Stress Exposures Contribute to Worse Joint Morning and Evening Fatigue Profiles in Patients With Cancer During Chemotherapy

Fatigue is a common symptom that limits the daily activities and quality of life of patients with cancer (National Comprehensive Cancer Network, 2023). Although most studies evaluate average fatigue severity (i.e., fatigue score without consideration of diurnal variations), a growing body of evidence suggests that diurnal variations in fatigue severity warrant additional investigation because different types of interventions may be warranted (Dhruva et al., 2013; Dimsdale et al., 2007; Pietrowsky & Lahl, 2008). In the authors’ previous studies of morning and evening fatigue as single symptoms, common and distinct risk factors (Wright, Cooper, et al., 2017; Wright et al., 2015, 2019) and underlying mechanisms (Kober et al., 2023; Wright, Hammer, et al., 2017) were identified.

More recently, to gain additional insights into patients who were at increased risk for high levels of both morning and evening fatigue, the authors used latent profile analysis to identify the following four classes of patients with distinct joint morning and evening fatigue profiles: both low (24%), low morning and moderate evening (26%), both moderate (39%), and both high (12%) (Wright et al., 2023). Risk factors associated with the worst severity profiles included younger age, decreased likelihood of being married or partnered, increased likelihood of living alone, and having a higher comorbidity burden and a lower functional status. In addition, patients with the worst severity profiles reported higher levels of anxiety, depression, sleep disturbance, and pain, as well as lower quality-of-life scores. The current article extends these findings by evaluating for differences in stress, resilience, and coping among the four distinct joint morning and evening fatigue profiles.

Background

Fatigue and Stress

In healthy individuals, fatigue is an adaptive response to acute stress that conserves energy and maintains homeostasis (Kop & Kupper, 2016). Intense, persistent, and/or cumulative life stress activates the autonomic nervous system and can overwhelm the regulatory feedback loop of the hypothalamic–pituitary–adrenal axis. This process results in a loss of homeostasis and an increase in allostatic load that leads to higher levels of physical fatigue (Shields & Slavich, 2017; Starr et al., 2019; Thorsteinsson et al., 2019). The chronicity and intensity of the stress, types of stressors, coping abilities, and environmental factors moderate an individual’s responses to stress (Galatzer-Levy et al., 2018).

Previous studies of patients with cancer found that higher levels of average fatigue were associated with higher levels of global stress (Higgins et al., 2008; Ho et al., 2015; Reinertsen et al., 2017; Sakamoto et al., 2017; Yeh, 2021), cancer-specific stress (Bower et al., 2021; Cohen et al., 2019; Fagundes et al., 2012; Higgins et al., 2008; Von Ah et al., 2008; Yee et al., 2017), and cumulative life stress (Bean et al., 2021; Bower et al., 2014, 2019, 2021; Fagundes et al., 2012). However, most of these studies included only women with breast cancer (Bean et al., 2021; Bower et al., 2014, 2019, 2021; Cohen et al., 2019; Fagundes et al., 2012; Higgins et al., 2008; Ho et al., 2015; Reinertsen et al., 2017; Von Ah et al., 2008; Yee et al., 2017).

Although longitudinal studies evaluated for changes in average fatigue severity during chemotherapy, the wide range in the timing of the assessments, such as every third chemotherapy cycle (Yeh, 2021), every three months (Von Ah et al., 2008), every six months (Bower et al., 2021), and after completion of treatment (Bower et al., 2014; Cohen et al., 2019; Fagundes et al., 2012; Reinertsen et al., 2017), makes it difficult to determine how stress affects fatigue severity during chemotherapy. For example, in a study that evaluated fatigue severity for six days following a cycle of chemotherapy (Higgins et al., 2008), higher levels of pretreatment distress were associated with increased severity of average fatigue. However, only a single measure of global stress was used in this analysis. None of the studies evaluated for differences in three distinct types of stress (i.e., global, cancer-specific, and cumulative life stress) among patients with cancer who had distinct joint morning and evening fatigue profiles. An evaluation of distinct types of stress is important to be able to provide individualized supportive care interventions; interventions may differ for patients with post-traumatic stress disorder (PTSD) and those with adverse childhood experiences (ACEs).

