Management of concurrent symptoms involves assessment, intervention, and ongoing monitoring and management of multiple patient symptoms that are experienced at the same time, rather than interventions focused on a single problem. Many concurrent symptoms may be seen as a symptom cluster, often occurring together. Studies have been done to examine the effect of managing multiple symptoms on the patients' experience of a variety of individual patient outcomes.
Kwekkeboom, K. L., Cherwin, C. H., Lee, J. W., & Wanta, B. (2010). Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. Journal of Pain and Symptom Management, 39, 126–138.
To identify and synthesize the evidence for mind-body interventions for which the evidence suggests benefit for at least two of the three cluster symptoms of pain, fatigue, and sleep disturbance.
Databases searched were CINAHL, MEDLINE, and PsycINFO through March 2009.
Search keywords were guided imagery, hypnosis, relaxation, biofeedback, cognitive behavioral therapy, coping skills training, meditation, virtual reality, music AND cancer AND fatigue, sleep disturbance, sleep difficulty, insomnia, and pain.
Studies were included in the review if they
Studies were excluded if they
A total of 47 studies were identified. In four of those, all testing virtual reality, only the symptom of fatigue was measured, so these were eliminated.
The final sample included 43 studies. Study sample sizes and total patients involved across studies were not reported.
Relaxation
Six studies examined relaxation interventions in hospitalized patients, outpatients with chronic pain, and women with early-stage breast cancer.
Imagery and Hypnosis
Six studies examined imagery and hypnosis.
Cognitive Behavioral Therapy (CBT)/Coping Skills Training (CST)
Twenty-one studies tested CBT/CST.
Meditation
Four studies were included.
Music
Findings of this review were equivocal.
Although the findings did not clearly demonstrate the effects of these interventions across studies, the authors concluded that these interventions hold promise. Although such interventions carry minimal risk to patients, some interventions would require substantial time and resource commitment to provide.
Armes, J., Chalder, T., Addington-Hall, J., Richardson, A., & Hotopf, M. A randomized controlled trial to evaluate the effectiveness of a brief, behaviorally oriented intervention for cancer-related fatigue. Cancer, 110, 1385–1395.
To test the effectiveness of a brief intervention using a cognitive and behaviorally oriented approach on symptoms of fatigue.
Patients were randomly assigned to the intervention or usual care control group. The intervention included three individual face-to-face, sixty-minute sessions that coincided with chemotherapy treatment schedules. These were aimed at clarifying meanings, setting goals, educating patients about cancer-related fatigue, developing and discussing coping strategies, and cognitive restructuring. Sessions were audiotaped to ensure treatment fidelity. Study assessments were performed at baseline (cycle three of chemotherapy), the end of treatment, four weeks after the end of treatment, and nine months after study entry.
Patients were undergoing the active antitumor treatment phase of care.
The study was a randomized, controlled trial.
VAS fatigue scores were significantly lower in the experimental group at Time 2, end of treatment (p = 0.03), but not at any other time point. EORTC physical functioning scores were higher in the experimental group at the end of treatment (p = 0.001) and at four weeks after treatment ended (p = 0.02). There was an overall trend over time favoring the experimental group; however, the trend was not significant and was smaller when data were controlled for medical conditions and HADS scores. No data for the nine-month time after treatment were provided.
Findings suggest that a cognitive-behavioral approach intervention can be beneficial in reducing fatigue during the short term after cancer treatment.
Findings suggest that cognitive-behavioral approach interventions to restructure thinking, set goals and coping strategies, and improve self-efficacy may be helpful in reducing fatigue immediately after chemotherapy treatment. This evidence is not strong, given the study limitations here, but the findings are potentially promising.
Brothers, B.M., Yang, H.C., Strunk, D.R., & Andersen, B.L. (2011). Cancer patients with major depressive disorder: Testing a biobehavioral/cognitive behavior intervention. Journal of Consulting and Clinical Psychology, 79, 253–260.
To evaluate the effectiveness of a combined biobehavioral intervention (CBI) and cognitive behavior therapy (CBT) for depressed patients coping with the stresses of cancer
12–20 individual 75-minute CBI and CBT sessions
Topics: Stress, coping, communication, seeking information
PHASE OF CARE: Late effects and survivorship
Single group pre-post design
Depressive symptoms, fatigue, and mental health significantly improved following intervention.
