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Impact of mood disturbance, sleep disturbance, fatigue and

pain among patients receiving cancer therapyecc_1372 70..78

K.K.F. CHENG, rn, pgdip epidemiol & biostat, phd, associate professor, Alice Lee Centre for Nursing Studies,

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, & R.M.W. YEUNG, md, consult-

ant, Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong

CHENG K.K.F. & YEUNG R.M.W. (2013) European Journal of Cancer Care 22, 70–78

Impact of mood disturbance, sleep disturbance, fatigue and pain among patients receiving cancer therapy

This paper describes the prevalence of mood disturbance, sleep disturbance, fatigue and pain (MSFP), either

alone or in combination in patients receiving cancer therapy, and determines its impact and whether it is a

predictor for functional status and the impairment of quality of life (QoL). This is a cross-sectional study using

secondary data from a sample of 214 patients being treated by chemotherapy or radiotherapy. In all, 87%, 68%,

66% and 38% of the patients reported MSFP respectively. Co-occurrence of any three and all of the four

symptoms, were reported separately at rates of 29% and 31%. Patients with all four symptoms recorded

significantly lower Karnofsky Performance Scale (KPS) scores (mean 77.7 12.9) and QoL scores (mean

subscales scores 9.0–17.6) than those with none or up to any three of the symptoms (P


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symptoms can lead to a profound impairment of the

patient’s quality of life (QoL) and functional status (Grassi

et al. 1996; Cleeland 2007; Delgado-Guay et al. 2011). In

addition, cancer and treatment-related symptoms can

directly affect survival rates if they become so severe that

patients abandon their cancer treatments, or if they give

rise to delays in the cancer treatment. Residual treatment-related symptoms can also complicate post-cancer treat-

ment rehabilitation (Cleeland 2007). Snyderman and

Wynn (2009) revealed that depression adversely affects the

cancer patients’ QoL, their compliance with the cancer

treatment and their relationship with their carers and may

ultimately have an effect on mortality (Snyderman &

Wynn 2009). The effects of sleep disturbance are physical

as well as psychological, with some research suggesting

that sleep disturbance may be associated with an

increased risk of immuno-suppression, as it carries with it

the potential to affect the course of the cancer (Davidsonet al. 2002; Bardwell et al. 2008). Fatigue in cancer

patients can interfere with their self-care activities, and be

extreme enough at times to cause a postponement or

reduction of the treatment (Delgado-Guay et al. 2011).

Pain is considered to be one of the most feared symptoms

of cancer and the one that most disrupts all aspects of life

(Cleeland et al. 2000; Tavoli et al. 2008).

Recent identification of correlated and co-varied symp-

toms has revealed novel insights into the co-occurrence of

the symptoms as a cluster. More pre-clinical and observa-

tional clinical studies on the etiological processes and

related physical and psychosocial implications of such a

symptom cluster should become available in the next few

years. To date, several studies documenting the multiplic-

ity of the symptoms experienced by cancer patients have

shown that pain, fatigue, sleep disturbance, emotional

distress and poor appetite are almost universally found to

be co-occurring. More than 20 studies into symptom clus-

ters for any of the MSFP symptoms in combination have

been undertaken (Spiegel et al. 1994; Glover et al. 1995;

Gaston-Johansson et al. 1999; Miaskowski & Lee 1999;

Redeker et al. 2000; Theobald 2004; Beck et al. 2005; Mys-

takidou et al. 2007; Kozachik & Bandeen-Roche 2008;Tavoli et al. 2008; So et al. 2009; Stepanski et al. 2009;

Laird et al. 2011; Manitta et al. 2011). Pain – sleep distur-

bance – fatigue (Miaskowski & Lee 1999; Beck et al. 2005;

Mystakidou et al. 2007; Kozachik & Bandeen-Roche

2008) and pain – depression – fatigue (Spiegel et al. 1994;

Gaston-Johansson et al. 1999; So et al. 2009; Laird et al.

2011) are commonly recognised as clinical symptom clus-

ters. These studies have shed much light on the possible

existence of symptom clusters of MSFP and the possibility

of streamlining treatments. Nonetheless, most of the prior

research into MSFP has focused on any two or three symp-

toms in combination, rather than on exploring the poten-

tial interactions and interrelationships between all of the

MSFP symptoms together. In addition, only a limited

number of studies have dealt with clusters of MSFP symp-

toms in patients receiving cancer treatment as compared

with those who are receiving palliative care and are at anadvanced stage of the disease. Thus, it is becoming

increasingly critical to address the effect of MSFP on

patients’ lives in order to reduce the burden of cancer

treatment. The purpose of the present study is to deter-

mine the impact of MSFP on patients’ functional status

and QoL, and evaluate whether MSFP can be a predictor of

functional status and the impairment of QoL during

cancer therapy, after adjusting for demographic and clini-

cal factors.

