Supportive Care in Cancer

, Volume 14, Issue 1, pp 78–83

Fatigue in gynaecological cancer patients: a pilot study

Authors

  • G. Prue
    • Health and Rehabilitation Sciences Research InstituteUniversity of Ulster
  • J. Rankin
    • Belvoir Park Hospital
  • F. Cramp
    • Faculty of Health and Social CareUniversity of the West of England
  • J. Allen
    • Health and Rehabilitation Sciences Research InstituteUniversity of Ulster
    • Health and Rehabilitation Sciences Research InstituteUniversity of Ulster
Original Article

DOI: 10.1007/s00520-005-0830-7

Cite this article as:
Prue, G., Rankin, J., Cramp, F. et al. Support Care Cancer (2006) 14: 78. doi:10.1007/s00520-005-0830-7

Abstract

Rationale

Fatigue is a frequent complaint of women with cancer. However, the incidence of fatigue has not been well studied, in particular gynaecological cancer, which despite its prevalence has received minimal investigation.

Goals of work

The study aims were (1) to explore the symptoms experienced in a gynaecological cancer population, primarily fatigue and (2) to determine the acceptability of a fatigue questionnaire for use in a longitudinal survey.

Patients and methods

Over the course of 1 month, women with gynaecological cancer attending a Regional Cancer Centre completed a demographic and symptom questionnaire and the Multidimensional Fatigue Symptom Inventory—Short Form (MFSI-SF).

Main results

Of the 32 individuals approached, 30 agreed to participate (mean age, 61 years; the most common treatment received was surgery followed by chemotherapy n=11; mean time from commencement of treatment, including surgery = 3 months). All participants completed the MFSI-SF. Tiredness was the most commonly reported symptom, experienced by 90% of subjects and the most frequently stated worst symptom, reported by 23.3%. Furthermore, 23 of 27 subjects reported that tiredness interfered completely with their daily living. The MFSI-SF mean total fatigue score was 14.4 (SD 15.9), ranging from −15 to 50. The possible total fatigue score ranges from −24 to 96.

Conclusion

Despite the heterogeneous nature of the group, all participants completed the MFSI-SF. The study suggests that fatigue could be a problem for this population group. Thus, a longitudinal survey using the MFSI-SF to investigate the phenomenon further would appear feasible and justified.

Keywords

GynaecologicalCancerFatigueFatigue measurement

Introduction

Cancer-related fatigue (CRF) is an abstract concept that is predominately a subjective experience. It is one of the most recurrent complaints of people with cancer, having a profound effect on the whole person [1] and directly influencing the desire to continue with treatment [6]. The aetiology remains to be fully elucidated; however, it is known to differ from the fatigue experienced by the general population, which is a protective response to physical and psychological stress [1].

A lack of consensus exists regarding the optimal means of assessing CRF [4]. To date, there is no universally accepted standard [7]; nevertheless, as CRF is a multidimensional experience, it should be assessed using a multidimensional measure [5]. For the current pilot study, the Multidimensional Fatigue Symptom Inventory—Short Form (MFSI-SF) was selected. The MFSI-SF is short, does not assume the presence of fatigue and makes no reference to a specific illness [10]. Therefore, it is ideal for use in a future longitudinal survey investigating the prevalence of fatigue in gynaecological cancer patients, a population group that has received minimal investigation in this area.

The aims of the pilot study were (1) to explore the incidence and magnitude of fatigue in a gynaecological cancer population, (2) to test the acceptability and feasibility of the MFSI-SF in a gynaecological cancer population, as previous use of the MFSI-SF has largely involved breast cancer patients [2, 9, 10] and (3) to chart the symptoms experienced by this population, to inform the choice of symptom assessment tool for use in the longitudinal survey.

Patients and methods

Ethical approval was obtained from the Belfast City Hospital Trust and the University of Ulster Research Ethics Committee.

Patients

Over the course of 1 month, a convenience sample of women diagnosed with gynaecological cancer, attending the Belfast City Hospital Trust for surgery, chemotherapy and/or radiotherapy on an in-patient or out-patient basis, were approached via their medical consultant.

