1. Cognitive and behavioural Factors associated with fatigue and disability in women with breast cancer
Dr Sahil Suleman
Guy’s & St Thomas’ NHS Foundation Trust
& Institute of Psychiatry

2. CANCER Increasingly viewed as an LTC
Survivorship = Symptoms & Side Effects from treatment
Pain
Swelling
Lymphoedema
Hair Loss
Dry mouth
Infection
Cognitive Impairment
Nausea
Hormonal Changes
FATIGUE

3. “CANCER-RELATED FATIGUE” (CRF)
“a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness, or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning”
National Comprehensive Cancer Network (2011)
Lack of consensus over definition
ICD-10 Criteria for Cancer Related Fatigue Syndrome

4. WHY FOCUS ON CANCER-RELATED FATIGUE?
39% - 90+% of those in treatment
(Prue et al., 2006)
Significant impact on the ability to function and quality of life
Most important and distressing symptom
(Curt et al., 2000)
Curt (2000) - Prevented “normal life” (91%) and changed daily routine (88%)
Carers – for 65%, fatigue had resulted in partners having taken at least one day (and a mean of four and a half days) off work
(Curt, 2000)
Range of prevalence rates is an artefact of the varied definitions and measures used

5. UNIQUENESS OF CANCER-RELATED FATIGUE EXPERIENCE VS. FATIGUE
More severe and distressing than fatigue
(Andrykowski et al., 2010; Jacobsen et al., 1999)
Less frequently relieved by adequate sleep or rest than fatigue
(Poulson, 2001; Stone et al., 1999)

6. FACTORS ASSOCIATED WITH CANCER-RELATED FATIGUE
Disease-related
Treatment-related
Other Physiological Markers
Demographic
Behavioural & Symptom
Psychological
Found to supersede physiological and demographic data in their ability to predict CRF
(Hwang et al., 2003)
Disease-related – e.g.
Treatment-related – e.g.
Other Physiological Markers – e.g.
Demographic - e.g.
Behavioural & Symptom – e.g.
Psychological – next slide

7. PSYCHOLOGICAL FACTORS ASSOCIATED WITH CANCER-RELATED FATIGUE
Depression & Anxiety
Personality Traits
Trait Anxiety
Neuroticism
Extraversion
Maladaptive Coping Styles
Higher order coping styles
Beliefs/Cognitions about experience and management of CRF
Relationship between Fatigue and Depression

8. INTERVENTIONS TARGETING CANCER-RELATED FATIGUE
Pharmacological
Exercise & Activity
Complementary & Lifestyle
Psychological
Wider Psychosocial Approaches
education, social support, relaxation, self-care
Cognitive Behavioural Approaches

9. SO WHERE DOES THIS LEAVE US…
Range of factors contributing to CRF
Psychological factors are important
Targeting psychological factors has been successful in reducing CRF
CBT works in CFS
CBT works for other physical health conditions and for specific symptoms
Limited evidence that CBT works in CRF…
But how/why does it work?

10. SULEMAN, S., RIMES, K. & CHALDER, T. (2011)
Cross-sectional investigation of the role of range of psychological variables in a sample of women undergoing chemotherapy for breast cancer
Relationship between these variables and Fatigue and Functional Impairment
Also considered demographic and clinical variables
Prospective exploratory investigation of the role of psychological (and other) variables identified at commencement of chemotherapy in predicting Fatigue and Functional Impairment after 3 cycles of chemotherapy
Preliminary evidence that cognitive behavioural variables may be relevant to cancer-related fatigue (Andrykowski et al., 2010; Andrykowski et al., 2005; Broeckel et al., 1998; Donovan et al., 2007)
And that cognitive behavioural intervention approaches have been successful in reducing fatigue in cancer (Armes et al., 2007; Gielissen, Verhagen, et al., 2007; Gielissen et al., 2006)
Members of staff within the clinic are seeking a clearer insight into the fatigue experience of their patients – decide appropriate time to intervene and how to go about it

