Fatigue is one of the most common adverse effects of cancer that might persist for years after treatment completion in otherwise healthy survivors. Cancer-related fatigue causes disruption in all aspects of quality of life and might be a risk factor of reduced survival. The prevalence and course of fatigue in patients with cancer have been well characterized and there is growing understanding of the underlying biological mechanisms. Inflammation seems to have a key role in fatigue before, during, and after cancer-treatment. However, there is a considerable variability in the presentation of cancer-related fatigue, much of which is not explained by disease-related or treatment-related characteristics, suggesting that host factors might be important in the development and persistence of this symptom. Indeed, longitudinal studies have identified genetic, biological, psychosocial, and behavioural risk factors associated with cancer-related fatigue. Although no current gold-standard treatment for fatigue is available, a variety of intervention approaches have shown beneficial effects in randomized controlled trials, including physical activity, psychosocial, mind-body, and pharmacological treatments. This Review describes the mechanisms, risk factors, and possible interventions for cancer-related fatigue, focusing on recent longitudinal studies and randomized trials that have targeted fatigued patients.

Cancer-related fatigue—mechanisms, risk factors, and treatments

Background
Message framing has been an important focus in health communication research, yet prior meta-analyses found limited support for using framing to increase persuasiveness of health messages.

Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review.

A compendium of neuropsychological tests: administration, norms, and commentary

The authors extended research linking individual differences in consideration of future consequences (CFC) with health behaviors by (a) testing whether individual differences in regulatory focus would mediate that link and (b) highlighting the value of a revised, two-factor CFC-14 scale with subscales assessing concern with future consequences (CFC-Future) and concern with immediate consequences (CFC-Immediate) proper. Exploratory and confirmatory factor analyses of the revised CFC-14 scale supported the presence of two highly reliable factors (CFC-Future and CFC-Immediate; αs from .80 to .84). Moreover, structural equation modeling showed that those high in CFC-Future engage in exercise and healthy eating because they adopt a promotion orientation. Future use of the two-factor CFC-14 scale is encouraged to shed additional light on how concern with future and concern with immediate consequences (proper) differentially impact the way people resolve a host of intertemporal dilemmas (e.g., health, financial, and environmental behavior).

Promotion Orientation Explains Why Future-Oriented People Exercise and Eat Healthy Evidence From the Two-Factor Consideration of Future Consequences-14 Scale

Importance Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known. Objective To summarize the international prevalence of exposure to indoor tanning. Data Sources Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature. Study Selection Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included. Data Extraction and Synthesis Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma. Main Outcomes and Measures Ever and past-year exposure to indoor tanning. Results The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia. Conclusions and Relevance Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

https://jamanetwork.com/journals/jamadermatology/articlepdf/1818976/doi130064.pdf

International Prevalence of Indoor Tanning: A Systematic Review and Meta-analysis

Heightened inflammatory activity has been proposed as a mechanism for the development of cancer-related fatigue (CRF), a common and distressing condition that can negatively affect quality of life. Inflammation is also implicated in the pathogenesis of depression, and depression is a strong predictor of CRF. Thus, the role of the pro-inflammatory cytokine network in CRF may be mediated by depression or both conditions may share similar underlying physiological processes. The current study investigated associations between fatigue, depression and inflammatory cytokine (IFN-γ, IL-6, TNF-α) and CRP concentrations, as well as kynurenine pathway (KP) activation, in 61 breast cancer patients prior to chemotherapy. Changes in inflammatory markers and KP activation over time were also explored, and associations with changes in fatigue and depression were examined. Higher levels of CRP were significantly correlated with fatigue and depression before chemotherapy; nevertheless, CRP predicted fatigue independently of depression. Although greater kynurenine concentrations were associated with increased immune activation, there was no evidence that the KP played a role in fatigue or depression. Furthermore, no relationships emerged between either fatigue or depression and IFN-γ, IL-6, or TNF-α before chemotherapy. Nevertheless, kynurenine levels pre- and post-treatment significantly predicted changes in depression, suggesting that heightened KP activation may contribute to depressive symptoms in patients treated for cancer. In addition, IL-6 significantly covaried with fatigue. These preliminary findings provide some support for the idea that low-grade inflammation contributes to the development of CRF, independently of depression; however, there was no evidence that this is mediated by KP activity.

C-reactive protein predicts fatigue independently of depression in breast cancer patients prior to chemotherapy.

Consideration of future consequences scale: Confirmatory Factor Analysis

Previous research using the Theory of Planned Behaviour (TPB) for predicting skin cancerrelated health behaviours has not adequately incorporated empirical advances in the conceptualization of the perceived behavioural control (PBC) component of the theory. This study examined the role of self-efficacy and controllability for predicting sunscreen and sunbed use intentions. Five hundred and ninety young adults completed a questionnaire on beliefs and intentions regarding sunscreen and sunbed use. Analysis using confirmatory factor analysis and multiple regression supported a conceptual distinction between two PBC subcomponents: controllability and self-efficacy. While selfefficacy—but not controllability—emerged as a significant predictor of intentions to use sunscreen, the opposite pattern was observed for the prediction of intentions to use sunbeds, whereby lower controllability beliefs were associated with higher intentions. Campaigns aimed at influencing health behaviours should consider the differential effects of the components of perceived control.

Differential effects of self-efficacy and perceived control on intention to perform skin cancer-related health behaviours

The objective of this study was to investigate the impact of messages differing in focus (health vs appearance) and frame (gain vs loss) on intentions for sunscreen use and sunbed use, and the potential moderating role of body consciousness. Questionnaire data from 390 young adults were analysed using factorial ANOVA. Results showed a significant interaction between message frame and body consciousness, such that gain-framed health or appearance messages had the strongest effect on sunscreen use intentions for those high in body consciousness, compared to those low in body consciousness. We conclude that message framing effects on precautionary sun behaviour intentions are moderated by body consciousness.

Body Consciousness Moderates the Effect of Message Framing on Intentions to Use Sunscreen

Objective: Cancer-related fatigue (CRF) is a potentially chronic condition that is inadequately discussed, diagnosed and treated. This study examined the factors that contribute to the absence of a discourse of CRF.Method: A thematic discourse analysis was carried out on the ‘additional comments’ left by 73 fatigued cancer patients and survivors as part of a questionnaire study on CRF.Results: The findings indicated that conflict between patients’ own conceptualisations of CRF and those of family/friends and/or medical professionals hampers social and medical dialogue of CRF. Fatigue forms a part of patients’ ongoing cancer identity even after cancer treatment has been completed; however, because of the dominance of wider social discourses on recovery from illness and cancer survivorship, others fail to recognise individual narratives of CRF when these deviate from or oppose such established discourses. Furthermore, the development of a discourse of CRF is actively obstructed because the enormity of cance...

Maria M. Pertl

Papers

C-reactive protein predicts fatigue independently of depression in breast cancer patients prior to chemotherapy.

Consideration of future consequences scale: Confirmatory Factor Analysis

Differential effects of self-efficacy and perceived control on intention to perform skin cancer-related health behaviours

Body Consciousness Moderates the Effect of Message Framing on Intentions to Use Sunscreen

'I'm not complaining because I'm alive': barriers to the emergence of a discourse of cancer-related fatigue.