Fatigue of the Patient with Cancer: a systematic review

A Fadiga do Paciente com câncer : uma revisão sistemática

Júlia Barbosa da Fontoura Gonzalez¹, Maria Isabel Pinto Coelho Gorini¹

¹ Universidade Federal do Rio Grande do Sul, RS, Brasil 

Abstract: Cancer is one of the most prevailing chronic diseases in Brazil and in the world. However, the utilized treatments may develop numberless collateral effects. Since the last decade, the symptom of fatigue has been associated directly with cancer and its treatments and has become the object of study in this field. This systematic review was elaborated with the objective of analyzing scientific articles about the fatigue of patients with cancer in the years between 2002 and 2006, in connection with nursing and through the descriptors fatigue, cancer and nursing from the data base of MEDLINE, LILACS and BDENF. This study sampled 27 articles whose authors counted on one nurse at least. The analysis comprised types of cancer and of treatment, the use of scales for measuring fatigue, the methodology, outline of the study, the place and the publication periodical. The results of this study point out to the need of improving the knowledge about fatigue considering that it is a subject still little known by health professionals; it also evidences the need of availing such knowledge and of giving continuity to further investigations in order to clear up better the results of the interventions and to lead to softening such debilitating symptom. 

Keywords: Fatigue, Neoplasms, Nursing. 

Resumo: O câncer é uma das doenças crônicas mais prevalentes no Brasil e no mundo, porém os tratamentos utilizados podem desenvolver inúmeros efeitos colaterais. Na última década, o sintoma fadiga teve sua associação direta com o câncer e seus tratamentos, e tornou-se objeto de estudo nesta área. Esta revisão sistemática foi elaborada com o objetivo de analisar artigos científicos ligados à enfermagem, sobre a fadiga dos pacientes com câncer, no período entre 2002 e 2006, com os descritores fadiga, câncer e enfermagem, nas bases de dados MEDLINE, LILACS e BDENF. Este estudo contou com uma amostra de 27 artigos, tendo em sua autoria ao menos um enfermeiro. Foram analisados os tipos de câncer, de tratamento, o uso de escalas para a mensuração da fadiga, a metodologia, o delineamento do estudo, o local e o periódico de publicação. A partir dos resultados deste estudo percebe-se a necessidade de aprimorar o conhecimento sobre a fadiga, visto ser um assunto ainda pouco conhecido pelos profissionais da área da saúde, e evidencia-se a necessidade de disponibilizar o saber e dar continuidade a novas investigações a fim de esclarecer melhor os resultados das intervenções e conduzir à amenização deste sintoma tão debilitante. 

Palavras-chave: Fadiga, Neoplasias, Enfermagem.

Introduction

            More and more, cancer is a disease present in our environment due to its genetic, environmental and social determinants. According to data available at the Brazilian National Cancer Institute (INCA), the forecast for the year 2006 foresaw the incidence of 234,570 new cases of neoplasias in the masculine sex and 237,480 new cases in the feminine sex, totaling 472,050 new cases of neoplasias and 130,000 deaths caused by cancer all over the Brazilian territory¹. Technological breakthroughs have allowed more precocious and accurate diagnosis making appropriate interventions possible in a short period of time. However, in the attempt of controlling and curing cancer, currently utilized treatments still cause several collateral effects which require other interventions in order to minimize them.

Since the last decade approximately, health professionals have been concerned with taking care of the patient who shows a set of symptoms denominated fatigue. Fatigue is characterized as “an oppressive sensation, comprising exhaustion and the reduced capacity of performing physical and mental work at the usual level”^2:114. Studies affirm that there is lack of consistency among the authors about the concept of fatigue due to the small quantity of researches dedicated to the understanding of this phenomenon as well as due to the diversity of health disciplines that analyze it, each one according to its perspective³. Notwithstanding, scholars agree that fatigue is “subjective, multifactor and comprises the physical, emotional and cognitive ranges of the patient”^4:579. Psychological and social factors are intimately connected with the rise of fatigue, what is evidenced by the difficulty of performing the daily activities, lack of concentration, lack of interest, committed libido, verbalization of extreme tiredness and feeling of guilt for not meeting the social roles⁵, being such symptoms the defining features of fatigue. Among the factors involved in fatigue, one can point out cancer, chemotherapy, radiotherapy, modifiers of biological response, anemia, infection, lung infections, hepatic or kidney insufficiency, nutrition deficit, dehydration, electrolytic disturbances, sleeping disturbances, chronic pain, lack of exercises, the action of drugs like those derived from opium, among others^6.