Fatigue and Resilience

Resilience is an individualized, dynamic process of positive adaptation to stressors that can decrease allostatic load (Charney, 2004). In studies that evaluated for associations among resilience, fatigue, and stress in patients during cancer treatment, lower resilience scores were associated with higher levels of fatigue, global stress (Min et al., 2013), and cancer-specific stress (Alarcón et al., 2020). In one systematic review (Tamura et al., 2021), lower levels of resilience were associated with higher levels of depression, anxiety, and fatigue in patients with cancer. However, only 2 of the 39 studies included in this review evaluated for associations between fatigue and resilience (Ristevska-Dimitrovska et al., 2015; Zou et al., 2018). In two additional studies, higher levels of average fatigue were associated with lower levels of resilience (Lin et al., 2020; Öcalan & Üzar-Özçetin, 2022). These findings suggest that decreased resilience is a risk factor for more severe fatigue. Additional research is warranted because the three studies that evaluated patients during chemotherapy were cross-sectional (Öcalan & Üzar-Özçetin, 2021; Ristevska-Dimitrovska et al., 2015; Zou et al., 2018). In addition, the fourth longitudinal study evaluated only patients with colorectal cancer following surgery (Lin et al., 2020).

Fatigue and Coping

Healthy individuals employ coping strategies to respond to stress and maintain homeostasis (Folkman et al., 1986; Lazarus & Folkman, 1984). Coping strategies can be broadly classified as engagement strategies (e.g., positive reframing, seeking instrumental and emotional support) or disengagement strategies (e.g., avoidance, denial) (Carver et al., 1989; Folkman et al., 1986; Langford et al., 2017; Lazarus & Folkman, 1984). Although engagement coping strategies are associated with decreased fatigue severity, across multiple cancer diagnoses (Dsouza et al., 2018; Narayanan et al., 2020; Reuter et al., 2006; van de Wiel et al., 2021; Yeun & Jeon, 2020), the use of disengagement coping strategies is associated with higher levels of average fatigue (Baussard et al., 2022; Bussell & Naus, 2010; Dahal & Meheta, 2018; Dong et al., 2021; Ichikura et al., 2018; Levkovich, 2021). However, because these studies evaluated only average fatigue, no information is available on associations with diurnal variations in fatigue severity.

An examination of differences in stress, resilience, and the use of coping strategies among patients with worse joint morning and evening fatigue profiles may identify modifiable risk factors that can be targeted to decrease both types of physical fatigue (i.e., morning and evening). Therefore, this study aimed to evaluate for differences in global, cancer-specific, and cumulative life stress, as well as resilience and coping, in subgroups of patients (i.e., latent classes) with distinct joint morning and evening fatigue profiles.

Methods

Patients and Settings

Details about the parent longitudinal study, which was guided by the theory of symptom management (Weiss et al., 2023) are published elsewhere (Miaskowski et al., 2014). In brief, eligible patients were aged 18 years or older; had a diagnosis of breast, gastrointestinal, gynecologic, or lung cancer; had received chemotherapy within the preceding four weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent.

Patients were recruited from two National Cancer Institute–designated comprehensive cancer centers, one Veterans Affairs hospital, and four community-based oncology programs. A total of 2,234 patients were approached during their first or second cycle of chemotherapy and 1,343 consented to participate (60% accrual rate). The primary reason indicated for declining to participate in the study was being overwhelmed with their cancer treatment.

Study Procedures

The study was approved by the Committee on Human Research at the University of California, San Francisco, and by the institutional review board at each of the study sites. Eligible patients were approached by a research staff member in the infusion unit during their first or second cycle of chemotherapy to discuss the study procedures and their interest in study participation. Written informed consent was obtained from all patients. Patients completed the morning and evening fatigue measures in their homes using paper questionnaires. Measures were completed a total of six times over two cycles of chemotherapy: prior to chemotherapy (assessments 1 and 4), one week following the administration of chemotherapy (assessments 2 and 5), and two weeks following the administration of chemotherapy (assessments 3 and 6). The remaining questionnaires were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Medical records were reviewed for disease and treatment information. The 1,334 patients who completed both the morning and evening fatigue measures were included in this analysis.