Eligible participants were women aged 18 years or over, fully aware of their diagnosis and able to read and understand English. All participants gave written informed consent before study entry. Participants with cognitive impairment or incompetence, those with comorbidities that would interfere with study participation, those who had received antineoplastic treatment for a previous cancer diagnosis, and those participating in other research studies were excluded. Individuals with a long-standing history of depression, that is, subjects who had been medically diagnosed with depression before their cancer diagnosis, were also excluded. This decision was made as a diagnosis of depression may affect the individuals’ interpretation of their cancer experience, as they come upon it with an already depressed attitude. Those participants that were diagnosed with depression after their cancer diagnosis were not excluded, as this depression could be associated with having cancer and can be considered as part of the cancer symptom experience.

Procedure

For this cross-sectional study, subjects who met the eligibility criteria and provided informed consent completed two questionnaires; the investigator-developed demographic and symptom experience questionnaire and a fatigue questionnaire, the MFSI-SF.

Subjects’ medical records were accessed to gain information on their tumour site and stage, relevant past medical history, drug history, haemoglobin levels and treatment received. For chemotherapy, cycle dates and drug regimen were recorded; for radiotherapy, type, dates, dose and fractionation were documented.

Questionnaires

The investigator-developed questionnaire obtained details from three areas. Firstly, demographic information, that is, age, marital status and employment status. Secondly, participants were asked to give details of any previous cancer diagnosis, any other relevant past medical history and their current medication. Finally, each subject was asked to record the symptoms they had experienced and associated with the ordeal of cancer and the effect these symptoms had on their daily living (Table 1). They were asked to rate on a 5-point Likert scale, ranging from ‘strongly agree’ to ‘strongly disagree’, if a symptom interfered completely with their daily living. The decision to use an investigator-developed questionnaire was made to ensure all possible symptoms were recorded. This was facilitated by the inclusion of an open question inviting participants to list any other symptoms that they associated with having cancer. This will be used to inform the choice of an appropriate validated symptom assessment tool in a future longitudinal survey.
Table 1

Symptoms listed in the investigator-developed questionnaire

Physical

 

Tiredness

 

Pain

 

Nausea and vomiting

 

Fever/sweats/hot flushes

 

Gastrointestinal problems

 

Lymphodema

 

Itching

 

Loss/lack of appetite

 

Sleep problems

Psychological

 

Anxiety

 

Feelings of sadness

Fatigue assessment

A number of the available multidimensional fatigue scales are limited by their length and complicated response formats [10]. To address this limitation, the authors of the MFSI developed a shorter fatigue scale, the MFSI-SF [9, 10]. The MFSI consists of both rationally and empirically derived subscales, with each item measured on a 5-point Likert scale. The MFSI-SF consists of the 30 items of the empirically derived subscales of General Fatigue (GF), Physical Fatigue (PF), Emotional Fatigue (EF), Mental Fatigue (MF) and Vigor (V). The respondent is required to indicate the extent to which they have experienced each symptom during the preceding week (0 = not at all; 4 = extremely) [10]. Ratings are summed to obtain scores for each of the subscales detailed previously. In addition, a total fatigue (TF) score can be generated by totalling the four fatigue subscales and subtracting from this the Vigor scale [10].

The analysis of the MFSI has been undertaken on a sample of breast cancer patients. This showed that the empirically derived subscales have good internal consistency (GF 0.96, EF 0.93, PF 0.85, MF 0.90, and V 0.88) and test–retest correlations ranging from 0.51 to 0.64 (0 to 3–4 weeks) and from 0.60 to 0.70 (6–8 weeks) [9]. This satisfied the criteria for test–retest reliability considering that fatigue fluctuates on a regular basis. Construct validity has been verified, as has convergent and divergent [8] and concurrent validity [9]. This psychometric analysis was further verified in a larger mixed sample, which focused specifically on the MFSI-SF [10].

The MFSI-SF is a brief, valid, reliable measure that provides information on the overall level of fatigue and the extent to which an individual is experiencing fatigue in each of the five domains listed [10].

Statistical analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) Version 11 for Windows. The small size and heterogeneous nature of the sample resulted in demographic, clinical and symptom data summarized using descriptive statistics. The MFSI-SF was scored as described earlier.