             Studies are still needed in order to establish the causes of fatigue more precisely and, thus, determining more effective treatments in order to soften this symptom⁷, with the possibility of utilizing pharmacological and non-pharmacological therapies. Treatment against fatigue associated to cancer has multiple facets. It is important identifying the probable causes of fatigue and from here on employing adequate interventions for its treatment⁸. Nursing interventions are quite useful in order to soften this symptom such as energy control, humor control, nutrition control, exercising promotion, establishment of mutual goals and sleeping increment⁹.

            The objective of this study is identifying, through a systematic review, the scientific production on fatigue of patients with cancer between the years 2002 and 2006 published by health professionals.

             The justification of the study is based on the experience of the authors regarding the care to the patient undergoing ambulatory chemotherapy treatment and on the high prevalence of the symptom in the cases of advanced disease with occurrence in 75% to 95% of the cases⁴. The knowledge regarding fatigue presented by the patients with cancer and the possible nursing interventions are very important in order to diminish in a significant way its incidence and its impact in the health of the patient. In view of the fact that this knowledge is not spread among health professionals, they still face difficulties in order to give an adequate treatment to the fatigued patient. Nursing professionals have showed in recent studies that they do not have a satisfactory knowledge about the etiology and the treatments, what compromises the efficacy of the interventions and consequently the improvement of the patients¹⁰. Therefore, it is necessary that more researches on this subject be made and that nursing teams are prepared in order to minimize the occurrence of fatigue and offering a better quality of life to the patient during the period of treatment.  

Methodology

            The study type is the systematic review with the use of the multi method, that is, a quantitative and qualitative approach. “By means of systematic reviews, one identifies studies already completed which approach a research issue and one evaluates the results of these studies in order to reach conclusions about one body of knowledge”^11:233.

The collection of data was done through the Virtual Health Library (BIREME) in the MEDLINE, LILACS and BDENF data base between the years of 2002 and 2006, by utilizing the descriptors: fatigue, cancer and nursing. Initially, all of the articles that had the descriptor fatigue in their titles and abstracts were accepted, resulting in a selection of 75 articles. Upon applying the inclusion and exclusion criteria, 48 articles were excluded, resulting in a sampling of 27 articles.

The sampling selected among these articles is constituted by those which have the descriptor fatigue in their title or abstract. The complete text was obtained through the concession of the author himself or through the library of the Nursing School of the Federal University of Rio Grande do Sul and which met the criteria of inclusion and exclusion.

In order to be included in the study, the article should have the descriptor fatigue in its title or abstract, be national or international, be available in English, Portuguese and/or Spanish, independent of the origin place, be available on line, been granted by the author himself or available by the library of the EEUFRGS. Each article should have at least one nurse as author.

            The exclusion criteria of the study were: articles that approached non-cancer related fatigue, complete articles that demanded much time in order to be received via library (2 months or more), complete articles that were not granted by the authors or by the library of the Nursing School before the stipulated limit term.

            In order to delimit the time for collecting the articles, one stipulated that only those whose complete text would be obtained in the period of time between March and May 2007 would be included.

Complete texts that did not contemplate the inclusion criteria were excluded. After the preliminary acceptance, there was an effort in order to obtain the selected articles. Most of the articles were requested by e-mail directly to the authors. The electronic addresses that were not available were requested to the Library of the Nursing School of the Federal University of Rio Grande do Sul.

             After obtaining the articles with the complete text, a form for data collection was utilized in order to get relevant information from their content in a structured way, thus making the data analysis possible. In order to help the methodological development of this work, a flow diagram was utilized in order to perform a systematic review¹². The flow is characterized by the definition of the problem, design of the relevance test, definition of the data base and uniterms, and survey of data. 

The first stage of the relevance test application was done in the abstract of the articles where their preliminary acceptance or rejection was possible. A second stage of the relevance test was applied in the complete text in order to obtain the definitive rejection or acceptance. After the definitive acceptance, the articles were analyzed quantitatively through the OpenOffice.org Base software in a data base on which consultations were performed for the analysis of the information and presented through frequency (f) and percentage (%) tables. The data were also analyzed qualitatively through the Content Analysis Technique¹³. Each analyzed article received the denomination of the capital letter A followed by an Arabic number in order to make its identification easy. The ethical aspects regarding the authorship of the consulted articles were respected and they were mentioned in this study. 