Measures

Demographic and Clinical Characteristics

Patients completed a demographic questionnaire, the Karnofsky Performance Status Scale (Karnofsky, 1977), and the Self-Administered Comorbidity Questionnaire (Sangha et al., 2003). Medical records were reviewed for disease and treatment information.

Fatigue

The 18-item Lee Fatigue Scale (LFS) was designed to assess physical fatigue and energy (Lee et al., 1991). Each item is rated on a 0–10 numeric rating scale. Total fatigue and energy scores are calculated as the mean of the 13 fatigue items and the mean of the 5 energy items, respectively. Higher scores on the fatigue items indicate greater fatigue severity, and higher scores on the energy items indicate higher levels of energy. Using separate LFS questionnaires, patients were asked to rate each item based on how they felt within 30 minutes of awakening (morning fatigue) and before going to bed (evening fatigue). The LFS has established cutoff scores for clinically meaningful levels of fatigue (3.2 or greater for morning fatigue, 5.6 or greater for evening fatigue) and energy (6.2 or less for morning energy, 3.5 or less for evening energy) (Fletcher et al., 2008). Cronbach’s alphas were 0.96 for morning fatigue and 0.93 for evening fatigue, and they were 0.95 for morning energy and 0.93 for evening energy.

Global Stress

The 14-item Perceived Stress Scale (PSS) was used to measure global perceived stress according to the degree to which life circumstances during the previous week were appraised as stressful (Cohen et al., 1983). Each item is rated on a scale ranging from 0 (never) to 4 (very often). Total scores are summed and can range from 0 to 56. The Cronbach’s alpha for the PSS was 0.85.

Cancer-Specific Stress

The 22-item Impact of Event Scale–Revised (IES-R) was used to measure cancer-related distress (Horowitz et al., 1979). Patients rate each item based on how distressing each potential difficulty was for them during the past week “with respect to their cancer and its treatment.” Three subscales evaluate levels of avoidance, intrusion, and hyperarousal perceived by the patient. For the IES-R total score, sum scores of 24 or greater indicate clinically meaningful post-traumatic symptomatology, and scores of 33 or greater indicate probable PTSD (Creamer et al., 2003). The Cronbach’s alpha for the IES-R total score was 0.92.

Cumulative Life Stress

The 30-item Life Stressor Checklist–Revised (LSC-R) is an index of lifetime trauma exposure (e.g., mugging, the death of a loved one, a sexual assault) (Wolfe & Kimmerling, 1997). The total LSC-R score is obtained by summing the total number of events endorsed. If patients endorse an event, they are asked to indicate how much that stressor affected their life in the past year. These responses are summed to yield a mean “affected sum” score. In addition, a PTSD sum score is created based on the number of positively endorsed items (out of 21) that reflect the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) PTSD Criteria A for having experienced a traumatic event. 

Resilience

The 10-item Connor–Davidson Resilience Scale (CDRS) evaluates a patient’s ability to handle adversity (e.g., “I am able to adapt when changes occur”) (Campbell-Sills & Stein, 2007). Total scores range from 0 to 40, with higher scores indicating higher self-perceived resilience. The normative mean score for adults in the United States is 31.8 (SD = 5.4) (Campbell-Sills et al., 2009). The Cronbach’s alpha of the CDRS was 0.9.