Results

Of the 32 participants who were eligible to participate, two declined due to emotional reasons, one participant had suffered a family bereavement; the second had just undergone surgery and become aware of her diagnosis. Complete data was collected from 30 participants.

Information about demographic characteristics of the subjects are presented in Table 2. The mean age of the sample was 60.9 years (SD 13.5) ranging from 31 to 84 years. Most participants were married (56.7%). Regarding employment status, 28 of the 30 subjects were not working, with 8 of this 28 citing their cancer as the reason for not working.
Table 2

Patient demographics

 

Number

Tumour type

 Cervix

6

 Vagina

1

 Vulva

3

 Uterus

12

 Ovary

8

Tumour stage

 1

8

 2

6

 3

9

 4

5

 Unknown

2

Treatment received

 Radiotherapy

1

 Chemotherapy

2

 Surgery

3

 Surgery, radiotherapy, chemotherapy

3

 Surgery, radiotherapy

8

 Surgery, chemotherapy

11

 Radiotherapy, chemotherapy

2

Time from commencement of treatment (months)

 ≤1

6

 ≤2

6

 ≤3

5

 ≤4

5

 ≤5

3

 ≤6

1

 ≤7

1

 ≤8

0

 ≤9

1

 ≤10

2

The most common gynaecological malignancy was endometrial carcinoma (40%). The sample was heterogeneous as regards antineoplastic treatment received; thus, at the time of questionnaire completion, subjects were at a variety of stages in their cancer management. Most of the participants had received surgery and were in the process of receiving radiotherapy (n=8), chemotherapy (n=11) or chemotherapy and radiotherapy (n=3). Three had just received surgery, and five were undergoing antineoplastic treatment with no surgery: radiotherapy (n=1), chemotherapy (n=2) and chemotherapy and radiotherapy (n=2). Surgical procedures consisted of radical hysterectomy and pelvic node dissection (n=2) with oophrectomy (n=1); total abdominal hysterectomy and bilateral salpingo-oophrectomy (n=9) with omentectomy (n=5); radical or partial vulvectomy and bilateral groin node excision (n=1, respectively) and omentectomy and oophrectomy (n=2). Three had undergone an examination under anaesthetic and one subject, a hemicolectomy. The chemotherapy regimens administered were doxorubicin/cisplatin (n=3), carboplatin/taxol (n=9), doxorubicin/ifosfamide (n=1) and weekly cisplatin (n=5). For radiotherapy the total dose was 45 Gy (n=9), 42 Gy (n=1) and 50.4 Gy followed by internal radiation of 24 Gy (n=1); for three participants, inadequate detail on radiotherapy dose was provided. The average time from commencement of intervention (including surgery) was 3.39 months (SD 2.54), ranging from 1 week to 10 months.

Symptom experience

Two participants stated that they did not associate any symptoms with the gynaecological cancer experience.

Tiredness was the most common symptom reported and the most frequently reported worst symptom. Other common symptoms and regularly reported worst symptoms are listed in Table 3. Participants were also given the opportunity to list any other symptoms they associated with the cancer experience. These were pins and needles in the extremities (n=3), depression (n=1), increased appetite (n=1), palpitations (n=1), staining (n=1), breathlessness (n=1), bladder problems (n=1), lack of taste (n=1) and shock (n=1).
Table 3

Symptom experience and impact on daily living

Symptom

Number

Most common symptom experienced?

 Tiredness

27

 Loss/lack of appetite

20

 GI problems

18

 Nausea and vomiting

16

Worst symptom experienced?

 Tiredness

7

 Unable to differentiate

6

 Pain

3

Did symptom interfere completely with daily living?

 Tiredness

23

 Nausea and vomiting

11

 Loss/lack of appetite

9

 Sleep problems

8

 GI problems

7

 Pain

5

 Fever/sweats/hot flushes

5

 Itching

2

Impact on daily living

This section was irrelevant for two participants who had not experienced any symptoms up to this stage in their cancer experience. One participant completed the psychological questions only (anxiety and feelings of sadness). Therefore, 27 participants completed the physical symptom questions, with 28 completing the psychological symptom questions.