M ET HODS

This cross-sectional study used secondary data from a

convenience sample of 214 patients, 18 years of age and

older, with head/neck, colorectal, breast, lung, gynaeco-

logical or other cancers receiving chemotherapy or radio-

therapy at an oncology unit of a regional hospital in Hong

Kong. The study sample was drawn from a previously

conducted observational validation study (Cheng et al.

2009). The original database consisted of 370 patients who

were undergoing cancer therapy or at the early post-

treatment stage for any diagnosed cancer. The study was

conducted in accordance with the Declaration of Helsinki;

all of the subjects provided written informed consent

before being enrolled in the study.

Mood disturbance, sleep disturbance, fatigue and pain

were measured using the respective items from the

Chinese version of the Symptom Distress Scale (SDS). The

possible score ranges from 1 to 5, with 5 indicating a high

level of symptom distress (McCorkle & Young 1978). For

this study, a symptom was considered to be present if the

SDS score was 2. The patients’ QoL was assessed using

the Chinese version of the Functional Assessment of

Cancer Therapy-General (FACT-G). The physical, social,emotional, and functional subscales and total scores were

computed as previously described. A lower score indicates

a poorer QoL (Cella et al. 1993). The Chinese versions of

both the SDS and FACT-G are accepted as being valid and

reliable psychometric tools, and to have an acceptable

cultural equivalence with the original version (Chan 2000;

Yu et al. 2000).

The observer rated Karnofsky Performance Scale (KPS)

was used to measure functional status. This is an 11-point

rating scale ranging from 0 to 100 (0 = dead, 100 = normal

Cancer therapy-related affective and somatic symptoms

© 2012 Blackwell Publishing Ltd 71


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function) widely used to assess patients’ physical func-

tional level related to cancer and its treatment (Yates et al.

1980). A validation study strongly suggests that the score

reflects the physical functioning of the patient (Mor et al.

1984).

Statistical analysis

Pearson’s simple correlation test was performed for the

correlations between the MSFP symptoms, and thus to

determine the relationships between those symptoms, the

KPS, and the FACT-G subscale/total scores. Univariable

and multivariable conditional logistic regression analyses

were performed in order to estimate the odds ratios (OR) for

the patients whoreported co-occurrence of any three symp-

toms of MSFP or all of the four symptoms. Any variables

with P-values


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FACT-G total: 84.3) (P < 0.001). As for patients with any

three of the four symptoms, post hoc comparisons with

Bonferroni corrections show that the FACT-G social,

emotional and functional subscale and total scores were

significantly lower than those without any symptoms andfor those with any one or two of the four symptoms

(P < 0.001).

The correlations between the KPS scores, the FACT-G

subscale/total scores and the MSFP showed moderate

negative correlations ( r = -0.20 to -0.57, P < 0.001)

(Table 2). Only those with r > 0.3 are reported here. In

terms of functional status, the KPS scores showed a mild

to moderate negative correlation with the four symptoms

( r = -0.28 to -0.57, P < 0.001). Correlations between the

FACT-G subscale/total scores and the symptoms of MSFP

showed moderate negative correlations of the physical

( r = -0.39 to -0.55, P < 0.001), emotional ( r = -0.24 to

-0.53, P < 0.001) and functional ( r = -0.43 to -0.52, P <

0.001) subscales and total ( r = -0.44 to -0.57, P < 0.001)

scores for the four symptoms.As shown in Table 5, regression of the KPS scores

against the symptoms of MSFP revealed that the increase

in explained variance of 25% was significant (F change =

25.3, P < 0.0001). Pain (b = -0.34, P < 0.001) and fatigue

(b = -0.26, P < 0.001) showed significant independent

effects on the KPS scores, whereas mood disturbance and

sleep disturbance were not seen as influencing the KPS

scores independently (P > 0.05).

