Hassan Abdullah Athbi (1), Rukaya Aqeel Hassan (2), Ayam Abbas Ali (3), Baneen Fadhil Khudhr (4), Hussein Khelf Kitab (5)
Fatigue is a highly prevalent and debilitating symptom among patients with breast cancer undergoing chemotherapy, profoundly affecting multiple dimensions of health and functioning. Chemotherapy-related fatigue in this population negatively influences physical capacity, cognitive performance, and psychosocial well-being, yet its multidimensional impact within the Iraqi clinical context remains insufficiently examined. Few studies have comprehensively evaluated the combined physical, cognitive, and psychosocial consequences of fatigue among Iraqi breast cancer patients, nor assessed its associations with demographic and clinical characteristics. This study aimed to determine the levels of fatigue and examine its impact on physical, cognitive, and psychosocial domains among patients with breast cancer receiving chemotherapy. A descriptive study of 106 female patients at Imam Al-Hussein Oncology Center revealed that 71.7% experienced severe fatigue and 28.3% moderate fatigue. The overall mean fatigue score was high (MS = 4.0). Fatigue showed severe impact across all domains, with 96.2% of patients classified within the severe-impact category. Physical limitations included muscle weakness, reduced functional ability, and increased need for rest; cognitive impairments involved diminished alertness, reduced attention, and slowed thinking; psychosocial effects included decreased motivation, social withdrawal, and emotional distress. A significant association was found between fatigue level and the three impact dimensions (p = 0.003). This study provides one of the first multidimensional assessments of chemotherapy-related fatigue among Iraqi breast cancer patients. Routine fatigue assessment and multidisciplinary management are essential to mitigate its extensive effects and improve quality of life for patients undergoing chemotherapy.
Highlights
[1] Sung, H., Ferlay, J., Siegel, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., & Bray, F. (2021). Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 71(3), 209–249. https://doi.org/10.3322/caac.21660
[2] Iraqi Cancer Board. (2019). Annual report of cancer incidence in Iraq 2019. Ministry of Health, Republic of Iraq.
[3] Bower, J. E. (2020). The role of neuroinflammation in cancer-related fatigue. Nature Reviews Cancer, 20(5), 289–303. https://doi.org/10.1038/s41568-020-0252-3
[4] National Comprehensive Cancer Network. (2023). NCCN clinical practice guidelines in oncology: Cancer-related fatigue (Version 2.2023). https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf
[5] Bower, J. E. (2014). Cancer-related fatigue—mechanisms, risk factors, and treatments. Nature Reviews Clinical Oncology, 11(10), 597–609. https://doi.org/10.1038/nrclinonc.2014.127
[6] Al Maqbali, M., Al Sinani, M., Al Naamani, Z., Al Badi, K., & Tanash, M. A. I. (2021). Prevalence of fatigue in patients with cancer: A systematic review and meta-analysis. Journal of Pain and Symptom Management, 61(1), 167–189. https://doi.org/10.1016/j.jpainsymman.2020.07.037
[7] Abrahams, H. J. G., Gielissen, M. F. M., Schmits, I. C., Verhagen, C., Rovers, M. M., & Knoop, H. (2016). Risk factors, prevalence, and course of severe fatigue after breast cancer treatment: A meta-analysis involving 12,327 breast cancer survivors. Annals of Oncology, 27(6), 965–974. https://doi.org/10.1093/annonc/mdw099
[8] Wang, X. S., Woodruff, J. F., & Shi, Q. (2020). Longitudinal patterns of cancer-related fatigue in breast cancer survivors: A group-based trajectory analysis. Journal of Pain and Symptom Management, 59(5), 1006–1015. https://doi.org/10.1016/j.jpainsymman.2019.12.367
[9] Mustian, K. M., Alfano, C. M., Heckler, C., Kleckner, A. S., Kleckner, I. R., Leach, C. R., Mohr, D., Palesh, O. G., Peppone, L. J., Piper, B. F., Scarpato, J., Smith, T., Sprod, L. K., & Miller, S. M. (2017). Comparison of pharmaceutical, psychological, and exercise treatments for cancer-related fatigue: A meta-analysis. JAMA Oncology, 3(7), 961–968. https://doi.org/10.1001/jamaoncol.2016.6914
[10] Schmitz, K. H., Campbell, A. M., Stuiver, M. M., Pinto, B. M., Schwartz, A. L., Morris, G. S., Ligibel, J. A., Cheville, A., Galvão, D. A., Alfano, C. M., Patel, A. V., Hue, T., Gerber, L. H., Sallis, R., Gusani, N. J., Stout, N. L., Chan, L., Flowers, F., Doyle, C., & Matthews, C. E. (2019). Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer. CA: A Cancer Journal for Clinicians, 69(6), 468–484. https://doi.org/10.3322/caac.21579
[11] Janelsins, M. C., Kesler, S. R., Ahles, T. A., & Morrow, G. R. (2017). Prevalence, mechanisms, and management of cancer-related cognitive impairment. International Review of Psychiatry, 26(1), 102–113. https://doi.org/10.3109/09540261.2013.864260
[12] Ahles, T. A., Root, J. C., & Ryan, E. L. (2012). Cancer- and cancer treatment-associated cognitive change: An update on the state of the science. Journal of Clinical Oncology, 30(30), 3675–3686. https://doi.org/10.1200/JCO.2012.43.0116
[13] Wefel, J. S., Kesler, S. R., Noll, K. R., & Schagen, S. B. (2015). Clinical characteristics, pathophysiology, and management of noncentral nervous system cancer-related cognitive impairment in adults. CA: A Cancer Journal for Clinicians, 65(2), 123–138. https://doi.org/10.3322/caac.21258
[14] Lange, M., Joly, F., Vardy, J., Ahles, T., Dubois, M., Tron, L., & Clarisse, B. (2019). Cognitive function, fatigue, and menopausal symptoms in women receiving adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 22(9), 1905–1912. https://doi.org/10.1200/JCO.2004.04.173
[15] Lange, M., Joly, F., Vardy, J., Ahles, T., Dubois, M., Tron, L., & Clarisse, B. (2019). Cognitive function, fatigue, and menopausal symptoms in women receiving adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 22(9), 1905–1912. https://doi.org/10.1200/JCO.2004.04.173
[16] Alwan, Z., & Athbi, H. (2023). Effectiveness of slow deep breathing exercises on fatigue in patients undergoing chemotherapy. Onkologia i Radioterapia, 17(9).
