; 95% CI, 145.5-450.1) and psychological distress scores (Δ, 5.7; 95% CI, 3.4-7.9) and higher quality-of-life scores (Δ, 11.7; 95% CI, 5.8-17.7) compared with CAU, with medium to large effect sizes (Cohen d = 0.6-0.8). CONCLUSIONS: ICBT appears to be effective in reducing severe fatigue and related symptoms and meets the current need for easy accessible and more efficient evidence-based treatment options for severely fatigued survivors of breast cancer. Cancer 2017;123:3825-34. © 2017 American Cancer Society.

Study protocol of the TIRED study: a randomised controlled trial comparing either graded exercise therapy for severe fatigue or cognitive behaviour therapy with usual care in patients with incurable cancer.

BACKGROUND: Fatigue is a common and debilitating symptom for patients with incurable cancer receiving systemic treatment with palliative intent. There is evidence that non-pharmacological interventions such as graded exercise therapy (GET) or cognitive behaviour therapy (CBT) reduce cancer-related fatigue in disease-free cancer patients and in patients receiving treatment with curative intent. These interventions may also result in a reduction of fatigue in patients receiving treatment with palliative intent, by improving physical fitness (GET) or changing fatigue-related cognitions and behaviour (CBT). The primary aim of our study is to assess the efficacy of GET or CBT compared to usual care (UC) in reducing fatigue in patients with incurable cancer. METHODS: The TIRED study is a multicentre three-armed randomised controlled trial (RCT) for incurable cancer patients receiving systemic treatment with palliative intent. Participants will be randomised to GET, CBT, or UC. In addition to UC, the GET group will participate in a 12-week supervised exercise programme. The CBT group will receive a 12-week CBT intervention in addition to UC. Primary and secondary outcome measures will be assessed at baseline, post-intervention (14 weeks), and at follow-up assessments (18 and 26 weeks post-randomisation). The primary outcome measure is fatigue severity (Checklist Individual Strength subscale fatigue severity). Secondary outcome measures are fatigue (EORTC-QLQ-C30 subscale fatigue), functional impairments (Sickness Impact Profile total score, EORTC-QLQ-C30 subscale emotional functioning, subscale physical functioning) and quality of life (EORTC-QLQ-C30 subscale QoL). Outcomes at 14 weeks (primary endpoint) of either treatment arm will be compared to those of UC participants. In addition, outcomes at 18 and 26 weeks (follow-up assessments) of either treatment arm will be compared to those of UC participants. DISCUSSION: To our knowledge, the TIRED study is the first RCT investigating the efficacy of GET and CBT on reducing fatigue during treatment with palliative intent in incurable cancer patients. The results of this study will provide information about the possibility and efficacy of GET and CBT for severely fatigued incurable cancer patients. TRIAL REGISTRATION: NTR3812 ; date of registration: 23/01/2013.

Fatigue in Advanced Cancer Patients: Congruence Between Patients and Their Informal Caregivers About Patients' Fatigue Severity During Cancer Treatment With Palliative Intent and Predictors of Agreement.

CONTEXT: Informal caregivers (ICs) are increasingly involved in the monitoring of symptoms during advanced cancer patients' treatment with palliative intent. A common but subjective symptom during this extended treatment phase is fatigue. OBJECTIVES: This exploratory longitudinal study aimed to determine agreement between patients and ICs about patients' fatigue severity. In addition, predictors of agreement over time were studied. METHODS: A sample of 107 patients with advanced cancer (life expectancy ≥ six months) and their ICs completed the subscale fatigue severity of the Checklist Individual Strength based on the patient's status at baseline and six months later. This eight-item subscale has a validated cutoff to determine the presence of clinically relevant levels of fatigue. ICs' own fatigue severity, strain, self-esteem, and relationship satisfaction were examined as predictors of agreement. RESULTS: A total of 107 dyads completed measures at baseline and 69 dyads six months later. At baseline, ICs' significantly overestimated patients' fatigue severity (P < 0.001) with a moderate amount of bias (Cohen's d = 0.48). In 81 of the 107 dyads (76%), there was congruence about the presence or absence of severe fatigue. On a group level, congruence did not significantly change over time. On a dyad level, there was a tendency to either remain congruent or reach congruence. Next to baseline congruence, ICs' fatigue severity and strain predicted ICs' fatigue ratings (R(2) = 0.22). CONCLUSION: Most ICs accurately predict presence or absence of clinically relevant levels of patients' fatigue. ICs' own fatigue severity and strain should be taken into account as they influence agreement.