Of the 27 participants, 23 (85%) agreed that tiredness interfered completely with their daily living; this was the highest level of agreement across any of the symptoms. The incidence of other listed symptoms reported to interfere completely with daily living is detailed in Table 3.

Emotional aspect

Throughout their cancer experience, a higher number of participants felt they had not experienced anxiety (n=16) or feelings of sadness (n=20) than those that had. Furthermore, 22 (79%) of the 28 that completed this section disagreed that anxiety interfered with their daily living; regarding feelings of sadness, 23 (82%) of the 28 disagreed.

MFSI-SF

The MFSI-SF was self-assessed by participants who rated their fatigue experience over the past week. There was a 100% completion for all items of the MFSI-SF. The observed mean scores and range for TF and each fatigue subscale are presented in Table 4. The mean score for TF was 14.4 (SD 15.9) ranging from −15 to 50.
Table 4

Observed MFSI-SF scores

 

Number

Range

Mean

SD

Minimum

Maximum

Total fatigue score

30

−15

50

14.37

15.91

General fatigue score

30

2

22

10.80

5.96

Physical fatigue score

30

0

14

3.50

4.07

Mental fatigue score

30

0

10

2.97

3.00

Emotional fatigue score

30

0

18

4.93

5.00

Vigor score

30

0

18

7.83

5.15

Comparisons of the TF and fatigue subscales for surgery vs no surgery and for undergoing chemotherapy and/or radiotherapy vs awaiting chemotherapy and/or radiotherapy are presented in Table 5 and Table 6, respectively.
Table 5

Mean MFSI-SF scores for surgery vs no surgery

 

Group 1 (surgery), n=25

Group 2 (no surgery), n=5

Total fatigue score

11.28 (14.71)

29.80 (13.44)

General fatigue score

10.08 (5.66)

14.40 (6.80)

Physical fatigue score

2.88 (3.90)

6.60 (3.78)

Mental fatigue score

2.64 (2.77)

4.60 (3.91)

Emotional fatigue score

3.96 (4.44)

9.80 (5.22)

Vigor score

8.28 (5.42)

5.60 (2.97)

Values in parentheses are standard deviations

Table 6

Mean MFSI-SF scores for undergoing treatment vs still to start treatment

 

Group 1 (receiving treatment), n=27

Group 2 (awaiting treatment), n=3

Total fatigue score

13.00 (16.10)

26.67 (7.02)

General fatigue score

10.78 (6.03)

11.00 (6.56)

Physical fatigue score

3.44 (3.95)

4.00 (6.08)

Mental fatigue score

2.07 (2.83)

5.33 (4.16)

Emotional fatigue score

4.30 (4.76)

10.67 (3.51)

Vigor score

8.22 (5.26)

4.33 (2.08)

Values in parentheses are standard deviations

The mean TF score for those who had undergone surgery was 11.3 (SD 14.7); for those who had not undergone surgery the mean was 29.8 (SD 13.4). In all of the subscales, the non-surgical group had higher fatigue scores.

The mean TF score for those currently receiving chemotherapy and/or radiotherapy was 13.0 (SD 16.1), in comparison to 26.7 (SD 7.0) for those awaiting chemotherapy and/or radiotherapy. The subscale scores for GF and PF were similar for these two groups (Table 6); for EF and MF, the group awaiting chemotherapy and/or radiotherapy had higher mean scores (EF 10.7 compared with 4.3 and MF 5.3 compared with 2.7).

Discussion

In this cross-sectional study, the symptom experience of 30 women diagnosed with gynaecological cancer was examined. Special attention was given to CRF, including the application of the MFSI-SF, to determine if a longitudinal survey to investigate the phenomenon further using this assessment tool is feasible and justified. Indeed, tiredness was the most common symptom reported by the subjects and the most frequently reported worst symptom, and the largest majority of subjects agreed that it interfered completely with their daily living. These data add to past research that indicates that people with cancer perceive fatigue as a real and prevalent problem [11] and underscores the high prevalence of the symptom, warranting further research in this population.