As for the QoL, regression of the FACT-G physical sub-

scale score against the symptoms of MSFP revealed that

Table 2. Correlation coefficients among mood disturbance, sleep disturbance, fatigue and pain, and among KPS and FACT-G subscale andtotal scores ( n = 214)

Mood Sleep disturbance Fatigue Pain

Sleep disturbance 0.32*Fatigue 0.33* 0.42*

Pain 0.25* 0.26* 0.39*

KPS -0.29* -0.28* -0.48* -0.57*

QoL scoresPhysical -0.49* -0.39* -0.50* -0.55*

Social -0.27* -0.20* -0.32* -0.26*Emotion -0.53* -0.29* -0.39* -0.24*

Functional -0.48* -0.44* -0.52* -0.43*

Total -0.57* -0.44* -0.55* -0.47*

Coefficients greater than 0.30 are in bold type.*P < 0.001.FACT-G, Functional Assessment of Cancer Therapy-General; KPS, Karnofsky Performance Scale; QoL, quality of life.

Table 3. Associations between patients’ characteristics and the no. of combined mood disturbance, sleep disturbance, fatigue and pain( n = 214)

0–2 symptoms( n = 85)

3 symptoms( n = 127)

Bivariate analysis†P-value

Multivariate analysisP-valueOdds ratio (95% CI) Odds ratio (95% CI)

Age 53.81 11.4 54.52 11.7 1.01 (0.98–1.03) 0.659 – –

Gender

Male 42 (48.8%) 68 (53.1%) 1.0 (referent) 0.539 1.46 (0.66–3.20) 0.350

Female 44 (51.2%) 60 (46.9%) 1.19 (0.69–2.05)

Cancer diagnosis

Head and neck 19 (22.1%) 29 (22.7%) 1.0 (referent)

Colorectal 20 (23.3%) 25 (19.5%) 0.82 (0.36–1.87) 0.635 0.64 (0.27–1.56) 0.328

Breast 21 (24.4%) 20 (15.6%) 0.62 (0.27–1.45) 0.272 0.46 (0.16–1.37) 0.163

Lung 7 (8.1%) 27 (21.1%) 2.58 (0.92–6.96) 0.073 2.81 (1.16–6.85) 0.023*

Gynaecological 8 (9.3%) 7 (5.5%) 0.57 (0.18–1.84) 0.350 0.40 (0.10–1.53) 0.179

Others 11 (12.8%) 20 (15.6%) 1.19 (0.47–3.04) 0.714 1.14 (0.42–3.10) 0.791

Cancer therapy

Chemotherapy 53 (62.4%) 75 (60.5%) 1.0 (referent)Radiotherapy 6 (7.1%) 18 (14.5%) 2.12 (0.79–5.70) 0.136 1.68 (0.57–4.98) 0.351

Chemoradiotherapy 26 (30.6%) 31 (25.0%) 0.84 (0.45–1.58) 0.593 0.84 (0.43–1.63) 0.598

Values are mean SD or frequency (%).*P < 0.05.†Any variables with P-values 0.50 in the univariate model were tried in the multivariate model.




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the increase in explained variance of 43% was significant

(F change = 42.1, P < 0.001). Pain (b = -0.33, P < 0.001),

mood disturbance (b = -0.29, P

a n y t h r e e M S F P .

* T h e m e a n K P S s c o r e r a n g e s 0 t o 1

0 0 ; h i g h e r s c o r e r e p r e s e n t s a b e t t e r f u n c

t i o n a l s t a t u s .

† T h e m e a n F A C T - G p h y s i c a l , s o c i a

l , a n d f u n c t i o n a l s u b s c a l e s c o r e s r a n g e 0 t o 2 8 ; h i g h e r s c o r e r e p r e s e n t s a b e t t e r

Q o L .

‡ T h e m e a n F A C T - G e m o t i o n s u b s c

a l e s c o r e r a n g e 0 t o 2 4 ; h i g h e r s c o r e r e p

r e s e n t s a b e t t e r Q o L .

§ T h e m e a n F A C T - G t o t a l s c o r e r a n

g e 0 t o 1 1 6 ; h i g h e r s c o r e r e p r e s e n t s a b e t t e r Q o L .

F A C T - G , F u n c t i o n a l A s s e s s m e n t o f C a n c e r T h e r a p y - G e n e r a l ; K P S , K a r n o f s k y P e r f o r m a n c e S c a l e ; M S F P , m o o d d i s t

u r b a n c e , s l e e p d i s t u r b a n c e , f a t i g u e a n d p a i n ; Q o L , q u a l i t y o f

l i f e .