Prevalence, Impact, and Correlates of Severe Fatigue in Patients With Gastrointestinal Stromal Tumors.

CONTEXT: The introduction of the tyrosine kinase inhibitor (TKI) imatinib in the treatment of gastrointestinal stromal tumor (GIST) in 2000 was the start of a new era of targeted treatment. Since then, the median survival of patients with GIST has substantially increased. Prolonged survival and chronic TKI use are associated with treatment-induced symptoms, such as fatigue, which can compromise quality of life (QoL). OBJECTIVES: This study determined the prevalence of severe fatigue in GIST patients compared to matched healthy controls, the impact of fatigue on daily life, and associations between fatigue and current TKI use. METHODS: One hundred nineteen patients treated with surgery and/or a TKI for GIST were asked to participate. Participants completed questionnaires including the Checklist Individual Strength-Fatigue Severity scale (CIS-fatigue), Short-Form 36-Item Health Survey, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, Fatigue Catastrophizing Scale, Self-Efficacy Scale, and the Hospital Anxiety and Depression Scale. RESULTS: Eighty-nine GIST patients (75%) completed questionnaires, 61 patients (69%) were on a TKI. Prevalence of severe fatigue measured with CIS-fatigue was significantly higher in GIST patients (30%) than in 234 matched healthy controls (15%). The prevalence of severe fatigue did not differ significantly between patients receiving treatment with curative (29%) or palliative intent (36%). Severely fatigued patients reported lower QoL and more impairment on all functional domains. TKI use, more psychological distress, and lower physical functioning were associated with fatigue. CONCLUSION: Severe fatigue occurs in 30% of GIST patients and in 33% of GIST patients on a TKI. The fatigue is disabling and is not only associated with current TKI use but also with psychological distress and physical functioning. GIST patients should be informed about these associated factors of fatigue that deserve appropriate management.

Fatigue and its associated psychosocial factors in cancer patients on active palliative treatment measured over time.

PURPOSE: Fatigue is a frequently reported symptom by patients with advanced cancer, but hardly any prospective information is available about fatigue while on treatment in the palliative setting. In a previous cross-sectional study, we found several factors contributing to fatigue in these patients. In this study, we investigated the course of fatigue over time and if psychosocial factors were associated with fatigue over time. METHODS: Patients on cancer treatment for incurable solid tumors were observed over 6 months. Patients filled in the Checklist Individual Strength monthly to measure the course of fatigue. Baseline questionnaires were used to measure disease acceptance, anxiety, depressive mood, fatigue catastrophizing, sleeping problems, discrepancies in social support, and self-reported physical activity for their relation with fatigue over time. RESULTS: At baseline 137 patients and after 6 months 89 patients participated. The mean duration of participation was 4.9 months. At most time points, fatigue scores were significantly higher in the group dropouts in comparison with the group participating 6 months (completers). Overall fatigue levels remained stable over time for the majority of participants. In the completers, 42% never experienced severe fatigue, 29% persisted being severely fatigued, and others had either an increasing or decreasing level. Of the investigated factors, low reported physical activity and non-acceptance of cancer were associated significantly to fatigue. CONCLUSION: A substantial number of participants never experienced severe fatigue and fatigue levels remained stable over time. For those who do experience severe fatigue, non-acceptance of having incurable cancer and low self-reported physical activity may be fatigue-perpetuating factors.

Neuropathic Pain Components in Patients with Cancer: Prevalence, Treatment, and Interference with Daily Activities.

