Cognitive and behavioural Factors associated with fatigue and disability in women with breast cancer

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Cognitive and behavioural Factors associated with
fatigue and disability in women with breast cancer

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

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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

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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

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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)

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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)

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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)

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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

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INTERVENTIONS TARGETING CANCER-RELATED FATIGUE

• Pharmacological
• Exercise Activity
• Complementary Lifestyle
• Psychological
• Wider Psychosocial Approaches
• education, social support, relaxation, self-care
• Cognitive Behavioural Approaches

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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?

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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

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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

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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

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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

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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

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CROSS-SECTIONAL CORRELATIONS
Fatigue Social Adjustment Physical Functioning
Cognitive Behavioural Variables Cognitive Behavioural Variables Cognitive Behavioural Variables 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
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CROSS-SECTIONAL CORRELATIONS (CONTD)
Fatigue Social Adjustment Physical Functioning
Wider Psychological, Behavioural Personality Variables Wider Psychological, Behavioural Personality Variables Wider Psychological, Behavioural Personality Variables Wider Psychological, Behavioural Personality Variables
Anxiety (HADS)
Depression (HADS)
Sleep
Trait Anxiety
Exploratory Variables Exploratory Variables Exploratory Variables Exploratory Variables
Use of coping strategies
Expectation of future fatigue
Cancer-specific cognitions
Significance .05 level .01 level
.001 level
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CROSS-SECTIONAL CORRELATIONS (CONTD)
Fatigue Social Adjustment Physical Functioning
Demographic Clinical Variables Demographic Clinical Variables Demographic Clinical Variables 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 Spearmans
  rank correlation coefficients
• No significant correlations found for age, having
  sought help for other psychiatric problems, 5
  comorbidity variables and 6 medication variables

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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

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CROSS-SECTIONAL PREDICTORS OF FATIGUE
Model
Psychological Predictors of Fatigue Psychological Predictors of Fatigue
Embarrassment avoidance (cancer-related) F(4,85) 8.19 plt.001 Total R2 0.28
All-or-nothing behaviour F(4,85) 8.19 plt.001 Total R2 0.28
Punishing responses from significant other F(4,85) 8.19 plt.001 Total R2 0.28
Sleep F(4,85) 8.19 plt.001 Total R2 0.28

• Demographic / Clinical predictors in final model
• Further education vs. no further education
• Help sought for fatigue previously
• Exploratory predictors
• Expectation of future fatigue

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CROSS-SECTIONAL PREDICTORS OF SOCIAL ADJUSTMENT
Model
Psychological Predictors of Social Adjustment Psychological Predictors of Social Adjustment
Avoidance behaviour F(3,85) 29.56 plt.001 Total R2 0.51
Health anxiety F(3,85) 29.56 plt.001 Total R2 0.51
Depression F(3,85) 29.56 plt.001 Total R2 0.51

• Demographic / Clinical predictors in final model
• White vs. non-white
• Help sought for fatigue previously
• Exploratory predictors
• Expectation of future fatigue (minimally
  significant)

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CROSS-SECTIONAL PREDICTORS OF PHYSICAL FUNCTIONING
Model
Psychological Predictors of Physical Functioning Psychological Predictors of Physical Functioning
Avoidance behaviour F(3,85) 26.42 plt.001 Total R2 0.48
Beliefs about negative emotions F(3,85) 26.42 plt.001 Total R2 0.48
Depression F(3,85) 26.42 plt.001 Total R2 0.48

• 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

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PROSPECTIVE PREDICTORS AN EXPLORATORY ANALYSIS
Model
Pre-chemotherapy Predictors of Fatigue after 3 cycles of chemotherapy 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 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 Pre-chemotherapy Predictors of Physical Functioning after 3 cycles of chemotherapy
Depression F(1,31) 8.73 p.006 R2 0.22
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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

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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

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