11. METHODOLOGY Questionnaire Study
100 Female Patients from Breast Care Clinic at King’s College Hospital, London
3 groups - pre-chemotherapy, in chemotherapy or post-chemotherapy
33 pre-chemotherapy participants followed up after 3 cycles of chemotherapy
FEC-T Chemotherapy Regimen

12. MEASURES
Fatigue - Chalder Fatigue Questionnaire (Chalder et al., 1993) & Visual Analogue Scale – Fatigue (VAS-F)
Physical Functioning - European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, Version 3 (EORTC QLQ-C30; Aaronson et al., 1993)
Social Functioning - Work and Social Adjustment Scale (Marks, 1986)
Cognitive and Behavioural Responses to Symptoms Questionnaire (CBRSQ; Moss-Morris et al., in preparation)
Beliefs about Emotions Scale (BES; Rimes & Chalder, 2010)
West Haven-Yale Multidimensional Pain Inventory – Part II - Significant Other Response Scales (WHYMPI; Kerns et al., 1985)
Short Health Anxiety Inventory - Retrospective (SHAI-R; Salkovskis et al., 2002)
Very Short Health Anxiety Inventory (Salkovskis, correspondence)
Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983)
State Trait Anxiety Inventory – Trait (STAI-T; Spielberger et al., 1970)
Jenkins Sleep Scale (Jenkins et al., 1988)
Visual Analogue Scale – Expected Fatigue (VAS-E)
Cancer-specific Cognitions (exploratory)
Use of Coping Strategies (exploratory)
Demographic & Clinical Information

13. MEASURES (CONTINUED)
Cognitive and Behavioural Responses to Symptoms Questionnaire
6 subscales
catastrophising, symptom-focusing, fear avoidance, embarrassment avoidance, avoidance behaviour, all-or-nothing behaviour
1 new scale – ‘embarrassment avoidance (cancer-related)’
Beliefs about Emotions Scale
West Haven-Yale Multidimensional Pain Inventory – Part II - Significant Other Response Scales
Perceived punishing, distracting and over-solicitous responses
Name subscales & Give Examples

14. PRELIMINARY RESULTS Comparison between sample and population norms
(Fayers et al., 2001; Loge et al., 1998)
Comparison of 3 groups – One way ANOVA
No difference between pre-chemotherapy, in chemotherapy and post-chemotherapy groups on fatigue, social adjustment or physical functioning scores
Treated as 1 group for subsequent analyses

15. CROSS-SECTIONAL CORRELATIONS
Fatigue
Social Adjustment
Physical Functioning
Cognitive Behavioural Variables
Symptom focusing **
Catastrophising *
Fear avoidance
Embarrassment avoidance
Embarrassment avoidance (cancer-related)
Avoidance behaviour
***
All-or-nothing behaviour
Punishing responses from significant other
Solicitous responses from significant other
Distracting responses from significant other
Beliefs about negative emotions
Current health anxiety
Past health anxiety
Significance
* = .05 level
** = .01 level
*** = .001 level

16. CROSS-SECTIONAL CORRELATIONS (CONT’D)
Fatigue
Social Adjustment
Physical Functioning
Wider Psychological, Behavioural & Personality Variables
Anxiety (HADS) **
***
Depression (HADS)
Sleep *
Trait Anxiety
Exploratory Variables
Use of coping strategies
Expectation of future fatigue
Cancer-specific cognitions
Significance
* = .05 level
** = .01 level
*** = .001 level

17. CROSS-SECTIONAL CORRELATIONS (CONT’D)
Fatigue
Social Adjustment
Physical Functioning
Demographic & Clinical Variables
Ethnicity (being non-white) **
Marital status (not being married or living with a partner) *
Further education (none or school only)
Employment status (unemployed)
Help sought previously - fatigue
Help sought previously - mood
Help sought previously - anxiety
Stage of cancer
Number of comorbidities
Significance
* = .05 level
** = .01 level
*** = .001 level
Point bi-serial correlations of dichotomised demographic and clinical variables OR Spearman’s rank correlation coefficients
No significant correlations found for age, having sought help for other psychiatric problems, 5 comorbidity variables and 6 medication variables