BACKGROUND: Pain and neuropathic symptoms impact quality of life of patients with cancer. To obtain more insight in the prevalence, severity, and treatment of neuropathic symptoms in patients with cancer and their interference with daily activities, we conducted a cross-sectional study at the outpatient clinic of a Dutch university hospital. METHODS: A cross-sectional study among outpatients with cancer. To identify pain, its intensity, quality, and interference with daily activities, the Brief Pain Inventory (BPI) was used. Neuropathic symptoms were identified with the Douleur Neuropathique (DN4) interview and pain characteristics with the McGill Pain Questionnaire (MPQ). Pain medication and adjuvant analgesics were also collected with a prestructured questionnaire. Descriptives, chi-squared tests, t-tests, and a logistic regression analysis were conducted. RESULTS: 892 patients completed the questionnaires. Twenty-three percent (n = 204) reported moderate to severe pain, and 19% (n = 170) scored positive on neuropathic symptoms (DN4 ≥ 3). Particularly in patients with a rating on a numeric rating scale (NRS) < 5, existence of neuropathic symptoms significantly increased interference with daily activities. Of patients with neuropathic symptoms, 8% received adjuvant pain treatment. Receiving curative treatment, using a systemic drug with neurotoxicity, having had an operation, and having had a lymph node dissection independently contributed to having neuropathic symptoms. CONCLUSIONS: This study shows that over 40% of the patients with moderate to severe pain also have neuropathic symptoms, causing increased interference with daily activities. Most of these patients do not receive adjuvant analgesics. There is a need to improve management of neuropathic symptoms in patients with cancer.

Addressing Palliative Sedation during Expert Consultation: A Descriptive Analysis of the Practice of Dutch Palliative Care Consultation Teams.

MAIN OBJECTIVE: Since palliative sedation is considered a complex intervention, consultation teams are increasingly established to support general practice. This study aims to offer insight into the frequency and characteristics of expert consultations regarding palliative sedation. METHODS: We performed a retrospective analysis of a longitudinal database. This database contained all patient-related consultations by Dutch Palliative Care Consultation teams, that were requested between 2004 and 2011. We described the frequency and characteristics of these consultations, in particular of the subgroup of consultations in which palliative sedation was addressed (i.e. PSa consultations). We used multivariate regression analysis to explore consultation characteristics associated with a higher likelihood of PSa consultations. MAIN RESULTS AND THEIR SIGNIFICANCE: Of the 44,443 initial consultations, most were requested by general practitioners (73%) and most concerned patients with cancer (86%). Palliative sedation was addressed in 18.1% of all consultations. Palliative sedation was relatively more often discussed during consultations for patients with a neurologic disease (OR 1.79; 95% CI: 1.51-2.12) or COPD (OR 1.39; 95% CI: 1.15-1.69) than for patients with cancer. We observed a higher likelihood of PSa consultations if the following topics were also addressed during consultation: dyspnoea (OR 1.30; 95% CI: 1.22-1.40), agitation/delirium (OR 1.57; 95% CI: 1.47-1.68), exhaustion (OR 2.89; 95% CI: 2.61-3.20), euthanasia-related questions (OR 2.65; 95% CI: 2.37-2.96) or existential issues (OR 1.55; 95% CI: 1.31-1.83). CONCLUSION: In conclusion, PSa consultations accounted for almost one-fifth of all expert consultations and were associated with several case-related characteristics. These characteristics may help clinicians in identifying patients at risk for a more complex disease trajectory at the end of life.

Feasibility and impact of a physical exercise program in patients with advanced cancer: a pilot study.

OBJECTIVE: Our aim was to investigate the feasibility of completing an exercise program in patients with advanced cancer and to obtain preliminary data of its impact on physical and quality of life (QoL) outcomes. METHODS: We conducted a nonrandomized pilot study. Participants were 26 palliative care patients with advanced cancer (mean age=54.5 years; standard deviation [SD] 8.9 years) of the outpatient clinic of the medical oncology and the urology departments of a medical center in The Netherlands. Participants followed an individually graded group exercise program, consisting of resistance training and aerobic exercise, twice a week during 6 weeks. Feasibility of the training program, muscle strength, aerobic fitness, body composition, QoL, fatigue, and physical role, social, and activities of daily living (ADL) functioning were assessed at baseline and immediately after the intervention. RESULTS: Dropout rate during the training period was 35% due to disease progression. After the training period, based on intention to treat analysis, muscle strength and aerobic functional fitness had increased significantly (p≤0.01). A significant decrease in fat percentage (p≤0.02) was observed. QoL had increased significantly (p≤0.02), as well as social (p≤0.04), physical role (p≤0.01), and ADL functioning (p≤0.05). Fatigue decreased significantly on the Checklist Individual Strength (CIS) and RAND-36 questionnaires (p≤0.02), however not on the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (p=0.48). No change in physical functioning was observed with the EORTC QLQ-C30 and RAND-36 (respectively, p=0.33 and p=0.09). CONCLUSIONS: These preliminary results show that physical exercise in patients with advanced cancer is feasible. A significant impact was observed on physical and QoL outcomes. These findings need to be confirmed with a larger-scale, randomized controlled trial.

