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Dr Sahil Suleman Guys & St Thomas NHS Foundation Trust & Institute of Psychiatry.

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Presentation on theme: "Dr Sahil Suleman Guys & St Thomas NHS Foundation Trust & Institute of Psychiatry."— Presentation transcript:

1 Dr Sahil Suleman Guys & 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)

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)

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

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

11 METHODOLOGY Questionnaire Study 100 Female Patients from Breast Care Clinic at Kings 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

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 FatigueSocial 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 (CONTD) FatigueSocial 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 FatigueSocial 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 CROSS-SECTIONAL CORRELATIONS (CONTD) Point bi-serial correlations of dichotomised demographic and clinical variables OR Spearmans 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

19 CROSS-SECTIONAL PREDICTORS OF FATIGUE Model Psychological Predictors of Fatigue Embarrassment avoidance (cancer-related) F(4,85) = 8.19; p<.001 Total R 2 = 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 R 2 = 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 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 Model Psychological Predictors of Physical Functioning Avoidance behaviour F(3,85) = 26.42; p<.001 Total R 2 = 0.48 Beliefs about negative emotions Depression

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 R 2 = 0.22 Model Pre-chemotherapy Predictors of Social Adjustment after 3 cycles of chemotherapy Avoidance behaviour F(1,31) = 7.13; p=.012 R 2 = 0.19 Model Pre-chemotherapy Predictors of Physical Functioning after 3 cycles of chemotherapy Depression F(1,31) = 8.73; p=.006 R 2 = 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


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