CHENG & YEUNG

© 2012 Blackwell Publishing Ltd74


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38%, sleep disturbance 57%). One probable explanation

for the high prevalence of mood disturbance in our study

was the escalating distress associated with the debilitating

side effects or medical complications of cancer therapy.

Palesh et al. (2010) also indicated that mood disturbance

and sleep disturbance often increase during the treatment

period. The incidence of fatigue (66%) and pain (38%)

reported by patients in this study is consistent with earlier

reports of haemato-oncological patients receiving inpa-

tient and outpatient services (fatigue 69%, pain 39%)

(Manitta et al. 2011). Hickok et al. (2005) studied 372

patients undergoing radiotherapy and found that 57% of

the patients reported some degree of fatigue at the initia-

tion stage of radiotherapy, and the proportion increased to

76% by week 3 and then to 78% at week 5. The currentstudy also showed that MSFP were moderately distressing

for patients during cancer therapy. A cross-sectional study

of 263 cancer patients who were undergoing chemo-

therapy also found a moderate distress level for fatigue

(mean = 2.64) and sleep disturbance (mean = 2.08) as mea-

sured by a 5-point SDS (Redeker et al. 2000).

The present study reveals that 60% of patients receiving

cancer therapy suffered from a co-occurrence of any three

or all of the four symptoms. The high prevalence of the

co-occurrence of multiple symptoms in cancer settings

indicates areas for continued research into symptom clus-

ters and innovative treatment to target multiple symp-

toms. The results also show that patients with lung cancer

are associated with a greater risk of co-occurrence of any

three or all four of the MSFP symptoms. In a population-

based study to examine cancer symptoms and perfor-

mance outcomes, Barbera et al. (2010) also found that lung

cancer patients had the worst burden of symptoms. Nev-

ertheless, differences in the symptoms reported for cancer

subgroups require further investigation. Congruent with

other studies, the inter-correlation found in this study

between MSFP was mild to moderate (Gaston-Johansson

et al. 1999; Theobald 2004; Stepanski et al. 2009). There is

a growing volume of literature that supports its observa-

tions that MSFP occur concurrently and are interrelated.Several other recent studies have shown that depression is

also often part of a cluster of interrelated symptoms,

including pain, fatigue and sleep disturbance (Redeker

et al. 2000; Theobald 2004). It has been suggested that the

link between pain and depression are reciprocally related.

Fatigue is another symptom related to both pain and

depression in cancer patients (Spiegel et al. 1994; Glover

et al. 1995; So et al. 2009). It is notable that sleep distur-

bance in the context of cancer seldom occurs by itself

and is more commonly clustered with pain, fatigue and

Table 5. Regression coefficients of the KPS and FACT-G subscale and total scores against mood disturbance, sleep disturbance, fatigueand pain ( n = 214)

Standardised coefficients b

KPS

FACT-G (C)

Physical Social Emotional Functional Total

Age -0.11 0.05 -0.03 0.22** 0.03 0.10

GenderMale 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent)

Female 0.05 -0.03 0.19* 0.02 0.15 0.10

Cancer diagnosis

Head and neck 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent)

Colorectal -0.28† -0.26 0.14 -0.29 -0.28 -0.27

Breast -0.34* -0.23 0.01 -0.33 -0.34 -0.39

Lung 0.13* 0.29 0.16 0.11 0.13 0.20

Gynaecological -0.20 -0.38 0.06 -0.22 -0.20 -0.42

Others 0.01 -0.13 0.19 -0.01 0.01 -0.50

Cancer therapy

Chemotherapy 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent) 1 (Referent)

Radiotherapy -0.25 -0.10 -0.13 -0.22** -0.05 -0.15*

Chemoradiotherapy 0.02 -0.02 -0.01 -0.05 0.10 -0.03

Mood disturbance -0.05 -0.29† -0.11 -0.40‡ -0.26† -0.35†

Sleep disturbance -0.04 -0.12* 0.01 -0.06 -0.29† -0.14*Fatigue -0.26† -0.23† -0.20* -0.22** -0.27† -0.27†