CBI and CBT showed significant improvement in depression, fatigue, and quality of life and reduced cancer stress.
Cancer survivors who display depressive symptoms may benefit from CBI and CBT.
Dalton, J. A., Keefe, F. J., Carlson, J., & Youngblood, R. (2004). Tailoring cognitive-behavioral treatment for cancer pain. Pain Management Nursing, 5, 3–18.
Participants received standard cognitive-based therapy, profile-tailored cognitive-based therapy, or usual care. Those in both therapy groups received 5- to 50-minute sessions. Standard cognitive-based therapy includes comprehensive cognitive and behavioral therapy that evaluates thoughts, feelings, and behaviors. It uses six to eight treatment strategies to teach patients to understand the relationship between pain, suffering, and emotions; to use symptom coping skills, problem-solving, relaxation, and self control; and to modify cognitive distortions associated with emotional distress. Profile-tailored cognitive-behavioral therapy (CBT) matched patient scores on the Biobehavioral Pain Profile (BPP) to specific CBT modules: environmental influences, loss of control, health care avoidance, past and current experience, physiological responsitivity, and thoughts of disease progression.
One inpatient and three outpatient cancer centers in the Southeastern United States
Participants were undergoing the active treatment phase of care.
The study was a randomized trial.
Profile of Mood States (POMS) Symptom Distress Scale
No significant effects on fatigue were found.
de Raaf, P.J., de Klerk, C., Timman, R., Busschbach, J.J., Oldenmenger, W.H., & van der Rijt, C.C. (2013). Systematic monitoring and treatment of physical symptoms to alleviate fatigue in patients with advanced cancer: A randomized controlled trial. Journal of Clinical Oncology, 31, 716–723.
To investigate whether nurse monitoring and protocol management of physical symptoms alleviates fatigue
Patients were randomized to receive either usual care or nurse management patient-tailored treatment using treatment management protocols. In the experimental group, nurse specialists recorded interventions for multiple physical symptoms. During outpatient meetings with the nurse, symptom severity was monitored. When any symptoms were rated ≥ 4 on an 11-point scale, the nurse referred the patient to the oncologist for further assessment and initiation of treatment according to palliative care guidelines, such as medication adjustment, other referrals, or other interventions. Nurses managed as many symptoms independently as possible. Highly specific interventions for pain, nausea, vomiting, constipation, diarrhea, anorexia, dyspnea, cough, and dry mouth were used. No specific interventions aimed at fatigue were identified. Patients met with the nurse at 1, 2–4, 5–7, and 8–10 weeks. Study assessments were done via mail at baseline and one, two, and three months.
A randomized controlled trial design was used.
Patients reported that the most troublesome symptoms were pain, dyspnea, and anorexia. Patients had a median of two symptoms with NRS scores of at least 4 at baseline. MFI scores for general fatigue declined significantly over time in the intervention group compared to controls, with effect size ranging from 0.26 to 0.35 (p = 0.01). NRS fatigue scores also demonstrated decline compared to usual care controls (p < 0.001). BFI scores were not reported. Overall symptom burden was reported to decrease over time in the intervention group, while there was no change in controls (maximal effect size = 0.64, p = 0.002). Anxiety decreased in the intervention group compared to controls (maximal effect size = 0.32, p < 0.001).
Findings suggest that comprehensive management and monitoring for symptom control by nurse specialists was effective in reducing anxiety and fatigue in patients with cancer.
Findings suggest that continued symptom management and monitoring with a protocol approach can be effective for reducing symptoms overall, and reducing fatigue and anxiety. There were no specific intervention approaches identified that were used for fatigue, so the suggestion is that reducing other symptoms can have a positive impact on fatigue. There were also no specific interventions identified for anxiety, but anxiety also declined over time. These results suggest that ongoing monitoring and attention to patients alone may positively impact these symptoms.
Gielissen, M. F., Verhagen, S., Witjes, F., & Bleijenberg, G. (2006). Effects of cognitive behavior therapy in severely fatigued disease-free cancer patients compared with patients waiting for cognitive behavior therapy: a randomized controlled trial. Journal of Clinical Oncology, 24, 4882–4887.