18. CROSS-SECTIONAL PREDICTORS – MULTIPLE REGRESSION
Psychological Predictors
- Hierarchical stepwise multiple regression
Step 1 – cognitive behavioural variables
Step 2 – wider psychological and behavioural variables
Psychological & Demographic/Clinical Predictors
- Hierarchical forced entry multiple regression
Step 1 – demographic/clinical variables
Step 2 – psychological predictors from previous model
Provide quick rationale for why we chose our method of regression

19. CROSS-SECTIONAL PREDICTORS OF FATIGUE
Model
Psychological Predictors of Fatigue
Embarrassment avoidance (cancer-related)
F(4,85) = 8.19; p<.001
Total R2 = 0.28
All-or-nothing behaviour
Punishing responses from significant other
Sleep
Demographic / Clinical predictors in final model
Further education vs. no further education
Help sought for fatigue previously
Exploratory predictors
Expectation of future fatigue

20. CROSS-SECTIONAL PREDICTORS OF SOCIAL ADJUSTMENT
Model
Psychological Predictors of Social Adjustment
Avoidance behaviour
F(3,85) = 29.56; p<.001
Total R2 = 0.51
Health anxiety
Depression
Demographic / Clinical predictors in final model
White vs. non-white
Help sought for fatigue previously
Exploratory predictors
Expectation of future fatigue (minimally significant)

21. CROSS-SECTIONAL PREDICTORS OF PHYSICAL FUNCTIONING
Model
Psychological Predictors of Physical Functioning
Avoidance behaviour
F(3,85) = 26.42; p<.001
Total R2 = 0.48
Beliefs about negative emotions
Depression
Demographic / Clinical predictors in final model
Further education vs. no further education
White vs. non-white
Working vs. not working
Help sought for fatigue previously
Exploratory predictors
Expectation of future fatigue
At end of this slide, make a comment about the exploratory variables and how they would have explained even more variance

22. PROSPECTIVE PREDICTORS – AN EXPLORATORY ANALYSIS
Model
Pre-chemotherapy Predictors of Fatigue after 3 cycles of chemotherapy
Embarrassment avoidance (cancer-related)
F(1,32) = 8.76; p=.006
R2 = 0.22
Model
Pre-chemotherapy Predictors of Social Adjustment after 3 cycles of chemotherapy
Avoidance behaviour
F(1,31) = 7.13; p=.012
R2 = 0.19
Model
Pre-chemotherapy Predictors of Physical Functioning after 3 cycles of chemotherapy
Depression
F(1,31) = 8.73; p=.006
R2 = 0.22

23. KEY FINDINGS
More detailed picture of cognitions, behaviours and other psychological factors playing a part in CRF
Beyond umbrella terms e.g. ‘depression’
Preliminary evidence of presence of maladaptive cognitions and behaviours prior to chemotherapy impacting on CRF over course of chemotherapy i.e. predictive role
Corroborates evidence from chronic fatigue syndrome and comparable health conditions
Wide range of patterns of cognition and behaviour
Unique aspects of CRF e.g. embarrassment avoidance (cancer-related), perceived punishing responses of significant others
Preliminary evidence for psychometric properties of new ‘embarrassment avoidance (cancer-related)’ scale

24. CLINICAL IMPLICATIONS
Development of targeted CBT interventions for CRF
Particular prominence to cognitive and behavioural aspects of avoidance behaviour and embarrassment avoidance in cancer
Screening and early intervention
Informing staff and validating patients
Carers
Staff training
Stepped care approach
Limitations
Future Research

25. THANK YOU FOR LISTENING