Fatigue in patients with adjuvant radiation therapy for breast cancer: long-term follow-up

  • Hans Geinitz
  • Frank B. Zimmermann
  • Reinhard Thamm
  • Monika Keller
  • Raymonde Busch
  • Michael Molls
Original Paper



The aim of this study was to evaluate fatigue 2.5 years after adjuvant radiation therapy (RT) in patients with localized breast cancer and to assess its relation to pre- and immediate post-treatment fatigue values. The association of fatigue with psychological distress and functional impairment was analyzed as well as pretreatment predictors for chronic fatigue.


Of a set of 41 patients whose fatigue was evaluated during adjuvant radiation therapy, 38 patients alive and free of cancer at 2.5 years (t2) after RT were assessed in this study. Patients received the Fatigue Assessment Questionnaire (FAQ), a visual analog scale on fatigue intensity (VAS-F) as well as on cancer-related distress (VAS-D), the Hospital Anxiety and Depression Scale (HADS), and three questions of the Short-Form 36-Item Health Survey (SF-36) per mail. All 38 patients returned their questionnaires. The values were compared to pretreatment (t0) and immediate post-treatment levels (2 months after RT, t1).


There was no significant difference between chronic fatigue levels at 2.5 years after RT and pretreatment values. When compared to immediate post-treatment levels the FAQ global score and the HADS anxiety score displayed a significant increase. Cancer-related distress correlated closely with fatigue scores. Patients with functional impairment had slightly higher fatigue values. Age or hormonal therapy were not associated with chronic fatigue levels. Pretreatment fatigue and pretreatment HADS anxiety and depression scores were good predictors of fatigue at 2.5 years after RT explaining 60% (FAQ) and 49% (VAS-F) of its variance.


Fatigue 2.5 years after RT did not increase above baseline levels before RT in conservatively operated breast cancer patients. Chronic fatigue correlated closely with psychological distress. Patients with pretreatment elevated fatigue, anxiety or depression levels are at risk for chronic fatigue.


Breast cancer Radiation therapy Anxiety Depression FAQ HADS 



We would like to thank Dr. Agnes Glaus for kindly providing us with the Fatigue Assessment Questionnaire and Dr. Lisa Sprague for reading the manuscript