Intervention treatments were individualized based on patient scores on specific questionnaires that measured the six modules (perpetuating factors) of postcancer fatigue. These included:
If a patient had a score on a questionnaire that indicated problems in a specific module, the accessory module became part of the treatment. Therapy only varied in the number of modules, but within each module, the therapy was standardized. The intervention was delivered by three therapists with previous experience with patients with chronic fatigue. Therapy sessions ranged between five and 26 sessions (mean = 12.5 sessions [standard deviation = 4.7 sessions]), with a duration of one hour during a six-month period. Cognitive and behavioral techniques used in therapy addressed the six modules of postcancer fatigue. Patient outcomes were assessed at baseline and six months after enrollment.
Patients were undergoing the active treatment phase of care.
The study was a randomized, controlled trial with a
Checklist Individual Strength (CIS)
Patients in the CBT intervention group experienced a statistically significant decline in fatigue severity (difference, 13.3; 95% confidence interval [CI] [8.6, 18.1]), as well as functional impairment (difference, 21.6; 95% CI [12.7, 30.4]) compared with patients in the waiting list condition (p < 0.001). The proportion of patients with significant improvements in fatigue severity and functional impairment was significantly higher than the intervention condition compared with the waiting list condition, indicating clinical significance (p < 0.001).
Goedendorp, M. M., Peters, M. E., Gielissen, M. F., Witjes, J. A., Leer, J. W., Verhagen, C. A., & Bleijenberg, G. (2010). Is increasing physical activity necessary to diminish fatigue during cancer treatment? Comparing cognitive behavior therapy and a brief nursing intervention with usual care in a multicenter randomized controlled trial. The Oncologist, 15, 1122–1132.
The primary aim was to demonstrate the efficacy of a brief nursing intervention (BNI) and cognitive-behavioral therapy (CBT) compared to usual care (UC). The secondary aim was to determine the role of physical activity in reducing fatigue during cancer treatment.
In total, 220 patients were randomly assigned to one of three groups: BNI, CBT, or UC.
The study was a multicenter, randomized, controlled trial.
The CBT group was significantly less fatigued than the UC group. Between the BNI and the UC groups, no significant difference in fatigue was found. Physical activity was found not to mediate the effect of CBT on fatigue.
CBT during curative cancer treatment resulted in less fatigue compared to the BNI and UC groups. The mediation hypothesis was rejected.
Further study is warranted to determine the effects of specific nursing interventions on the experience of fatigue in patients with cancer.
Kwekkeboom, K. L., Abbott-Anderson, K., Cherwin, C., Roiland, R., Serlin, R. C., & Ward, S. E. (2012). Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. Journal of Pain and Symptom Management, 44, 810–822.
To test the effects of a psychoeducational intervention on pain, fatigue, and sleep disturbance.
Patients were randomly assigned to the intervention group or the wait-list control group. The intervention consisted of a single one-on-one training session with a research nurse, which was followed by recorded guidance that provided imagery, relaxation exercises, and nature sounds. Most exercises lasted 20 minutes and were delivered via an mp3 player. The study lasted two weeks.
Patients were undergoing the active antitumor treatment phase of care.
The study used a randomized, controlled trial, pre- and postintervention design.
The intervention demonstrated a small statistically significant effect on the symptoms of pain and fatigue and the overall symptom cluster of pain, fatigue, and sleep disturbance.
The intervention was a relaxation or imagery therapy rather than a true CBT. The intervention was associated with short-term statistically significant benefits, but the actual size of the effect was small. Findings suggested that approaches using relaxation and imagery may result in some small benefit for patients, but the effect was weak.
Lee, H., Lim, Y., Yoo, M. S., & Kim, Y. (2011). Effects of a nurse-led cognitive-behavior therapy on fatigue and quality of life of patients with breast cancer undergoing radiotherapy: an exploratory study. Cancer Nursing, 34, E22–E30.
To examine the effects of nurse-led cognitive-behavior therapy (CBT) on fatigue and quality of life (QOL) experienced by patients with breast cancer who were currently undergoing radiotherapy.
An oncology nurse-led six-week intervention program that included cognitive restructuring, education about breast cancer and medical treatment, relaxation therapy, and rehabilitation exercise was offered to women receiving radiation therapy at a university hospital in Korea. Nurses who led the course attended the beginner’s course of CBT for 36 hours.
Single site
Patients were undergoing the active antitumor treatment phase of care.
The study used a quasiexperimental pre-/posttest design with a nonequivalent control group.