Pain -0.34† -0.33† -0.12 0.03 -0.29† -0.19**

D R2 0.25 0.43 0.09 0.27 0.37 0.41

D F -value 25.3 42.1 4.98 22.5 34.1 44.5

P -value


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depression (Redeker et al. 2000; Theobald 2004). Stepan-

ski et al. (2009) studied the relationship between trouble

in sleeping, depressed moods, pain and fatigue in 11 445

cancer patients undergoing treatment in a large commu-

nity oncology practice, and revealed that trouble in sleep-

ing occurred in 55% of patients and was associated with

significantly increased fatigue, pain and depressed moods.The same study indicated that the effect of depressed

moods on fatigue and pain was mediated by trouble in

sleeping, and the effect of trouble in sleeping on fatigue

was mediated by pain as shown by structural equation

modelling. The relationship between pain and sleep has

often been assumed to be reciprocal – pain can lead to

disturbed sleep, and vice versa (Smith & Haythornthwaite

2004). A small body of research has accumulated which

suggests that there is a bi-directional link between depres-

sion and sleep disturbance (Ford & Kamerow 1989; Savard

& Morin 2001). In a study of patients with advancedcancer receiving palliative care, Delgado-Guay et al.

(2011) revealed that patients with sleep disturbance were

more likely to report pain (P = 0.0132), depression (P =

0.019), anxiety (P = 0.01) and a poorer sense of well-being

(P = 0.035) compared with patients who did not experience

sleep disturbance. A sample of adult patients with lung

and colon cancer revealed that 56% attributed their sleep

disturbance to experiencing pain (Savard & Morin 2001).

Several studies have established relationships between

fatigue and sleep disturbance both during cancer treat-

ment as well as after (Servaes et al. 2002; Hickok et al.

2005). Beck et al. (2005) examined the interrelationships

between symptoms of pain, fatigue and sleep disturbance,

and found that pain and sleep disturbance predicted

fatigue. In future, more empirical data are needed to deter-

mine the interrelationships and the complex patterns of

co-variation among MSFP symptoms, as well as the tra-

jectories and response shift of the symptoms over the

course of cancer therapy in order to develop a robust

causal model of the symptoms in order to improve MSFP

management strategies.

The results in this study suggest an association

between the symptoms of MSFP, functional status andQoL. Patients who had a co-occurrence of any three or all

four of the symptoms of MSFP reported the worst func-

tional status and poorest QoL. Miaskowski et al. (2006)

and Pud et al. (2008) analysed 191 and 228 adults under-

going active cancer treatment respectively, and also

found that the subgroup of patients who had high levels

of MSFP reported poor functional status and QoL. In the

current study, one-fifth to half of the variance (25–43%)

in functional status as well as physical, emotional and

functional well-being and total QoL was explained by the

symptoms of MSFP in patients receiving cancer therapy

after adjustment for gender, age, cancer diagnosis and

treatment modality. These findings are consistent with

those of Redeker et al. (2000) in whose study fatigue,

sleep disturbance, anxiety and depression together

explained 47% of the variance in QoL in patients under-

going initial chemotherapy for cancer. On the other hand,our data revealed that all four of these symptoms have

less effect on the social well-being (9% of the variance) of

patients during cancer therapy. It is notable that the vari-

ables explaining the greatest proportion of the variance

in functional status were pain and fatigue. Dodd et al.

(2001) also revealed that the symptoms of pain and

fatigue contributed most to explaining the change in

functional status for patients receiving chemotherapy.

The findings in the present study also suggest that MSFP

appear to be equally important in explaining changes in

the functional sphere of QoL for patients receiving cancertherapy. It was notable that pain and mood disturbance

had the greatest influence on physical QoL, while mood

disturbance and fatigue had the greatest influence on

emotional and total QoL. Redeker et al. (2000) studied

263 patients undergoing chemotherapy using the Profile

of Mood States. They found that depression, fatigue and

anxiety affected the patients’ QoL, and that depression

was the largest contributor. Undoubtedly, the experience

of the diagnosis and treatment of cancer for an individual

is a life episode that represents an emotional challenge.

The literature indicates that mood disturbance often

increase during the treatment period (Glajchen 1999;

Palesh et al. 2010) and should not be neglected. A previ-

ous review also indicated that the psychological burden

of the diagnosis and treatment of cancer can reach clini-

cally significant levels (Martin & Cheng 2006). Neverthe-

less, it seems possible that mood disturbance was not

merely additive in its influence on the patients’ func-

tional status and QoL. Rather, it would occur in associa-

tion with sleep disturbance, fatigue and pain as a cluster

of symptoms that reinforce each other in an interactive

manner. Lenz et al. asserted that concurrent symptoms

are likely to result in an experience that is multiplicativerather than additive (Lenz et al. 1997). More work is

needed to determine the causal nature of the relation-

ships between these symptoms in patients and to support

this theoretical proposition.