Analysis and Discussion

            The articles were characterized according to the publication year, by relating their respective places of origin, occupation of the authors and the data base where they were published. Analyses were also performed of the publication periodicals, the frequency of utilization of the descriptors, fatigue, cancer and nursing, the type of methodology applied in the articles, the types of cancer and treatments and, finally, the employment of scales for measuring fatigue.  

            In the year 2002, only 2 North American publications (USA) were selected. They had only nurses as authors and were published in the Cancer Nursing periodical and indexed in the MEDLINE data base. In the year 2003, the number of selected articles was much more expressive with a sampling of 6 studies, all of them published in the MEDLINE data base. Out of these, 2 were published in Scotland and the remaining articles in the United States (USA). Most of the articles were written by nursing professionals only (66,7%) while the authors of the remaining 33,3% were, besides nurses, other health professionals. Out of the 6 selected studies, 2 were published in Cancer Nursing, 2 in the European Journal of Oncology Nursing, 1 in the Clinical Journal of Oncology Nursing and 1 in the Oncology Nursing Forum. The largest sampling was of the year 2004 with a total of 8 selected articles, 7 out of them published in the USA and only 1 in England, all of them found in the MEDLINE data base. Regarding the occupation of the authors, 62,5% of the articles had, as authors, nurses only while the authorship of the remaining 37,5% included nurses and other health professionals. Out of the total of articles, 3 (37,5%) were published in the Cancer Nursing periodical. The periodicals Cancer, Journal of the National Cancer Institute Monographs, Oncology Nursing Forum, Professional Nurse and Rehabilitation Nursing had only 1 article each. In 2005, 5 selected articles were available in the MEDLINE data base being 3 published in the USA and 2 in England. Out of these, 60% had, as authors, nurses only, while the authorship of the remaining 40% included nurses and other health professionals. Only one publication was found in each of these periodicals: Cancer, Journal of Clinical Nursing, Nursing Times, Oncology Nursing Forum and Policy, Politics & Nursing Practice. In the year 2006, 6 articles were selected, 4 out of them published in the USA, 1 in Scotland and 1 in Brazil. All of them could be found in the MEDLINE data base. The Brazilian article, however, was still published in the LILACS and BDENF data base. Most of the articles (83,3%) were written by nurses only while the remaining 16,7% were written by nurses and other health professionals. Out of the 6 articles, 2 were published in the periodical Oncology Nursing Forum, 1 in the Journal of Nursing Measurement, 1 in the European Journal of Oncology Nursing, 1 in the Cancer Nursing and 1 in the Revista Latino-Americana de Enfermería.

             As mentioned previously, the articles should obligatorily count on the descriptor fatigue; however, the frequency of the descriptors cancer and nursing was also analyzed. Thus, out of the total of the sampling of 27 articles, 33,33% counted only on the descriptor fatigue while 40,74% on fatigue and cancer, 14,82% on all of the descriptors fatigue, cancer and nursing and 11,11% on fatigue and nursing.  

When the analysis of the type of methodology employed in the studies was made, 29,63% utilized the bibliographic review as methodology. The second most utilized methodology was the longitudinal study with 22,22% followed by clinical studies (clinical trials) with 14,82%, study of case with 11,11% and pilot study with 11,11%. The less utilized methodologies among the articles were the exploratory/descriptive study (7,41%) and the one of reflection (3,70%).

            In the data collection form utilized in this research, the articles could present either the qualitative, quantitative or quantitative-qualitative methods. When it was not possible determining clearly the type of method utilized in the article, this one was accounted as not discriminated. The findings as to the employed methodology showed that 13 articles utilized the quantitative method, 10 the qualitative method, 3 the quantitative-qualitative method and in 1 article it was not possible to discriminate the methodology.  

            Half of the studied articles focused their studies on fatigue in patients with some specific type of malignant tumor. Among them, the hematological tumors (specially the multiple myeloma) were the most approached ones (14, 8%). Some studies were directly connected to patients with mama cancer (11,1%) and lung cancer (11,1%) while the remaining 11,1% approached different types of cancer like gastric-intestinal, genitourinary, gynecological, and of head and neck. 51,9% of the articles did not specify any type of cancer connected to fatigue in their studies. These were based on the management of fatigue, in the nursing interventions, in the efficacy of education materials, in the benefits of physical exercises, among other subjects not connected to any specific type of cancer.       