Coping Strategies

The 28-item Brief Coping Orientation to Problems Experienced Inventory scale was designed to assess a broad range of coping responses among adults (Carver, 1997; Carver et al., 1989). Each item is rated on a Likert-type scale ranging from 1 (“I haven’t been doing this at all”) to 4 (“I have been doing this a lot”). Higher scores indicate greater use of the various coping strategies. In total, the following 14 dimensions are evaluated using this instrument (with their respective Cronbach’s alphas): self-distraction (alpha = 0.46), active coping (alpha = 0.75), denial (alpha = 0.72), substance use (alpha = 0.87), use of emotional support (alpha = 0.77), use of instrumental support (alpha = 0.77), behavioral disengagement (alpha = 0.57), venting (alpha = 0.65), positive reframing (alpha = 0.79), planning (alpha = 0.74), humor (alpha = 0.83), acceptance (alpha = 0.68), religion (alpha = 0.92), and self-blame (alpha = 0.73). Each dimension is evaluated using two items.

Data Analysis

As previously reported by Wright et al. (2023), latent profile analysis was used to identify subgroups of patients with distinct joint morning and evening fatigue profiles (using the morning and evening LFS scores obtained during the six assessments in a single latent profile analysis). Mplus, version 8.4 (Muthén & Muthén, 1998–2017), was used to conduct the analysis. This approach provides a profile description of these two symptoms with parallel profiles over time. 

Additional data were analyzed using IBM SPSS Statistics, version 28.0. Differences among the groups with distinct joint morning and evening fatigue profiles in global, cancer-specific, and cumulative life stress, as well as in resilience and the use of coping strategies at enrollment, were evaluated using parametric (e.g., analysis of variance) and nonparametric (e.g., Kruskal–Wallis) tests. A Bonferroni-corrected p value of p < 0.008 was considered statistically significant for the pairwise contrasts (0.05/6 possible pairwise contrasts).

Results

Sample Characteristics

As previously noted by Wright et al. (2023), in brief, compared to the both low class, patients in the both high class were younger, were less likely to be married or partnered, were more likely to live alone, had a higher comorbidity burden, and had a lower functional status. In addition, patients in the both high class reported significantly higher anxiety, depression, sleep disturbance, and pain scores, and lower quality-of-life scores.

Stress and Resilience

As shown in Table 1, across the four classes, significant increases in PSS scores were found to be consistent with increased morning and/or evening fatigue. PSS scores occurred in the following order, from lowest to highest: both low, low morning and moderate evening, both moderate, and both high. Compared to the both low class and the low morning and moderate evening class, the other two classes had higher IES-R subscale and total scores. Compared to the other three classes, the both high class had higher LSC-R total scores. Compared to the both low class, the both moderate and both high classes had higher LSC-R affected and PTSD sum scores. In terms of resilience, compared to the both low and the low morning and moderate evening classes, the other two classes had lower CDRS scores.

Occurrence of Stressful Life Events

Significant differences were found among the joint morning and evening fatigue classes for all the interpersonal violence, abuse, and neglect stressors evaluated using the LSC-R (see Table 2). Compared to the other three classes, the both high class was more likely to report family violence in childhood, emotional abuse, and physical abuse at younger than age 16 years and at age 16 years or older. Compared to the both low and low morning and moderate evening classes, the both high class was more likely to report being exposed to physical neglect and forced to have sex at age 16 years or older. Compared to the low morning and moderate evening class, the both high class was more likely to report being forced to sexually touch at younger than age 16 years and at age 16 years or older and to have been forced to have sex at younger than age 16 years. Compared to the both low class, the both moderate class was more likely to report emotional abuse and being forced to sexually touch at age 16 years or older.

In terms of other stressful life events (SLEs), compared to the both low class, the both high class was more likely to report parental separation or divorce; serious physical or mental illness other than cancer; separation from their child; caring for someone with a severe physical or mental handicap; and having seen a robbery or a mugging and having been robbed or mugged. Compared to the low morning and moderate evening class, the both high class was more likely to report a family member being incarcerated, having a serious physical or mental illness other than cancer, and having been robbed or mugged. Compared to the other three classes, the both high class reported serious money problems. Compared to the low morning and moderate evening class, the both moderate class was more likely to report parental separation or divorce and serious money problems.