The effects of cognitive behavioral therapy for postcancer fatigue on perceived cognitive disabilities and neuropsychological test performance.

CONTEXT: After successful cancer treatment, a substantial number of survivors continue to experience fatigue and related concentration and memory problems. Severe fatigue after cancer treatment can be treated effectively with cognitive behavioral therapy (CBT), but it is unclear whether CBT has an effect on cognitive functioning. OBJECTIVES: We hypothesized that patients would report less cognitive disability after treatment with CBT for cancer-related fatigue. CBT was not expected to affect neuropsychological test performance, as it has been shown that fatigue is not associated with test performance. METHODS: Data were used from a randomized controlled trial in which 98 severely fatigued cancer survivors, treated at least one year previously, were assessed at baseline (T1) and six months post-baseline (T2). Patients were randomly assigned to receive CBT (n = 50) or to a waiting list (WL) control condition (n = 48). Self-reported cognitive disability was assessed by the Concentration subscale of the Checklist Individual Strength and the Alertness Behavior subscale of the Sickness Impact Profile. Neuropsychological test performance was measured by the symbol digit modalities task and two reaction time tasks. RESULTS: Patients who received CBT for post-cancer fatigue reported significantly less cognitive disability compared with those in the WL group. CBT also was associated with a clinically relevant reduction in concentration problems (CBT, 32% vs. WL, 2%). There were no significant differences in neuropsychological test performance between the CBT and WL groups. CONCLUSION: CBT for post-cancer fatigue has already been shown to be an effective therapy. The present study demonstrates that CBT also may lead to a decrease in perceived cognitive disability.

Severe fatigue during the palliative treatment phase of cancer: an exploratory study.

BACKGROUND: Because of a rise in incidence and more effective treatments, the prevalence of patients with metastatic cancer is increasing fast. When palliative treatment is aimed at maintaining or improving patients' quality of life, knowledge about severe fatigue is clinically relevant because of its debilitating effect, but at present this information is lacking. OBJECTIVE: This study investigated the prevalence of severe fatigue in patients with various incurable cancers and whether severe fatigue increased with further treatment lines and differed between various cancers and treatment modalities. In addition, a relationship between severe fatigue and other symptoms was examined. METHODS: Patients were asked to fill in the Checklist Individual Strength, European Organization of Research and Treatment of Cancer-Quality of Life Questionnaire C30, and the McGill Pain Questionnaire during palliative anticancer treatment, and hemoglobin levels were collected. RESULTS: Of all participating patients (n = 137), 47% were severely fatigued. Patients who received first line of treatment were significantly less often severely fatigued (40%) compared with patients who received further lines (60%). Significantly more severe fatigue was observed when patients had more pain, dyspnea, appetite loss, nausea, vomiting, and constipation. CONCLUSIONS: During the phase of palliative anticancer treatment, fatigue was the most common symptom, nearly half of the patients had severe fatigue increasing with further treatment lines. Various treatment-related symptoms were related to more severe fatigue. IMPLICATIONS FOR PRACTICE: As severe fatigue is significantly related to other symptoms of cancer and its treatment, the screening and treatment of these cancer-related symptoms should be more stringent, as they might negatively influence each other.

Assessment of neuropathic pain in patients with cancer: the interobserver reliability. An observational study in daily practice.