No attempt was made to recruit a homogenous sample of participants with respect to tumour type, stage or treatment regime. With regard to stage of intervention, including surgery, participants ranged from 1 week to 10 months of treatment. Recruitment of a heterogeneous group intended to ensure the MFSI-SF was a suitable measure for use with participants at various treatment stages, thus providing some support for its use in a longitudinal survey. Despite the heterogeneous nature of the group, reflected by the wide range of MFSI-SF scores reported, all participants were able to complete the MFSI-SF; thus, this measure appears to be a user-friendly tool for use with this population.

The possible subscales scores for the MFSI-SF range from 0 to 24 with the possible TF range from −24 to 98. Therefore, although there was a wide range of scores shown for each of the subscales, no subject scored the maximum fatigue score. The wide range in scores reflects the heterogeneous nature of the sample. Subjects varied with respect to tumour site, stage and treatment; thus, their total fatigue score had high variability. However, there were no extreme scores. When the scores are compared with the mean scores of healthy volunteers [9], the gynaecological individuals scored higher in all subscales, except in the Mental Fatigue subscale. This is a very crude comparison as it is unknown if the two groups are comparable as they are from two separate studies.

Those participants who had yet to commence chemotherapy and/or radiotherapy had a higher fatigue score than those undergoing treatment, as a result of high EF and MF subscale scores. This suggests that individuals might be anxious while awaiting treatment [4]. Moreover, high EF and MF scores may reflect the fact that women with gynaecological cancer do suffer more on an emotional than on a physical level, possibly indicating a coping issue. These hypotheses would require further investigation in a larger, methodologically sound longitudinal survey, with adequate documentation of pertinent variables that would have an effect on fatigue such as time since surgery, weight loss and depression. Further investigation into the higher fatigue scores reported by the non-surgical group, possibly due to advanced tumour stage [13] and treatment progression [14], is also warranted.

Inconsistencies were found in the results with regard to the prevalence and impact of symptoms. Loss/lack of appetite and gastrointestinal problems were the second and third most commonly experienced symptoms, respectively, yet most of the participants disagreed that these symptoms interfered with their daily living. This may indicate that although these symptoms are common, participants can deal with them on a day-to-day basis. Interestingly, the accepted common symptoms of pain, nausea and vomiting were not prevalent and had no impact on the subjects’ daily living. This may indicate that these symptoms are anticipated and thus well managed [3]. In contrast, the high prevalence of fatigue may suggest that individuals may not know how to manage their fatigue effectively.

Limitations

The small sample size and cross-sectional nature of the survey are limitations of the study. The small sample and the heterogeneity of the treatment received prevented meaningful statistics from being performed and reduced the ability to generalize the results to the population as a whole. Furthermore, the ‘one-off’ administration of the MFSI-SF does not provide the full spectrum of the participants’ fatigue. The results reflect only the fatigue experienced during the preceding week. However, the aim of this study was to determine if fatigue was a problem in this population group and to confirm the MFSI-SF as an acceptable measure for use with this population. This in turn provides some justification for a longitudinal survey to chart fully the fatigue experienced by a gynaecological cancer population. This survey will incorporate, for comparison purposes, a group of healthy female volunteers. This is a more effective method of investigating the fatigue experience, because although costly in terms of time and resources, longitudinal studies provide more information on the true manifestation of fatigue [5]. Moreover, inasmuch as fatigue is a common complaint among the general population this must be taken into account when reporting the prevalence of this symptom among patients with cancer [12].

Conclusions

The 100% completion rate would indicate that the MFSI-SF is an acceptable measure for the study of patients with gynaecological cancer. Furthermore, it would appear that fatigue is a prevalent problem in this population group because in spite of the variance in time since initiation of treatment and the type of treatment received, 90% of the participants experienced fatigue that they associated with having cancer. The exact cause of this fatigue remains to be elucidated. Therefore, further research into fatigue in this population group using the MFSI-SF is warranted. Finally, the use of an investigator-developed symptom questionnaire enabled symptoms experienced by this population to be documented and to inform the choice of an appropriate validated symptom assessment tool for future research in this population.

Acknowledgements

This study was supported by a research grant from the Department of Employment and Learning (Northern Ireland). The authors would like to thank the staff of the Belfast City Hospital Trust for their help during data collection, and those who took part in the study for their time and effort.

Copyright information

© Springer-Verlag 2005