The incidence and mortality rates for gynecologic cancers continue to increase globally. Albeit limited research suggests that these patients experience a very high symptom burden. In fact, patients with gynecologic cancers reported an average of 14 co-occurring symptoms. These unrelieved symptoms have a negative impact on patients’ functional status and quality of life (QOL). Given the deleterious effects of these symptoms, detailed information on their occurrence, severity, and distress is needed to guide the development of effective symptom management interventions for these patients.Therefore, the first two aims of this dissertation were to: 1) conduct a systematic review to assess the symptom burden and determine the prevalence rates for multiple co-occurring symptoms in patients with gynecologic cancers and 2) develop a comprehensive conceptual model of energy in patients with cancer. In addition, using data from a sample of patients with gynecologic cancers (n = 233), the third and fourth aims of this dissertation were to: 3) evaluate for differences in demographic, clinical, and symptom characteristics and QOL outcomes among patients with distinct morning and evening fatigue profiles and 4) evaluate for differences in demographic, clinical, and symptom characteristics and QOL outcomes among patients with distinct morning and evening energy profiles.
In terms of Aim 1, a systematic review was done that synthesized the extant literature on multiple co-occurring symptoms in patients receiving treatment for gynecologic cancers. A total of 118 studies were included in this review. Ninety-six symptoms were assessed across these studies. Grand mean prevalence rates for the top six symptoms were: lack of energy (64.4%), fatigue (62.1%), abdominal pain (53.3%), depression (52.6%), concentration dysfunction (52.0%), and drowsiness (51.9%). Numerous methodologic challenges were evident across these studies. This review concluded with directions for future research.
In terms of Aim 2, an original comprehensive conceptual model of energy in patients with cancer, named the Multidimensional Model of Energy in Patients with Cancer (MMEPC), was developed. The MMEPC was designed to determine various factors associated with variations in energy levels using published literature from patients with cancer as well as evidence from the general population and patients with other chronic conditions. The specific concepts in the MMEPC include person factors, clinical factors, cancer-related factors, and biological factors; factors associated with energy balance; as well as the impact of co-occurring symptoms on energy levels. The model can be used to design preclinical and clinical studies of energy.
In terms of Aim 3, a latent profile analysis identified four subgroups of patients with distinct morning fatigue profiles (i.e., Low (36.1%), Changing (12.0%), High (40.7%), and Very High (11.2%)). For evening fatigue, two distinct profiles were identified (i.e., Low (28.0%) and High (72.0%)). Common demographic and clinical risk factors associated with the higher morning and evening fatigue profiles included younger age, higher body mass index, lower Karnosky Performance Status (KPS) scores, and higher self-reported comorbidity questionnaire (SCQ) scores. Higher levels of depression, sleep disturbance, and trait anxiety, as well as lower levels of cognitive function and evening energy, were associated with the worst morning and evening fatigue profiles. The worst morning and evening fatigue profiles were associated with lower QOL scores.
In terms of Aim 4, a latent profile analysis identified three latent classes of patients with distinct morning energy profiles (i.e., High (9.4%), Low (63.1%) and Very Low (27.5%)). For evening energy, two latent classes were identified (i.e., Moderate (30.6%) and Very Low (69.4%)). Higher SCQ and MAX2 scores, as well as lower levels of KPS scores, were associated with only the worst morning energy profiles. Higher levels of evening fatigue, depression, and sleep disturbance, and lower levels of cognitive function were associated with the worst morning and evening energy profiles. Lower physical component and mental component summary scores for the Medical Outcomes Study Short Form-12 and all the subscales of the Multidimensional Quality of Life Scale – Patient Version were associated with the worst morning and evening energy profiles.
Morning and evening fatigue, as well as morning and evening energy, are distinct symptoms in patients with gynecologic cancers. Increased knowledge of modifiable risk factors for fatigue and decrements in energy, as well as co-occurring symptoms, will assist clinicians to identify higher risk patients and assist with the development and testing of interventions to relieve symptom burden and improve the QOL of these vulnerable patients.
