Dr Sahil Suleman Guy’s & St Thomas’ NHS Foundation Trust & Institute of Psychiatry

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

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 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

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 Significance * = .05 level ** = .01 level *** = .001 level

16. CROSS-SECTIONAL CORRELATIONS (CONT’D) Significance * = .05 level ** = .01 level *** = .001 level

17. CROSS-SECTIONAL CORRELATIONS (CONT’D) • 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

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 • 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 • 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

22. PROSPECTIVE PREDICTORS – AN EXPLORATORY ANALYSIS

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

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