BACKGROUND: Neuropathic pain (NeP) is a burdensome problem in all stages of cancer. Although clinical judgment is accepted as a surrogate for an objective gold standard in diagnosing NeP, no publications were found about its reliability. OBJECTIVES: Therefore, levels of agreement on the clinical examination of NeP were estimated by calculating kappa-value (K) and percentage of pair wise agreement (PA) to determine the interobserver reliability of diagnosing NeP. SETTING: The outpatient clinic of medical oncology of the Radboud University Nijmegen Medical Centre. METHODS: Patients with cancer with potential NeP complaints were recruited from the outpatient clinic of medical oncology. Physicians were recruited from the department of pain and palliative medicine. Physicians and patients were recruited for participation in an observational study in daily practice. Each patient (N = 34) was examined by 2 specialists via independent clinical assessment. All consultations were video recorded.  After each assessment, physicians were asked to indicate the most adequate characterization of the pain: pure NeP, pure nociceptive pain (NoP), mixed pain (MiP), or no pain (NP). RESULTS: Kappa (K) for the diagnosis of the most adequate pain characterization was 0.50, PA 64.7%. For diagnosing pure NeP k was 0.78 (PA 91.2%), for the NeP component (NeP + MiP)  and NoP component (NoP + MiP), it was respectively 0.52 (PA  76.5%) and 0.61 (PA 82.4%). For the diagnosis on the basis of the grading system between physicians, K was 0.34 (PA 52.9%). The intrarater reliability for the diagnosis of an NeP component on the basis of clinical assessment and the NeP component on the basis of the grading system, for pain specialists K was 0.69 (PA 85.3%) and for palliative care specialists K was 0.61 (PA 79.4%). LIMITATIONS: The values of K and the PA for the existence of an NeP component are not satisfying and the clinical agreement between physicians around findings from physical examination should encourage a better standardization of the clinical assessment and classification of pain in patients with cancer in respect with the identification of NeP.  CONCLUSIONS: A substantial level of agreement was found for the diagnosis of pure NeP and a moderate level of agreement for the diagnosis of the NeP component was found, both with a PA = 70%. There was only a fair agreement between the physicians regarding the grading system. However, there was a substantial level of (interrater) agreement for the diagnosis of an NeP component and the outcome of the grading system. The findings in this study also suggest that a better standardization of the clinical assessment and classification of pain in patients with cancer with respect to the identification of neuropathic pain is necessary.

Development of fatigue in cancer survivors: a prospective follow-up study from diagnosis into the year after treatment.

CONTEXT: There is a lack of longitudinal studies investigating fatigue from before cancer treatment to long after successful cancer treatment. OBJECTIVES: This prospective follow-up study aimed to determine the prevalence and predictors of persistent fatigue in cancer survivors in the first year after completion of cancer treatment. METHODS: Sixty patients with various malignancies were assessed before (T1), shortly after curative cancer treatment (T2), and one year after T2 (T3). Fatigue was assessed monthly between T2 and T3. Fatigue severity was measured using the subscale of the Checklist Individual Strength. Questionnaires were used to measure impaired sleep and rest, physical activity, social support, fatigue catastrophizing, and somatic-related attributions regarding fatigue. Linear regression analyses were performed to identify predictors of persistent fatigue. RESULTS: In total, 22% of survivors had severe persistent fatigue over the last six months in the first year after cancer treatment. Fatigue at T1, T2, and negative interactions predicted the severity of persistent fatigue. Analyses without fatigue showed that more negative interactions, impaired sleep and rest, fatigue catastrophizing, and lower self-reported physical activity at T2 were associated with the severity of persistent fatigue. CONCLUSION: Twenty-two percent of the survivors had severe persistent fatigue in the year after cancer treatment. Fatigue and cognitive behavioral factors predicted persistent fatigue in the year after cancer treatment. Diagnosis or cancer treatment did not predict persistent fatigue. The implication is that cognitive behavioral therapy for postcancer fatigue, aimed at the fatigue-perpetuating factors, could be offered from two months after successful cancer treatment.

Palliative medicine update: a multidisciplinary approach.

Palliative medicine is a young specialty that is officially recognized in relatively few countries. The World Health Organization published an adapted definition in 2002, describing palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. When the accent is shifting from curative to palliative, the goal of management is the maintenance or improvement of the patient's quality of life. The different dimensions of palliative care and the multitude of types of care to be provided require a multidisciplinary, well-functioning team, effective communication and a clear task division between primary and hospital care. Considering the complexity of care for incurable patients, a multidisciplinary approach is a prerequisite to balance curative and palliative intervention options. Optimal functioning of a team requires excellent training, communication and a description of the tasks and responsibilities of each team member. More and more advanced care planning is introduced in palliative care, focusing on an early identification of patients in a palliative trajectory and on the prevention of annoying symptoms, hoping that this approach results in an improved quality of life for the individual patient, less useless technical investigations and a better end-of-life care on the place the patient and his family desires.