Effect of SLEs

Significant differences were found among the joint morning and evening fatigue classes in the effect of various SLEs (see Table 3). Compared to the both low class, the both high class was more likely to have been affected by being forced to sexually touch at age younger than 16 years, being in a serious disaster, and having serious money problems. Compared to the low morning and moderate evening class, the both high class was more likely to have been affected by exposure to family violence during childhood, a serious disaster, parental separation or divorce, and serious money problems. Compared to the low morning and moderate evening class, the both moderate and both high classes were more likely to have been affected by an abortion or miscarriage. Compared to the both low class, the both moderate class was more likely to have been affected by caring for someone with a physical or mental handicap. Compared to the both low class, the both moderate and both high classes were more likely to have been affected by someone close to them dying suddenly. Compared to the other three classes, the both high class was more likely to have been affected by someone close to them dying during the past year.

Coping Strategies

Regarding engagement coping strategies, compared to the low morning and moderate evening class, the both high class was less likely to use active coping and the both moderate class was less likely to use acceptance (see Table 4). Compared to the both low class, the other three classes were more likely to use planning. Compared to the both low class, the low morning and moderate evening class was more likely to use emotional support and the both moderate class was more likely to use instrumental support.

In terms of disengagement coping strategies, compared to the both low class, the other three classes were more likely to use self-distraction and venting. Compared to the low morning and moderate evening class, the both high class was more likely to use venting and denial and the both moderate class was more likely to use behavioral disengagement. Compared to the other three classes, the both high class was more likely to use behavioral disengagement and self-blame. Compared to the both low and the low morning and moderate evening classes, the both moderate class was more likely to use self-blame.

Discussion

Building on the authors’ previous analysis of morning and evening fatigue as individual symptoms (Wright, Cooper, et al., 2017; Wright et al., 2019, 2020) and the authors’ findings on various demographic, clinical, and symptom characteristics associated with joint morning and evening fatigue profiles (Wright et al., 2023), this study provides new insights into the association between joint fatigue profiles and global stress, cancer-specific stress, and the occurrence and effect of SLEs and ACEs, as well as resilience and coping. Patients in the both high class reported the highest stress scores, the highest occurrence rates for and effects from a number of ACEs, the lowest resilience scores, and higher use of disengagement coping strategies. The remainder of the discussion places these findings in the context of the extant literature, describes relevant mechanisms to support the findings, and provides recommendations for research and clinical practice.

Stress

The robust associations between all the stress measures and the worst joint morning and evening fatigue profiles can be partially explained by the fact that cancer and its treatment are significant stressors (Merluzzi et al., 2022) associated with dysregulation of the hypothalamic–pituitary–adrenal axis (Bower, 2019; Ravi et al., 2021). In terms of global stress, the both moderate and both high classes had PSS scores that are comparable to those of pregnant women in neighborhoods with high rates of violent crime (Shannon et al., 2020) and to those of men and women within one month after myocardial infarction (Xu et al., 2015). Higher levels of global stress were associated with greater fatigue severity in adults with inflammatory bowel disease (Luber et al., 2022), unexplained chronic fatigue (Campbell et al., 2017), and rheumatic conditions (Hung et al., 2020). Chronic stress activates the immune system with resultant increases in allostatic load and inflammation (Ravi et al., 2021). These processes may be common mechanisms that underlie these conditions, as well as the fatigue reported by patients and other chronic conditions. Future studies need to evaluate for additive or synergistic interactions between stress and inflammation and their contributions to the occurrence and severity of morning and/or evening fatigue.

In terms of cancer-specific stress, given the significant impact of a cancer diagnosis and its treatments (Merluzzi et al., 2022), the higher subscale and total IES-R scores for the both high class are not unexpected. The IES-R total score was higher than the clinically meaningful cutoff score for PTSD symptomatology of 24 or greater established in studies of earthquake survivors and survivors of the Tokyo subway sarin gas attack (Asukai et al., 2002; Creamer et al., 2003), and it met the criteria for subsyndromal PTSD (Weiss, 2007). The higher scores for the IES-R avoidance, intrusion, and hyperarousal subscales reported by the both high class suggest a PTSD diagnosis (Frances et al., 1995).

