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PATTERNS of FATIGUE and FACTORS INFLUENCING FATIGUE DURING ADJUVANT BREAST CANCER CHEMOTHERAPY by Ann Malone Berger a DISSERTATI

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PATTERNS of FATIGUE and FACTORS INFLUENCING FATIGUE DURING ADJUVANT BREAST CANCER CHEMOTHERAPY by Ann Malone Berger a DISSERTATI PATTERNS OF FATIGUE AND FACTORS INFLUENCING FATIGUE DURING ADJUVANT BREAST CANCER CHEMOTHERAPY By Ann Malone Berger A DISSERTATION Presented to the Faculty of The Graduate College in the University of Nebraska In Partial Fulfillment of Requirements For the Degree of Doctor of Philosophy Nursing Under the Supervision of Professor Susan Noble Walker Medical Center Omaha, Nebraska December, 1996 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TITLE Patterns of Fatigue and Factors Influencing Fatigue During Adjuvant Breast Cancer Chemotherapy BY Ann Malone Berger APPROVED DATE 11/25/96 Susan Noble Walker Lynne Farr________________________________ 11/25/96 Anne Kessinger 11/25/96 11/25/96 Ada Lindsey _______________________________________ _______ T . 7. 11/25/96 L a m Zimmerman ______ ___ ______________________ SUPERVISORY COMMITTEE GRADUATE COLLEGE UNIVERSITY OF NEBRASKA Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. PATTERNS OF FATIGUE AND FACTORS INFLUENCING FATIGUE DURING ADJUVANT BREAST CANCER CHEMOTHERAPY Ann Malone Berger, Ph.D. University of Nebraska, 1996 Advisor: Susan Noble Walker, Ed.D. Women beginning adjuvant chemotherapy for breast cancer seek information from health professionals regarding fatigue, but knowledge regarding this distressing symptom is currently limited. The purposes of this study were to describe the patterns of fatigue and of factors influencing fatigue across the first three cycles of chemotherapy and to determine the extent to which health and functional status, chemotherapy protocol, physical activity behaviors, activity/rest cycles, nutrition behaviors and status, stress management behaviors, interpersonal relations behaviors, symptom distress and reaction to the diagnosis of cancer explain fatigue at each treatment and predict fatigue at the mid-point of the first three chemotherapy cycles. A model drawn from Piper's framework (1987) guided this prospective, descriptive, repeated measures design study. Data collection included: Background data, Piper Fatigue Scale, MOS-SF-36, Health-Promoting Lifestyle Profile II, wrist actigraph, hematocrit, body mass index, Modified Symptom Distress Scale and Reaction to the Diagnosis of Cancer Questionnaire. Descriptive statistics, paired t-tests, simple and repeated measures ANOVA, cosinor and path analyses were used. In this sample of 60 women, total fatigue and its 4 dimensions and severity of symptoms distress fluctuated significantly from higher levels at treatment times to lower levels at cycle mid-points, with activity/rest cycles varying in an inverse pattern. Fatigue was explained at treatment times Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (R2^ 52-.71) by symptom distress (B=.54-.62), chemotherapy protocol (fi=32) and interpersonal relations behaviors (B= -.40) and predicted at cycle mid-points (RH45-.60) by symptom distress at the time of treatments (fi=.33-.43), physical function status (B=-.39), general health (B=-.32) and reaction to the diagnoses of cancer (B=-.39). Higher perceived fatigue levels were associated with lower daytime activity indicators and high levels of night­ time awakenings at various times. Women can be instructed to monitor fatigue intensity and to expect the patterns of fatigue to be similar during the first three chemotherapy cycles. These findings provide a foundation for future intervention studies aimed at modification of fatigue. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS With love and admiration I first thank my husband, Tom, for his steady support and encouragement throughout my professional career and my doctoral education. Special thanks also go to Alison and Greg Berger for their flexibility and understanding during this study. My accomplishments are a reflection of a united effort by our family. No one has believed in me or inspired me more during challenging times than my aunt Kay Davis, and for her love and support I am forever grateful. With deep admiration and respect, I thank Susan Noble Walker, my dissertation chairperson, for her untiring support and positive feedback throughout my doctoral program. Lynne Farr, Ada Lindsey, Anne Kessinger, Barbara Piper and Lani Zimmerman have also been excellent mentors to me, and I sincerely appreciate their time and talents. My research assistant, Patti Higginbotham, truly came from heaven and I am thankful to her for her assistance in meeting all data collection appointments! This study would not have been possible without the participation of 72 women newly diagnosed with breast cancer. To each one of you, thank you very much! I would also like to acknowledge the support I received from health-care institutions, physicians, nurses and the many others who each played a part in making this study a reality. Together, we have accomplished a lot. This study was funded by the Oncology Nursing Foundation-Cerenex Pharmaceuticals Research Award (1995-1997), the American Cancer Society's Doctoral Scholarship Award (1992-1996), and the Oncology Nursing Society's Doctoral Scholarship Awards (1992-1993, 1994-1995). iv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS LIST OF TABLES...........................................................................................................viii LIST OF FIGURES.........................................................................................................xiii Chapter 1. INTRODUCTION ...................................................................................................1 Conceptual Framework .............................................................................. 4 Purpose ........................................................................................................ 9 Significance ...............................................................................................10 Assumptions ...............................................................................................13 Limitations .................................................................................................14 Definitions .................................................................................................15 2. REVIEW OF THE LITERATURE ...................................................................... 20 Fatigue...................................................................................................... 20 Health/Disease Patterns ............................................................................ 22 Treatment Patterns .................................................................................... 26 Activity/Rest Patterns .............................................................................. 33 Energy and Energy Substrate Patterns ...................................................... 40 Psychological Patterns .............................................................................. 44 Social Patterns .......................................................................................... 48 Symptom Patterns .................................................................................... 53 Initial Reaction to the Diagnosis of Cancer .............................................. 54 Background Characteristics ...................................................................... 57 v Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Summary ..................................................................................................58 3. DESIGN & METHODS........................................................................................59 Pilot Studies ..............................................................................................59 Institutional Review Board Approval ......................................................66 Sam ple ..................................................................................................... 66 Population and Setting ............................................................................. 69 Procedures for Data Collection ................................................................74 Measurement of Variables........................................................................78 Procedures for Data Analysis ....................................................................88 4. ANALYSIS OF DATA ........................................................................................92 Research Question 1: Patterns of Fatigue and Factors Influencing Fatigue Over T im e....................................................................................94 Research Question 2: Factors Explaining Fatigue ..................................113 Research Question 3: Factors Predicting Fatigue ..................................127 5. SUMMARY, CONCLUSIONS, DISCUSSION, RECOMMENDATIONS AND IMPLICATIONS ..........................................................................144 Summary ................................................................................................144 Conclusions and Discussion ..................................................................147 Recommendations for Research .............................................................. 163 Implications for Practice ........................................................................166
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