Comparison of attitudes of guilt and forgiveness in cancer patients without evidence of disease and advanced cancer patients in a palliative care setting.

BACKGROUND: : Attitudes toward guilt and forgiveness may be important factors determining distress in cancer patients. Direct comparative studies in patients with different life expectancies exploring attitudes toward guilt and forgiveness are lacking. Also, sociodemographic and religious characteristics determining the attitudes toward guilt and forgiveness are unknown. OBJECTIVE: : The objective of this study was to compare attitudes toward guilt and forgiveness in cancer patients without evidence of disease and advanced cancer patients. METHODS: : A descriptive research design was used. Ninety-seven patients without evidence of disease and 55 advanced cancer patients filled out the Dutch Guilt Measurement Instrument and the Forgiveness of Others Scale. RESULTS: : Both groups had an attitude of nonreligious guilt and forgiveness, but not of religious guilt. No significant differences in attitudes toward guilt and forgiveness were observed between the 2 groups. In contrast to sociodemographic characteristics, religious characteristics were relevant predictors for guilt and forgiveness. Significant differences in relations between images of God and attitudes toward guilt were observed between the 2 patient groups. CONCLUSIONS: : An attitude of nonreligious guilt and forgiveness was found in cancer patients, irrespective of the stage of disease. Religious characteristics were significantly associated with attitudes of guilt and forgiveness. This correlation differed in the early and the advanced setting of disease. IMPLICATIONS FOR PRACTICE: : The observed relations between religious characteristics and attitudes of guilt and forgiveness suggest that a careful examination of the role of religious beliefs and values is relevant in the clinical care of patients with cancer, both in the setting of early and advanced disease.

Examining the role of physical activity in reducing postcancer fatigue.

PURPOSE: Persistent fatigue is a long-term adverse effect experienced in about a quarter of patients cured of cancer. It was shown that cognitive behavior therapy (CBT) especially designed for postcancer fatigue is highly effective in reducing severe fatigue. However, it is unclear by what mechanism the fatigue reduction is reached. In many fatigue reduction programs, an increase in physical activity is assumed to reduce fatigue. The purpose of the present study is to determine whether the effect of CBT on fatigue is mediated by an increase in physical activity. METHODS: Data of a previous randomized controlled trial on the efficacy of CBT for postcancer fatigue were reanalyzed (CBT, n = 41; waiting list condition, n = 42). Actigraphy was used to assess the level of objective physical activity. Cancer survivors were assessed prior as well as after the CBT and waiting list period. The mediation hypothesis was tested according to guidelines of Baron and Kenny. A non-parametric bootstrap approach was used to test statistical significance of the mediation effect. RESULTS: Although CBT effectively reduced postcancer fatigue, no change in level of objective physical activity was found. The mean mediation effect was 1.4% of the total treatment effect. This effect was not significant. CONCLUSION: The effect of CBT for postcancer fatigue is not mediated by a persistent increase in objective physical activity.

Moderators and long-term effectiveness of cognitive behaviour therapy for fatigue during cancer treatment.

OBJECTIVE: A randomised controlled trial (RCT) demonstrated that cognitive behaviour therapy (CBT) for fatigue during curative cancer treatment was effective shortly after cancer treatment. This study aimed to identify which patient characteristics predict fatigue improvement after CBT. In addition, the long-term effectiveness was investigated. METHODS: Patients with various malignancies participated in the RCT (n = 210). Participants were assessed before cancer treatment (T1), postintervention (T2), which was at least 2 months after cancer treatment, and after 1-year follow-up (T3). Monthly fatigue assessments were completed between T2 and T3. A regression analysis with interactions was performed to determine if domains of quality of life (EORTC-QLQ-C30) functioning (Health Survey Short Form-36) or psychological distress (Symptom Checklist-90) moderated the effect of CBT on fatigue. Analyses of covariance were used to study the long-term effectiveness of CBT. RESULTS: Fatigue at T2 was predicted by a significant interaction between self-reported cognitive functioning and CBT. No interactions were found between other domains of quality of life, functioning, psychological distress and CBT. At T3, no significant difference on fatigue was found between CBT and usual care. Exploratory analyses showed that the difference nearly reached significance until 7 months postintervention. CONCLUSIONS: Patients who experienced more concentration and memory problems at T1 benefited more from CBT for fatigue and are indicators. After a year of follow-up, the effect of CBT for fatigue was no longer observed, and the effect on fatigue seemed to be diminished 7 months postintervention. The implication is that CBT for fatigue should be offered to patients with cancer with the highest chance to benefit.