Exposure to ACEs during brain development (i.e., experiencing SLEs at age younger than 16 years) may alter neuroimmune interactions that increase the risk for PTSD (Andersen, 2022). The both high class endorsed the highest occurrence rates for several ACEs, including family violence in childhood (n = 43, 39%); emotional abuse (n = 46, 43%); physical neglect (n = 13, 12%); and physical abuse (n = 29, 27%), forced touching (n = 22, 20%), and forced sex (n = 9, 8%) at age younger than 16 years. These findings are consistent with prior research that identified associations between average fatigue and multiple ACEs in healthy college students (Kalmakis et al., 2022), adults with multiple sclerosis (Pust et al., 2021), patients with chronic fatigue syndrome (De Venter et al., 2017), and women with breast cancer (Bower et al., 2014, 2021). The synergy between the occurrence of ACEs (Briggs et al., 2021; Parnes & Schwartz, 2022) and worse joint morning and evening fatigue profiles warrants additional investigation in patients with cancer. One potential explanation for this association is that ACEs increase allostatic load (Bower et al., 2014; Lacey et al., 2020; Steel et al., 2020). In addition, increasing evidence suggests that various neuroimmune interactions contribute to a higher symptom burden in patients with cancer (Bower, 2019; Scheff & Saloman, 2021).

Taken together, these findings suggest that interventions aimed at decreasing stress, such as exercise (Oppegaard et al., 2021), mindfulness meditation (Xie et al., 2020), and yoga (Danhauer et al., 2019; Selvan et al., 2022), may decrease morning and evening fatigue severity. Clinicians who care for patients with cancer need to evaluate their levels of stress and ACE exposures and provide referrals to psychological services. Given the paucity of research on SLEs and ACEs in patients with cancer, studies are warranted to confirm or refute these findings and evaluate the effects of stress reduction or resilience-enhancing interventions to decrease morning and/or evening fatigue severity.

Resilience

Resilience is one factor that influences an individual’s susceptibility to the adverse effects of SLEs (Macía et al., 2020; Weber & O’Brien, 2017). For the both moderate and both high classes, their CDRS scores were below the normative score for the general population of the United States (Campbell-Sills et al., 2009). These findings are consistent with two studies of patients with gastric cancer that found that resilience was negatively correlated with fatigue severity and explained 15% (Zou et al., 2018) to 16% (Tian & Hong, 2014) of the variance in average fatigue. Higher levels of resilience are associated with more adaptive coping to physical and emotional challenges (Macía et al., 2020). Interventions to increase resilience, such as making meaning of the cancer experience (Seiler & Jenewein, 2019), social support (Abbott et al., 2021; Borgi et al., 2020; Seiler & Jenewein, 2019), and attention and interpretation therapy (Lin et al., 2020), may decrease stress, alter neuroimmune responses (Borgi et al., 2020), and decrease fatigue. To the authors’ knowledge, this study is the first to evaluate the impact of resilience on the co-occurrence of morning and evening fatigue.

Coping Strategies

Compared to the both low class, the other three classes were more likely to use planning as a coping strategy. Given that the use of planning was found to help patients with cancer adjust to their current situation (Nilsen et al., 2021), these findings may reflect patients’ efforts to mitigate the effects of morning and/or evening fatigue.

Compared to the other three classes, the both high class used more disengagement coping strategies. Of note, in studies of patients with end-stage kidney disease (Picariello et al., 2018), patients during cancer chemotherapy (Dahal & Meheta, 2018), and healthy working adults (Otsuka et al., 2009), disengagement coping strategies were used to decrease fatigue. Although engagement coping strategies are considered adaptive and encourage post-traumatic growth (Nik Jaafar et al., 2021; Shand et al., 2015), disengagement coping strategies were found to mediate the impact of ACEs on cancer-specific stress (Langford et al., 2017).

