Dr Sahil Suleman
Guy’s & St Thomas’ NHS Foundation Trust
& Institute of Psychiatry
CANCER
Increasingly viewed as an LTC
 Survivorship = Symptoms & Side
Effects from treatment
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Pain
Swelling
Lymphoedema
Hair Loss
Dry mouth
Infection
Cognitive Impairment
Nausea
Hormonal Changes
FATIGUE
“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

WHY FOCUS ON CANCERRELATED FATIGUE?
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39% - 90+% of those in treatment
(Prue et al., 2006)
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Significant impact on the ability to function and
quality of life
Most important and distressing symptom
(Curt et al., 2000)
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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)
UNIQUENESS OF CANCERRELATED 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)
FACTORS ASSOCIATED WITH
CANCER-RELATED FATIGUE

Disease-related
Treatment-related
Other Physiological Markers
Demographic
Behavioural & Symptom

Psychological
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 Found to supersede physiological and
demographic data in their ability to predict CRF
(Hwang et al., 2003)
PSYCHOLOGICAL FACTORS
ASSOCIATED WITH CANCERRELATED FATIGUE
Depression & Anxiety
 Personality Traits

 Trait Anxiety
 Neuroticism
 Extraversion

Maladaptive Coping Styles
 Higher order coping styles
 Beliefs/Cognitions about experience and
management of CRF
INTERVENTIONS TARGETING
CANCER-RELATED FATIGUE
Pharmacological
 Exercise & Activity
 Complementary & Lifestyle
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Psychological
 Wider Psychosocial Approaches
○ education, social support, relaxation, self-care
 Cognitive Behavioural Approaches
SO WHERE DOES THIS LEAVE
US…
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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…
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But how/why does it work?
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
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
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
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MEASURES
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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
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)’
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Beliefs about Emotions Scale
West Haven-Yale Multidimensional Pain
Inventory – Part II - Significant Other
Response Scales
 Perceived punishing, distracting and over-
solicitous responses
PRELIMINARY RESULTS
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Comparison between sample and population norms
(Fayers et al., 2001; Loge et al., 1998)
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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
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
CROSS-SECTIONAL CORRELATIONS
(CONT’D)
Fatigue
Social
Adjustment
Physical
Functioning
Wider Psychological, Behavioural & Personality Variables
Anxiety (HADS)
**
***
**
Depression (HADS)
**
***
***
Sleep
**
***
*
Use of coping strategies
*
*
**
Expectation of future fatigue
**
**
**
Cancer-specific cognitions
**
**
*
Trait Anxiety
Exploratory Variables
Significance
* = .05 level
** = .01 level
*** = .001 level
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
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*
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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
Significance
* = .05 level
** = .01 level
*** = .001 level
CROSS-SECTIONAL PREDICTORS –
MULTIPLE REGRESSION

Psychological Predictors
- Hierarchical stepwise multiple regression
 Step 1 – cognitive behavioural variables
 Step 2 – wider psychological and behavioural
variables
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Psychological & Demographic/Clinical
Predictors
- Hierarchical forced entry multiple regression
 Step 1 – demographic/clinical variables
 Step 2 – psychological predictors from previous
model
CROSS-SECTIONAL PREDICTORS
OF FATIGUE
Model
Psychological Predictors of Fatigue
Embarrassment avoidance (cancer-related)
All-or-nothing behaviour
F(4,85) = 8.19; p<.001
Punishing responses from significant other
Total R2 = 0.28
Sleep
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Demographic / Clinical predictors in final model
 Further education vs. no further education
 Help sought for fatigue previously
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Exploratory predictors
 Expectation of future fatigue
CROSS-SECTIONAL PREDICTORS
OF SOCIAL ADJUSTMENT
Model
Psychological Predictors of Social Adjustment
Avoidance behaviour
Health anxiety
Depression

F(3,85) = 29.56; p<.001
Total R2 = 0.51
Demographic / Clinical predictors in final model
 White vs. non-white
 Help sought for fatigue previously
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Exploratory predictors
 Expectation of future fatigue (minimally significant)
CROSS-SECTIONAL PREDICTORS
OF PHYSICAL FUNCTIONING
Model
Psychological Predictors of Physical Functioning
Avoidance behaviour
Beliefs about negative emotions
Depression
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Total R2 = 0.48
Demographic / Clinical predictors in final model
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F(3,85) = 26.42; p<.001
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
PROSPECTIVE PREDICTORS –
AN EXPLORATORY ANALYSIS
Model
Pre-chemotherapy Predictors of Fatigue after 3 cycles of chemotherapy
F(1,32) = 8.76; p=.006
Embarrassment avoidance (cancer-related)
R2 = 0.22
Model
Pre-chemotherapy Predictors of Social Adjustment after 3 cycles of chemotherapy
F(1,31) = 7.13; p=.012
Avoidance behaviour
R2 = 0.19
Model
Pre-chemotherapy Predictors of Physical Functioning after 3 cycles of chemotherapy
F(1,31) = 8.73; p=.006
Depression
R2 = 0.22
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
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Preliminary evidence for psychometric properties of
new ‘embarrassment avoidance (cancer-related)’ scale
CLINICAL IMPLICATIONS

Development of targeted CBT interventions for CRF
 Particular prominence to cognitive and behavioural aspects of
avoidance behaviour and embarrassment avoidance in cancer
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Screening and early intervention
 Informing staff and validating patients
 Carers
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Staff training
 Stepped care approach
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Limitations
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Future Research
THANK YOU FOR LISTENING