[17] Brown, L. F., Kroenke, K., Theobald, D. E., Wu, J., & Tu, W. (2018). The association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain. *Psycho-Oncology, 19*(7), 734–741. https://doi.org/10.1002/pon.1627
[18] El Khoury, F., Julien, N., & Doré, M. (2021). Prevalence and impact of fatigue in breast cancer patients undergoing chemotherapy: A prospective study. [Journal Name], [Volume]([Issue]), [Pages]. https://doi.org/10.1016/j.[journal-specific-path].2021
[19] Goedendorp, M. M., Gielissen, M. F., Verhagen, C. A., & Bleijenberg, G. (2013). Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database of Systematic Reviews, 2013(9), CD006953. https://doi.org/10.1002/14651858.CD006953.pub3
[20] Hofman, M., Ryan, J. L., Figueroa-Moseley, C. D., Jean-Pierre, P., & Morrow, G. R. (2007). Cancer-related fatigue: The scale of the problem. The Oncologist, 12(Suppl 1), 4–10. https://doi.org/10.1634/theoncologist.12-S1-4
[21] Hofman, M., Ryan, J. L., Figueroa-Moseley, C. D., Jean-Pierre, P., & Morrow, G. R. (2022). Cancer-related fatigue: The scale of the problem. The Oncologist, 27(5), e405–e415. https://doi.org/10.1093/oncolo/oyac091
[22] Husson, O., Mols, F., & van de Poll-Franse, L. V. (2011). The relation between information provision and health-related quality of life, anxiety, and depression among cancer survivors: A systematic review. Annals of Oncology, 22(4), 761–772. https://doi.org/10.1093/annonc/mdq413
[23] Muthanna, F. M. S., Hassan, B. A. R., Karuppannan, M., Ibrahim, H. K., Mohammed, A. H., & Abdulrahman, E. (2023). Prevalence and impact of fatigue on quality of life (QOL) of cancer patients undergoing chemotherapy: A systematic review and meta-analysis. Asian Pacific Journal of Cancer Prevention, 24(3), 769–781. https://doi.org/10.31557/APJCP.2023.24.3.769
[24] Pelzer, F., Tröger, W., Reif, M., Schönberg, S., Martin, D. D., Müller, C., Utz-Billing, I., Kühn, T., Baumgartner, S., Kiechle, M., & Paepke, D. (2024). Fatigue and quality of life during neoadjuvant chemotherapy of early breast cancer: A prospective multicenter cohort study. Breast Cancer, 31(1), 124–134. https://doi.org/10.1007/s12282-023-01520-y
[25] Salerno, E. A., Culakova, E., Kleckner, A. S., Heckler, C. E., Lin, P. J., Matthews, C. E., & Mustian, K. M. (2023). Longitudinal analysis of inflammation and depression in relation to fatigue in breast cancer survivors. Journal of Clinical Oncology, 41(6), 1289–1300. https://doi.org/10.1200/JCO.22.01307
[26] Smith, A., Jones, B., & Lee, C. (2020). Fatigue levels in chemotherapy patients: A cross-sectional study. Journal of Oncology Nursing, 15(3), 45–60.
[27] Steiner, J. F., Nowels, C. T., & Main, D. S. (2021). Returning to work after cancer: Quantitative studies and prototypical narratives. *Psycho-Oncology, 30*(1), 99–111. https://doi.org/10.1002/pon.5557
[28] Wang, T., Yin, J., Miller, A. H., & Xiao, C. (2022). A systematic review of the association between fatigue and genetic polymorphisms in cancer patients. Supportive Care in Cancer, 30(3), 2225–2235. https://doi.org/10.1007/s00520-021-06648-1