Time perception of cancer patients without evidence of disease and advanced cancer patients in a palliative, end-of-life-care setting.

BACKGROUND: Time perception may be an important factor influencing distress of cancer patients. However, no comparative studies have been performed for cancer patients without evidence of disease and advanced cancer patients in the palliative, end-of-life-care setting. OBJECTIVE: The objectives of the study were to assess time perception in disease-free and advanced cancer patients and examine the relation of time perception with patients' distress. METHODS: A descriptive research design was used. Ninety-six disease-free and 63 advanced cancer patients filled out Cottle's Circle Test to assess time coherence and time dominance, Cottle's Line Test to assess temporal extension and Bayes' question on speed of time, the European Organisation for Research-and-Treatment of Cancer QOL-Questionnaire version 2.0, Beck's Depression Inventory for primary care, and Beck's Hopelessness-Scale. RESULTS: In patients without evidence of disease, future dominance was most often observed, whereas in advanced cancer patients, the present was the dominant time segment. In both groups, a focus on the past was associated with distress. In contrast with patients without evidence of disease, advanced cancer patients perceived time as moving slowly, and this was correlated with distress. CONCLUSIONS: The time perception of cancer patients without evidence of disease and advanced cancer patients is significantly different and is related to distress. IMPLICATIONS FOR PRACTICE: The observed relation between a focus on the past and distress gives room for interventions of nurses and other healthcare professionals. Specific attention is needed for differences between cancer patients without evidence of disease and advanced cancer patients.

[Pitfalls in the treatment of neuropathic pain in patients with cancer]. / Valkuilen in de behandeling van neuropathische pijn bij patiënten met kanker.

Three patients with cancer experienced severe side-effects after starting anti-neuropathic pain therapy. All patients, 1 woman and 2 men aged between 69 and 71, fell or had problems with balance. These side-effects diminished after reducing the doses or stopping the medication. It seems that side-effects in patients with cancer are more common and more severe than in other populations with neuropathic pain, such as patients with diabetic neuropathy or postherpetic neuralgia. There is little research into the treatment of neuropathic pain in patients with cancer. In this patient group it is advisable to monitor the patient at least once a week for an optimal treatment and to prevent severe side-effects, especially in the first weeks after starting the treatment.

Perspectives on death and an afterlife in relation to quality of life, depression, and hopelessness in cancer patients without evidence of disease and advanced cancer patients.

CONTEXT: It is unknown whether cancer patients with different life expectancies have different attitudes and emotions toward death and an afterlife. Also, it is unclear whether these attitudes and emotions toward death and afterlife influence patients' distress. OBJECTIVES: To assess the relationship of attitudes and emotions towards death and an afterlife with quality of life, depression and hopelessness in cancer patients without evidence of disease and advanced cancer patients facing death. METHODS: Ninety-one cancer patients without evidence of disease and 57 advanced cancer patients completed the Dutch Attitudes Toward Death and Afterlife Scale. Emotions toward death were measured using the Self-Confrontation Method. Quality of life was measured with the Satisfaction with Life Scale and the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire. Depression and hopelessness were measured with the Beck Depression Inventory for Primary Care and the Beck Hopelessness Scale. RESULTS: Average scores on attitudes and emotions toward death and an afterlife were not significantly different between the two groups. However, in the no evidence of disease group, a negative association between negative emotions and social functioning was observed, which was not present in the advanced cancer group. In the advanced cancer group, associations were observed that were not present in the no evidence of disease group: positive associations between an explicitly religious attitude and global health status and between reincarnation belief and role and cognitive functioning, and a negative association between other-directed emotions and social functioning. CONCLUSION: Patients without evidence of disease and advanced cancer patients do not differ in attitudes or emotions toward death, but the relationship between these attitudes and emotions and aspects of quality of life varies. When there is no evidence of disease, negative emotions play the most important role, whereas in the advanced cancer situation, attitudes toward death and an afterlife, which may provide meaning and value, become more prominent.