            In order to make the data collection easy, the main types of treatment against cancer were specified by means of the question of multiple choice with the possibility of selecting more than one type of treatment when the article so required. Many times, patients present fatigue after the treatment against cancer like chemotherapy, radiotherapy, surgery and transplantation of bone marrow⁷. 51,8% of the articles evidenced association between fatigue and the treatment the patients with cancer were submitted to being most of them the most traditional ones: chemotherapy in 8 articles and radiotherapy in 7. These could appear as the sole treatment option or be associated between themselves with hormonal therapy or with transplantation of hematopoietic stem cells. In the articles which approached the hematologic cancer specifically, the patients were undergoing treatment with transplantation of hematopoietic stem cells exclusively (11,1%) or, in one of the articles (3,7%), associated to chemotherapy. In 48,2% of the articles of the sampling, no type of treatment was specified.

            Since it is a subjective experience, fatigue can be better managed with the use of a scale that evaluates the level at which the symptom is affecting the patient. The use of a scale in order to measure the fatigue level of the patient is still a new concept in Brazil. But, it is possible to perceive that the international articles of the sampling already utilize several scales in their studies. Out of the 27 articles, 44,44% utilized scale in order to measure the fatigue of the patients with cancer, 25,93% mentioned or suggested the employment of scales and only 29,63% of the articles did not utilize and neither mentioned the importance of the use of scales in their studies.

            In this research, one could recognize that the most utilized scales were the variations of the Piper scales: the Piper Fatigue Scale, the Revised Piper Fatigue Scale and the Integrated Piper Fatigue Model which were employed in 25,9% of the studied articles. Several other scales were applied in other articles, that is, General Fatigue Scale, Likert Scale, Profile of Mood States, Short form of the Profile of Mood States, Schwartz Cancer Fatigue Scale and Visual Analog Scale.

The below Table describes briefly the subjects approached in the articles.

Table 1: Synthesis of the content of the articles.

            Fatigue is prevailing in the advanced oncologic disease and it can manifest itself in 75% to 95% of the patients⁴. The table showing the meaning nuclei of the 27 articles indicates that in 13 out of them (A1, A3, A7, A8, A9, A11, A12, A13, A14, A20, A21, A23 e A24), the fatigue symptom was connected directly with disease/cancer. Treatments applied to cancer have evolved through the discovery of new technologies and the development of new techniques (antisepsis, anesthesiology and molecular biology) making the choice of the most adequate intervention possible for each type of patient⁴⁰. However, fatigue persists as a relevant symptom in the life of the patients submitted to different types of treatment (A3, A4, A5, A7, A10, A14, A16, A17, A19, A26 e A27). Fatigue can be directly connected with cancer and its treatments⁶. This can be seen concomitantly between the fatigue related to the treatment and the disease (A3, A7 e A14).

            Cancer, its treatments and sleeping disturbance are related to fatigue, (A23 e A24). A quite referred method in order to manage fatigue was the performance of exercises, either physical or breathing ones (A1, A6, A9, A11, A12 e A17).

            Education aspects that aim at minimizing fatigue symptoms were presented in several articles (A2, A8, A13, A15 e A21). The psychometric scales for fatigue evaluation were used; however, they depend on the context, on the disease and on the type of treatment (A25).

            The findings evidenced the concern of the nursing team with managing fatigue through energy conservation, education promotion, supervision and provision of emotional support^14,15. Thus, the ways pointed out in order to identify, prevent and treat fatigue are directly connected with care systematization (A22).

Final Considerations

            Articles still search for basic themes connected with fatigue like energy conservation techniques, emotional support, importance of physical and breathing exercises, approaches about the disease and its treatments, education of the patient, fatigue management techniques, sleeping disturbances, symptom impact, anemia, pain and suffering connected with fatigue. 

            There is no consensus regarding the best way of minimizing fatigue of the patient with cancer, be it with pharmacological or non-pharmacological treatment. This symptom must be seen with much attention by all health fields, specifically by nursing, in order to provide an effective care to the patient.

            New studies regarding fatigue associated with cancer vis-à-vis the context are certainly still needed mainly in Brazil due to the scarce bibliography available approaching this theme specifically, according to the methodology of this study.

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