In our study, the items were administered in a face-to-face interview, instead of presenting the items in a self-reported questionnaire for the practical reason that an unbiased response could be achieved as the patients were from diverse socioeconomic groups and were with different literacy status. In addition, filling in a self-report questionnaire was expected to be too time consuming for the patient.
In our study, majority of the patients were post-menopausal. Stage II was the most prevalent stage. Patients suffering from fatigue formed 83%. It was more prevalent in chemotherapy group than in radiotherapy group, and in anemic group in comparison to non-anemic group. In our study, we observed a significant increase in the prevalence of fatigue after the first cycle of chemotherapy. Then, it was stable in the subsequent cycles of chemotherapy. During post-chemotherapy, the prevalence of fatigue declined. Our findings corroborate the results of the study by de Jong et al
] During chemotherapy, fatigue scores were the lowest on the day after chemotherapy in the first cycle and increased in the subsequent cycles. Findings were comparable with earlier studies.[19
] Apprehension and chemotherapy side effects, mainly nausea, may be a reason for the lowest score on day 2of the first cycle. Scores stabilized from cycle two onward. This finding supports the hypothesis that the intensity of fatigue stays stable throughout the treatment cycles. Sitzia and Huggins[6
] found similar results. A reason for the stability could be habituation to the experience of fatigue.
Sixty-eight (87%) patients needed radiotherapy supplementary to chemotherapy. Interestingly, fatigue was more prevalent in pre-radiotherapy assessment than in pre-chemotherapy assessments.
Radiotherapy pretreatment scores were significantly low in comparison to chemotherapy period, corroborating previous results by de Jong et al
] It may be due to protracted effect of chemotherapy though the mean interval of chemotherapy and radiotherapy was long (1.5 months). Radiotherapy had a cumulative effect over fatigue scores. Scores were initially increased in the first cycle from pretreatment scores, but decreased in the third cycle to their lowest values. Scores were near pretreatment values at the fourth week follow-up. Janaki et al
. found similar results.[20
] Findings in radiotherapy period are explicable. It may be a limitation of our study that patients were not admitted during radiation therapy period unlike chemotherapy. Many patients had to travel a long distance every weekday for 5 weeks to have treatment. Besides, daily routine activities had to be adjusted to the treatments. Finally, it may be the effect of radiotherapy itself or a combination of therapies that makes these patients more fatigued. After completion of radiotherapy treatment, the scores became normalized to pretreatment values. The reasoning is partially supported by the study results of Irvine et al
MID values in chemotherapy period exactly showed similar changes as found using other statistical methodologies and affirmed by previous studies.[15
] This was also true for fourth week assessment during radiotherapy and subsequent assessments, but not in early week assessments. Persistence of chemotherapy-induced changes during early weeks of radiotherapy may be a reason for this discordance.
Emotional and functional subscale scores were persistently low in the whole treatment duration, with minimal fluctuations, corroborating partly with the findings of Janaki et al
] This area should be addressed with importance during fatigue intervention.
Fatigue related to surgery and disease process itself did not influence our results because all the patients had Modified Radical Mastectomy and metastatic breast cancer patients were excluded from the study.
Anemia was the only factor that significantly influenced the scores. Anemic patients were more fatigued. More specifically, lower the hemoglobin level, lower was the score. It was true for all subscale measurements. Concentrated RBC was transfused for correction of anemia. Correction of anemia improved the scores significantly, contradicting the results by So-Osman et al
] But similar results were found by Prick et al
] Other baseline parameters were not found to influence the fatigue scores significantly unlike earlier studies.[19
Our study had few limitations. Firstly, the mean intervals between surgery and chemotherapy (3.5 months ± 13days), and chemotherapy and radiotherapy (1.5 months ± 10days) were long. Reasons for this long delay were multiple. Twenty-eight patients (36%) had their surgery done outside. Majority of those patients were referred very late and not properly staged with standard work-up protocol. Four patients (6%) had postoperative complications and initiation of chemotherapy was delayed. But there was no loco-regional or distant failure reported in the study period. Patients are being followed up for chronic fatigue assessments. Impact of this delay over survival will be evident then. Delay in initiation of chemotherapy might not influence the fatigue scores; rather it was beneficial to overcome surgery-related fatigue. But long interval between chemotherapy and radiotherapy might be a confounding factor in radiotherapy assessments.
Secondly, in this study, we intended to find out the level of fatigue only up to fourth week of post-treatment period. Patients are under long-term follow-up to evaluate the nature of chronic fatigue in them. Findings will be reported later on.
Thirdly, except for anemia correction, we did not intervene to improve the fatigue scores specially addressing emotional and functional components of the patients.