The present study provides some insights contributing

to a better understanding of the prevalence, co-occurrence

and morbidities of MSFP symptoms in patients during

cancer therapy. These symptoms are critical and should be

monitored beyond the routine assessments of nausea

and vomiting, myelo-suppression and other biomedical

CHENG & YEUNG



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toxicities during cancer therapy. Nevertheless, there were

limitations that might affect the interpretation of the

study findings. This study only described MSFP symp-

toms at a single point in time, and was subject to potential

confounders because of possible variation in the pre-

existing coping ability of the patients and the availability

of support mechanisms, as well as the presence of othersymptoms and the supportive care given to the patients. In

addition, the SDS adopted in this study to assess MSFP

symptoms is a single-item score which might not

adequately tap the multidimensional nature of symptoms

as well as thoroughly address the levels of distress caused

by these symptoms. Further studies should be directed

towards investigating the persistence, the trajectories and

the burden of multiple symptoms over the course of

cancer therapy using multi-item symptom-specific scaleswith larger sample sizes to control covariates in a more

comprehensive fashion.

REFERENCES

Barbera L., Seow H., Howell D., SutradharR., Earle C., Liu Y., Stitt A., Husain A.,Sussman J. & Dudgeon D. (2010)Symptom burden and performance statusin a population-based cohort of ambula-tory cancer patients. Cancer 116, 5767–5776.

Bardwell W.A., Profant J., Casden D.R.,Dimsdale J.E., Ancoli-Israel S. & Natara-jan L. (2008) The relative importance ofspecific risk factors for insomnia inwomen treated for early-stage breastcancer. Psycho-Oncology 17, 9–18.

Beck S.L., Dudley W.N. & Barsevick A.(2005) Pain, sleep disturbance, andfatigue in patients with cancer: using amediation model to test a symptomcluster. Oncology Nursing Forum 32,E48–E55.

Cella D.F., Tulsky D.S., Gray G., SarafianB., Linn E., Bonomi A., Silberman M.,Yellen S.B., Winicour P. & Brannon J.

(1993) The functional assessment ofcancer therapy scale: development andvalidation of the general measure.Journal of Clinical Oncology 11, 570–579.

Chan W.H. (2000) The Chinese translationof the revised Piper Fatigue Scale andSymptom Distress Scale. ResearchReport. Nethersole School of Nursing,The Chinese University of Hong Kong,Hong Kong.

Cheng K.K.F., Wong E.M.C., Ling W.M.,Chan C.W. & Thompson D.R. (2009)Measuring the symptom experience ofChinese cancer patients: a validation of

the Chinese Version of the MemorialSymptom Assessment Scale. Journal of Pain and Symptom Management 37,44–57.

Cleeland C.S. (2007) Symptom burden:multiple symptoms and their impact aspatient-reported outcomes. Journal of theNational Cancer Institute 37, 16–21.

Cleeland C.S., Mendoza T.R., Wang X.S.,Chou C., Harle M.T., Morrissey M. &Engstrom M.C. (2000) Assessingsymptom distress in cancer patients: theM.D. Anderson Symptom Inventory.Cancer 89, 1634–1646.

Davidson J.R., MacLean A.W., BrundageM.D. & Schulze K. (2002) Sleep distur-bance in cancer patients. Social Scienceand Medicine 54, 1309–1321.

Delgado-Guay M., Yennurajalingam S. &Parsons H. (2011) Association betweenself-reported sleep disturbance and othersymptoms in patients with advancedcancer. Journal of Pain and Symptom

Management 41, 819–827.Dodd M.J., Miaskowski C. & Paul S.M.

(2001) Symptom clusters and their effecton the functional status of patients withcancer. Oncology Nursing Forum 28,465–470.

Ford D.E. & Kamerow D.B. (1989) Epide-miologic study of sleep disturbances andpsychiatric disorders: an opportunity forprevention? JAMA: the Journal of the

American Medical Association 262,1479–1484.

Gaston-Johansson F., Fall-Dickson J.M.,Bakos A.B. & Kennedy M.J. (1999)Fatigue, pain, and depression in pre-

autotransplant breast cancer patients.Cancer Practice 7, 240–247.Glajchen M. (1999) Psychosocial issues in

cancer care. In: Oncology Nursing: Assessment and Clinical Care (edsMiaskowski C. & Buchsel P.), pp. 305–318. Mosby, St Louis, MO, USA.