It is important to note that patients employ multiple coping strategies (Leonidou et al., 2019). Several qualitative studies highlight the need for clinicians to be aware of patients’ beliefs about their coping efficacy (Dong et al., 2021; Yeun & Jeon, 2020). Higher levels of coping efficacy are associated with higher levels of emotional and physical well-being (Merluzzi et al., 2022). Therefore, additional research is warranted on the efficacy of interventions that support patients’ coping efficacy and the development of more robust engagement strategies, such as personalizing support (Schellekens et al., 2021) and solution-focused interventions (Wang et al., 2021), to reduce fatigue and various types of stress.

Strengths and Limitations

The strengths of this study include a large sample size, patients with heterogeneous types of cancer, and the evaluation of three different types of stress, as well as resilience and coping. However, stress, resilience, and coping strategies were evaluated only upon enrollment. Therefore, associations between changes in the co-occurrence of morning and evening fatigue and changes in the various stress measures warrant evaluation during and following the completion of chemotherapy. In addition, an evaluation of stress biomarkers will increase knowledge of the mechanisms that underlie the relationships between the co-occurrence of morning and evening fatigue and stress. Equally important, future studies need to evaluate the impact of various social determinants of health (e.g., social support, neighborhood environments) that may contribute to both fatigue and stress.

Conclusion and Implications for Practice

This study is the first to evaluate for associations between higher levels of joint morning and evening fatigue profiles in the same patients as well as levels of different types of stress, resilience, and use of coping strategies. In addition to the clinical implications noted previously, a coordinated approach is needed to decrease stress and provide supportive services to patients undergoing chemotherapy. Clinical assessment of patients’ level of resilience, preferred coping strategies, and perceived coping efficacy has the potential to inform personalized supportive interventions such as referrals for psychosocial support, stress management, resilience training, and exercise. The diurnal nature of fatigue suggests that the timing of personalized interventions to decrease fatigue needs to be considered. Additional studies are needed to evaluate the prescription of personalized strategies based on a patient’s morning and evening fatigue profile to decrease both fatigue and stress.

About the Authors

Fay Wright, RN, PhD, APRN-BC, was, at the time of this writing, an assistant professor in the Rory Meyers College of Nursing at New York University in New York City, and is currently a nurse scientist at Northern Westchester Hospital, Northwell Health; Bruce A. Cooper, PhD, is a data analyst III and senior statistician in the Department of Physiological Nursing in the School of Nursing at the University of California, San Francisco; Marilyn J. Hammer, RN, PhD, DC, FAAN, is the director of the Phyllis F. Cantor Center for Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute in Boston, MA; Steven M. Paul, PhD, is a research data analyst III in the Department of Physiological Nursing in the School of Nursing at the University of California, San Francisco; Yvette P. Conley, PhD, FAAN, is a professor in the Department of Health Promotion and Development in the School of Nursing at the University of Pittsburgh in Pennsylvania; and Jon D. Levine, MD, PhD, is a professor in the Department of Oral and Maxillofacial Surgery in the School of Dentistry, Christine Miaskowski, RN, PhD, FAAN, is a professor in the Department of Physiological Nursing in the School of Nursing, and Kord M. Kober, PhD, is an associate professor in the Department of Physiological Nursing in the School of Nursing, all at the University of California, San Francisco. This research was funded, in part, by a grant from the National Cancer Institute (CA134900). Wright received research funding from New York University Langone Health’s Clinical and Translational Science Institute KL2 Scholar Award (TR 1446-6). Miaskowski is an American Cancer Society Clinical Research Professor. Wright, Conley, Miaskowski, and Kober contributed to the conceptualization and design. Wright, Hammer, and Miaskowski completed the data collection. Wright, Paul, and Miaskowski provided statistical support. Wright, Cooper, and Miaskowski provided the analysis. Wright, Hammer, Conley, Levine, and Miaskowski contributed to the manuscript preparation. Wright can be reached at fwright4@northwell.edu, with copy to ONFEditor@ons.org. (Submitted August 2023. Accepted November 29, 2023.)