  1. 1.
    Ahsberg E, Furst CJ (2001) Dimensions of fatigue during radiotherapy: an application of the Swedish occupational fatigue inventory (SOFI) on cancer patients. Acta Oncol 40:37–43CrossRefPubMedGoogle Scholar
  2. 2.
    Bower JE, Ganz PA, Desmond KA, Rowland JH, Meyerowitz BE, Belin TR (2000) Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol 18:743–753PubMedGoogle Scholar
  3. 3.
    Bullinger M (1995) German translation and psychometric testing of the SF-36 health survey: preliminary results from the IQOLA project. International quality of life assessment. Soc Sci Med 41:1359–1366PubMedGoogle Scholar
  4. 4.
    Cull A, Hay C, Love SB, Mackie M, Smets E, Stewart M (1996) What do cancer patients mean when they complain of concentration and memory problems? Br J Cancer 74:1674–1679PubMedGoogle Scholar
  5. 5.
    Geinitz H, Zimmermann F, Stoll P, Thamm R, Kaffenberger W, Ansorg K, Keller M, Busch R, van Beuningen D, Molls M (2001) Fatigue, serum cytokine levels and blood cell counts during radiation therapy of patients with breast cancer. Int J Radiat Oncol Biol Phys 51:691–698CrossRefPubMedGoogle Scholar
  6. 6.
    Glaus A (1998) Fatigue in patients with cancer. Analysis and assessment. Recent Results Cancer Res 145:1–172Google Scholar
  7. 7.
    Greenberg DB, Sawicka J, Eisenthal S, Ross D (1992) Fatigue syndrome due to localized radiation. J Pain Symptom Manage 7:38–45PubMedGoogle Scholar
  8. 8.
    Greenberg DB, Gray JL, Mannix CM, Eisenthal S, Carey M (1993) Treatment-related fatigue and serum interleukin-1 levels in patients during external beam irradiation for prostate cancer. J Pain Symptom Manage 8:196–200PubMedGoogle Scholar
  9. 9.
    Heaton KW, Ghosh S, Braddon FE (1991) How bad are the symptoms and bowel dysfunction of patients with the irritable bowel syndrome? A prospective, controlled study with emphasis on stool form. Gut 32:73–79PubMedGoogle Scholar
  10. 10.
    Herrmann C, Scholz KH, Kreuzer H (1991) Psychologic screening of patients of a cardiologic acute care clinic with the German version of the Hospital Anxiety and Depression Scale. Psychother Psychosom Med Psychol 41:83–92PubMedGoogle Scholar
  11. 11.
    Joly F, Henry-Amar M, Arveux P, Reman O, Tanguy A, Peny AM, Lebailly P, Mace-Lesec’h J, Vie B, Genot JY, Busson A, Troussard X, Leporrier M (1996) Late psychosocial sequelae in Hodgkin’s disease survivors: a French population-based case-control study. J Clin Oncol 14:2444–2453PubMedGoogle Scholar
  12. 12.
    Knobel H, Havard LJ, Brit LM, Forfang K, Nome O, Kaasa S (2001) Late medical complications and fatigue in Hodgkin’s disease survivors. J Clin Oncol 19:3226–3233PubMedGoogle Scholar
  13. 13.
    Komaroff AL, Fagioli LR, Doolittle TH, Gandek B, Gleit MA, Guerriero RT, Kornish RJ, Ware NC, Ware JE Jr, Bates DW (1996) Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups. Am J Med 101:281–290CrossRefPubMedGoogle Scholar
  14. 14.
    Loge JH, Abrahamsen AF, Ekeberg O, Kaasa S (1999) Hodgkin’s disease survivors more fatigued than the general population. J Clin Oncol 17:253–261PubMedGoogle Scholar
  15. 15.
    Loge JH, Abrahamsen AF, Ekeberg, Kaasa S (2000) Fatigue and psychiatric morbidity among Hodgkin’s disease survivors. J Pain Symptom Manage 19:91–99CrossRefPubMedGoogle Scholar
  16. 16.
    Marcus R, Peritz E, Gabriel KR (1976) On closed testing procedures with special reference to ordered analysis of variance. Biometrika 63:655–660Google Scholar
  17. 17.
    McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD (1994) The MOS 36-item short-form health survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 32:40–66PubMedGoogle Scholar
  18. 18.
    Monga U, Kerrigan AJ, Thornby J, Monga TN (1999) Prospective study of fatigue in localized prostate cancer patients undergoing radiotherapy. Radiat Oncol Investig 7:178–185CrossRefPubMedGoogle Scholar
  19. 19.
    Moorey S, Greer S, Watson M, Gorman C, Rowden L, Tunmore R, Robertson B, Bliss J (1991) The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. Br J Psychiatry 158:255–259PubMedGoogle Scholar
  20. 20.
    Mumford DB, Tareen IA, Bajwa MA, Bhatti MR, Karim R (1991a) The translation and evaluation of an Urdu version of the hospital anxiety and depression scale. Acta Psychiatr Scand 83:81–85PubMedGoogle Scholar
  21. 21.
    Mumford DB, Tareen IA, Bhatti MR, Bajwa MA, Ayub M, Pervaiz T (1991b) An investigation of ‘functional’ somatic symptoms among patients attending hospital medical clinics in Pakistan: II. Using somatic symptoms to identify patients with psychiatric disorders. J Psychosom Res 35:257–264CrossRefPubMedGoogle Scholar
  22. 22.
    Ryde-Brandt B (1988) Mothers of primary school children with Down’s syndrome. How do they experience their situation? Acta Psychiatr Scand 78:102–108PubMedGoogle Scholar
  23. 23.
    Smets EM, Garssen B, Schuster-Uitterhoeve AL, de Haes JC (1993) Fatigue in cancer patients. Br J Cancer 68:220–224PubMedGoogle Scholar
  24. 24.
    Smets EM, Visser MR, Willems-Groot AF, Garssen B, Oldenburger F, van Tienhoven G, de Haes JC (1998a) Fatigue and radiotherapy: (A) experience in patients undergoing treatment. Br J Cancer 78:899–906PubMedGoogle Scholar
  25. 25.
    Smets EM, Visser MR, Willems-Groot AF, Garssen B, Schuster-Uitterhoeve AL, de Haes JC (1998b) Fatigue and radiotherapy: (B) experience in patients 9 months following treatment. Br J Cancer 78:907–912PubMedGoogle Scholar
  26. 26.
    Thapar AK, Thapar A (1992) Psychological sequelae of miscarriage: a controlled study using the general health questionnaire and the hospital anxiety and depression scale. Br J Gen Pract 42:94–96PubMedGoogle Scholar
  27. 27.
    Visser MR, Smets EM (1998) Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer 6:101–108Google Scholar
  28. 28.
    Vordermark D, Schwab M, Flentje M, Sailer M, Kolbl O (2002) Chronic fatigue after radiotherapy for carcinoma of the prostate: correlation with anorectal and genitourinary function. Radiother Oncol 62:293–297CrossRefPubMedGoogle Scholar
  29. 29.
    Wands K, Merskey H, Hachinski VC, Fisman M, Fox H, Boniferro M (1990) A questionnaire investigation of anxiety and depression in early dementia. J Am Geriatr Soc 38:535–538PubMedGoogle Scholar
  30. 30.
    Wang XS, Janjan NA, Guo H, Johnson BA, Engstrom MC, Crane CH, Mendoza TR, Cleeland CS (2001) Fatigue during preoperative chemoradiation for resectable rectal cancer. Cancer 92:1725–1732CrossRefPubMedGoogle Scholar
  31. 31.
    Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473–483PubMedGoogle Scholar
  32. 32.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • Hans Geinitz
    • 1
  • Frank B. Zimmermann
    • 1
  • Reinhard Thamm
    • 1
  • Monika Keller
    • 2
  • Raymonde Busch
    • 3
  • Michael Molls
    • 1
  1. 1.Klinik und Poliklinik für Strahlentherapie der Technischen Universität MünchenMunichGermany
  2. 2.Psychosoziale NachsorgeeinrichtungChirurgische UniversitätsklinikHeidelbergGermany
  3. 3.Institut für Medizinische Statistik und EpidemiologieTechnische UniversitätMunichGermany

Personalised recommendations