Glover J., Dibble S.L., Dodd M.J. &Miaskowski C. (1995) Mood states ofoncology outpatients: does pain make dif-ference? Journal of Pain and Symptom

Management 10, 120–128.Grassi L., Indelli M., Marzola M., Maestri

A., Santini A., Piva E. & Boccalon M.(1996) Depressive symptoms and quality

of life in home-care-assisted cancerpatients. Journal of Pain and Symptom

Management 12, 300–307.Hickok J.T., Roscoe J.A., Morrow G.R.,

Mustian K., Okunieff P. & Bole C.W.(2005) Frequency, severity, clinicalcourse, and correlates of fatigue in 372patients during 5 weeks of radiotherapyfor cancer. Cancer 104, 1772–1778.

Kim Y., Hickok J.T. & Morrow G. (2006)Fatigue and depression in cancer patientsundergoing chemotherapy: an emotionapproach. Journal of Pain and Symptom

Management 32, 311–321.

Koopman C., Nouriani B., Erickson V.,Anupindi R., Butler L.D., BachmannM.H., Sephton S.E. & Spiegel D. (2002)Sleep disturbances in women with meta-static breast cancer. The Breast Journal 8,362–370.

Kozachik S.L. & Bandeen-Roche K. (2008)Predictors of patterns of pain, fatigue, andinsomnia during the first year after acancer diagnosis in the elderly. CancerNursing 31, 332–344.

Laird B.J.A., Scott A.C., Colvin L.A.,McKeon A.L., Murray G.D., Fearon K.C.& Fallon M.T. (2011) Pain, depression,and fatigue as a symptom cluster inadvanced cancer. Journal of Pain andSymptom Management 42, 1–11.

Lenz E.R., Pugh L.C., Milligan R.A., Gift A.& Suppe F. (1997) The middle-rangetheory of unpleasant symptoms: anupdate. ANS. Advances in Nursing Science 19, 14–27.

McCorkle R. & Young K. (1978) Develop-ment of a symptom distress scale. Cancer

Nursing 1, 373–378.McDaniel J.S., Musselman D.L., PorterM.R., Reed D.A. & Nemeroff C.B. (1995)Depression in patients with cancer. Diag-nosis, biology, and treatment. Archives of General Psychiatry 52, 89–99.

Manitta V., Zordan R., Cole-Sinclair M.,Nandurkar H. & Philip J. (2011) Thesymptom burden of patients with hema-tological malignancy: a cross-sectionalobservational study. Journal of Pain andSymptom Management 42, 432–442.

Martin C.R. & Cheng K.K.F. (2006) Issuesin the psychiatric screening of cancerpatients. Current Psychiatry Reviews 2,

3–10.Massie M.J. (2004) Prevalence of depression

in patients with cancer. Journal of theNational Cancer Institute 32, 57–71.

Meuser T., Pietruck C., Radbruch L., StuteP., Lehmann K.A. & Grond S. (2001)Symptoms during cancer pain treatmentfollowing WHO-guidelines: a longitudi-nal follow-up study of symptom preva-lence, severity and etiology. Pain 93,247–257.

Miaskowski C. & Lee K.A. (1999) Pain,fatigue, and sleep disturbances in oncol-ogy outpatients receiving radiation




9/10

therapy for bone metastasis: a pilot study.Journal of Pain and Symptom Manage-

ment 17, 320–332.Miaskowski C., Copper B.A., Paul S.M.,

Dodd M., Lee K., Aouizerat B.E., West C.,Cho M. & Bank A. (2006) Subgroups ofpatients with cancer with differentsymptom experiences and quality of life

outcomes: a cluster analysis. Oncology Nursing Forum 33, E79–E89.

Mor V., Laliberte L., Morris J.N. &Wiemann M. (1984) The Karnofsky Per-formance Status Scale: an examination ofits reliability and validity in a researchsetting. Cancer 53, 2002–2007.

Mystakidou K., Parpa E., Tsilika E.,Pathiaki M., Gennatas K., Smyrniotis V.& Vassiliou I. (2007) The relationship ofsubjective sleep quality, pain, and qualityof life in advanced cancer patients. Sleep

30, 737–742.Palesh O.G., Roscoe J.A., Mustian K.M.,

Roth T., Savard J., Ancoli-Israel S.,Heckler C., Purnell J.Q., Janelsins M.C.& Morrow G.R. (2010) Prevalence, demo-graphics, and psychological associationsof sleep disruption in patients withcancer: University of Rochester CancerCenter-Community Clinical OncologyProgram. Journal of Clinical Oncology 28, 292–298.