Levels of fatigue increased in both groups at the posttests. Increases in the levels of fatigue were greater in the control group than in the experimental group. Levels of QOL increased in the experimental group and decreased in the control group.
Nurse-led CBT did not show a significant effect in reducing the levels of cancer-related fatigue, although the increments of fatigue were significantly lower than the control group. Nurse-led CBT was effective in increasing QOL.
There is a role for oncology nurses to lead a structured cognitive-based intervention program to help alleviate cancer-related fatigue in women with breast cancer receiving radiotherapy.
Montgomery, G. H., Kangas, M., David, D., Hallquist, M. N., Green, S., Bovbjerg, D. H., & Schnur, J. B. (2009). Fatigue during breast cancer radiotherapy: an initial randomized study of cognitive-behavioral therapy plus hypnosis. Health Psychology, 28, 317–322.
To test the effectiveness of a psychological intervention combining cognitive-behavioral therapy (CBT) and hypnosis (CBTH) to treat radiotherapy-related fatigue.
Forty-five patients were randomized to two groups: CBTH and standard medical care. Weekly and daily fatigue were measured with two covariates: neuroticism and history of chemotherapy. In the CBTH group, the patients participated in a 15-minute hypnosis session with guided imagery and suggestions for reduced fatigue and a sense of relaxation and energy. Patients were given a CD of the hypnosis intervention to listen to at home. The therapist provided a 30-minute CBT skills session, including how to recognize negative beliefs, consequences of those beliefs, how to change these, and how to practice behavioral strategies and exercise to manage treatment-related fatigue. The therapist reviewed information and progress with each patient twice weekly for a total of 12 sessions in 5- to 15-minute sessions.
The study was a randomized, clinical trial using a repeated measures design.
Among the control group, weekly FSs increased over time at a rate of 1.57 points/week (p < 0.001). Over the course of radiotherapy, individuals in the intervention group had little increase in FS fatigue (0.6 points/week) (p = 0.01).
An intervention combining CBT and hypnosis was effective for controlling fatigue in patients with breast cancer undergoing radiotherapy, independent of neuroticism or past chemotherapy.
Replication of the intervention effects should be studied in a larger population with appropriate attentional control procedures.
Strong, V., Waters, R., Hibberd, C., Murray, G., Wall, L., Walker, J., . . . Sharpe, M. (2008). Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet, 372, 40–48.
To determine the effectiveness of integrating a depression management program into the care of patients with cancer and major depressive disorder (MDD).
Patients were randomized into the treatment group or the usual care group. The treatment group received up to 10 individual one-to-one 45-minute sessions over a three-month period; some occurred via telephone or in the patients' homes, as needed. The intervention consisted of education about depression and its treatment, problem-solving and coping strategies, and collaboration with each patient’s oncologist and primary care provider. Two repeat sessions were offered to persons whose Patient Health Questionnaire-9 (PHQ-9) scores were increasing. No further intervention occurred after six months, but a progress-monitoring interview was conducted at 12 months.
Patients were undergoing the active treatment and transitional phases of care.
The study was a randomized trial with a control (usual care) group.
Measurements revealed no statistically significant differences in the two groups at baseline, including differences in the use of antidepressant medication. However, at three and six months, more patients in the intervention group than in the control group were using a therapeutic level of antidepressants. Depression scores on the SCL-20 decreased between baseline and three months in both groups, but the scores decreased more in the intervention group. More patients in the intervention group had a depression score that decreased by at least 50% from baseline to the three-month follow-up (p = 0.0008). In addition, several patients in the intervention group no longer met the criteria for MDD at three months and had reduced anxiety and fatigue. The study showed no significant changes in pain or physical functioning at three or six months. In addition, at six and 12 months, the study showed a significant improvement in quality of life for patients in the intervention group.
Supplementation of usual care with a nurse-delivered intervention for the management of depression reduced the symptoms of depression, anxiety, and fatigue more than usual care alone. There were no significant improvements in pain or physical functioning. The authors noted the close relationship of anxiety and fatigue to depression as a possible rationale for the cluster of improvements.
A cost-effective, patient-acceptable, nurse-delivered intervention can support the management of depression, anxiety, and fatigue in patients with cancer and MDD. At 12 months, the evidence showed a sustained effect of the three-month intervention.