Patrick D.L., Ferketich S.L., Frame P.S.,Harris J.J., Hendricks C.B., Levin B., LinkM.P., Lustig C., McLaughlin J. Reid L.D.,Turrisi A.T., Unützer J. & Vernon S.W.(2004) National Institutes of HealthState-of-the-Science Conference State-ment: Symptom management in cancer:pain, depression, and fatigue. Journal of the National Cancer Institute. Mono-

graphs 32, 9–16.Pud D., Ami S.B., Cooper B.A., Aouizerat

B.E., Cohen D., Radiano R., Naveh P.,Nikkhu-Abeles R., Hagbi V., Kachta O.,

Yaffe A. & Miaskowski C. (2008) Thesymptom experience of oncology outpa-tietns has a different impact on quality-of-life outcomes. Journal of Pain andSymptom Management 35, 162–170.

Redeker N.S., Lev E.L. & Ruggiero J. (2000)Insomnia, fatigue, anxiety, depression,and quality of life of cancer patients

undergoing chemotherapy. Scholarly Inquiry for Nursing Practice 14, 275–290.

Savard J. & Morin C.M. (2001) Insomnia inthe context of cancer: a review of aneglected problem. Journal of ClinicalOncology 19, 895–908.

Servaes P., Verhagen C. & Bleijenberg G.(2002) Fatigue in cancer patients duringand after treatment: prevalence, corre-lates and intervention. European Journalof Cancer (Oxford, England: 1990) 38,27–43.

Shi Q., Smith T.G., Michonski J.D., SteinK.D., Kaw C. & Cleeland C.S. (2011)Symptom burden in cancer survivors 1year after diagnosis: a report from theAmerican Cancer Society’s studies ofcancer survivors. Cancer 117, 2779–2790.

Smith M.T. & Haythornthwaite J.A. (2004)How do sleep disturbance and chronicpain inter-relate? Insights from the longi-tudinal and cognitive-behavioral clinicaltrials literature. Sleep Medicine Reviews

8, 119–132.Snyderman D. & Wynn D. (2009) Depres-

sion in cancer patients. Primary Care 36,703–719.

So W.K.W., Marsh G., Ling W.M., LeungF.Y., Lo J.C., Yeung M. & Li G.K. (2009)The symptom cluster of fatigue, pain,anxiety, and depression and the effect onthe quality of life of women receivingtreatment for breast cancer: a multi-center study. Oncology Nursing Forum36, E205–E214.

Spiegel D., Sands S. & Koopman C. (1994)Pain and depression in patients withcancer. Cancer 74, 2570–2578.

Stepanski E.J., Walker M.S., SchwartzbergL.S., Blakely L.I., Ong J.C. & Houts A.C.(2009) The relation of trouble sleeping,depressed mood, pain, and fatigue inpatients with cancer. Journal of Clinical

Sleep Medicine 5, 132–136.Stone P., Richards M. & Hardy J. (1998)

Fatigue in patients with cancer. EuropeanJournal of Cancer (Oxford, England:

1990) 34, 1670–1676.Stone P., Richardson A., Ream E., Smith

A.G., Kerr D.J. & Kearney N. (2000)Cancer-related fatigue: inevitable, unim-portant and untreatable? Results of amulti-centre patient survey. Annals of Oncology 11, 971–975.

Tavoli A., Montazeri A., Roshan R., TavoliZ. & Melyani M. (2008) Depression andquality of life in cancer patients with andwithout pain: the role of pain beliefs.BMC Cancer 8, 177.

Theobald D.E. (2004) Cancer pain, fatigue,distress, and insomnia in cancer patients.Clinical Cornerstone 6, S15–S21.

Wells N. (2000) Pain intensity and paininterference in hospitalized patients withcancer. Oncology Nursing Forum 27,985–991.

Yates J.W., Chalmer B. & McKegney F.P.(1980) Evaluation of patients withadvanced cancer using the KarnofskyPerformance Scale. Cancer 45, 2220–2224.

Yu C.L.M., Fielding R., Chan C.L., TseV.K., Choi P.H., Lau W.H., Choy D.T., OS.K., Lee A.W. & Sham J.S. (2000) Mea-suring quality of life of Chinese cancerpatients: a validation of the Chineseversion of the functional assessment ofcancer therapy-general (FACT-G) scale.Cancer 88, 1715–1727.

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