|Year : 2019 | Volume
| Issue : 3 | Page : 645-652
Assessment of fatigability, depression, and self-esteem among head-and-neck carcinoma patients in a tertiary care hospital in South India
Nitin Joseph1, PU Prakash Saxena2, Apeksha Shettigar3, Shashidhar M Kotian1
1 Department of Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India
2 Department of Radiotherapy and Oncology, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Mangalore, Karnataka, India
3 Department of MBBS Student, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Mangalore, Karnataka, India
|Date of Web Publication||29-May-2019|
Dr. P U Prakash Saxena
Department of Radiotherapy and Oncology, Kasturba Medical College Hospital, Manipal Academy of Higher Education, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Head and Neck Carcinoma (HNCs) are the most common form of cancer in India. Patients with head-and-neck carcinomas often suffer from various distressing symptoms. The exact cause of these symptoms, as to whether disease or treatment or other factor induced, needs to be established.
Objectives: This study was done to assess fatigability, depression, and self-esteem among HNC study group before start, during, and in postradiation period and to find out the determinants of these parameters.
Materials and Methods: Seventy newly diagnosed HNC patients and equivalent number of age- and gender-matched controls were interviewed using standardized questionnaires, before start of concurrent chemoradiotherapy (CCRT). The study group patients were interviewed again in the 4th week and postcompletion of CCRT in the 7th week.
Results: Mean age of the study group was 55.1 ± 11.3 years. Three-fourth of them (52 [74.3%]) were males. Majority of them (26 [37.1%]) had oral carcinomas. Baseline fatigue (P < 0.001) and depression scores (P < 0.001) were significantly more, while self-esteem scores (P = 0.004) were significantly less among the study group compared to controls before the onset of radiation. Mean fatigue and depression scores were found to significantly increase (P < 0.001), while self-esteem scores were found to significantly deteriorate (P < 0.001) over the course of CCRT among these patients. There was significant positive correlation (P < 0.001) between fatigue and depression scores and negative correlation (P < 0.001) of these parameters with self-esteem scores before, during, and after CCRT. There was no association between age and gender of the study group with any of these parameters. Multivariate analysis showed that baseline fatigue was significant (P < 0.001) and, depression after completion of the entire course of CCRT was significantly influenced by baseline depression levels (P = 0.011).
Conclusions: Fatigue and depression need to be periodically screened among HNC study group on CCRT so as to initiate prompt remedial measures for its alleviation.
Keywords: Chemo-radiotherapy, depression, fatigue, head-and-neck carcinomas, self-esteem
|How to cite this article:|
Joseph N, Prakash Saxena P U, Shettigar A, Kotian SM. Assessment of fatigability, depression, and self-esteem among head-and-neck carcinoma patients in a tertiary care hospital in South India. J Can Res Ther 2019;15:645-52
|How to cite this URL:|
Joseph N, Prakash Saxena P U, Shettigar A, Kotian SM. Assessment of fatigability, depression, and self-esteem among head-and-neck carcinoma patients in a tertiary care hospital in South India. J Can Res Ther [serial online] 2019 [cited 2021 Jan 27];15:645-52. Available from: https://www.cancerjournal.net/text.asp?2019/15/3/645/231449
| > Introduction|| |
Head-and-neck carcinomas (HNCs) have the highest incidence rate in South-East Asian region. It is very common among Indian population and is the most common malignancy encountered in Indian males. The most common variety of HNC in India is oral carcinoma which constitutes more than 30% of all cancers with an age-adjusted incidence rate of 20/1,00,000 individuals.
Patients undergoing treatment for HNC by chemotherapy, radiation therapy, or both experience significant levels of fatigue. Cancer-related fatigue (CRF) is defined as an unpleasant feeling of physical, emotional, and cognitive tiredness which is not relieved by rest or sleep.
CRF can occur due to the disease and/or as an adverse reaction of treatment, the exact etiology of which is not known. Multiple factors such as poor nutritional status, pain, depression, anemia, disease-induced hypermetabolic state, and treatment of cancer in itself have been proposed as possible etiological factors. CRF is often underreported by patients as fatigue is believed by them to be inevitable, untreatable, and unimportant. It can also compromise the patient's compliance with treatment. Documentation of fatigue in medical records on the other hand is also not a common practice and fatigue is not effectively treated despite it being responsible for a multitude of problems in cancer patients. This is a result of professional barriers such as lack of assessment to determine the causes of fatigue. Therefore, assessment of its contributing factors becomes important for researchers.
CRF is documented to be more distressing than pain and it limits quality of life (QoL) by interfering with routine daily activities, especially among elderly patients., It has also resulted in change in employment in a number of patients. CRF thus has been linked to increased mood disturbances.
HNC may cause disfigurement of face with associated symptoms such as dysphonia, dysphagia, and halitosis causing repercussions with social relations, leading to social isolation. Thus, self-esteem might be compromised in these patients. Patients with HNC have been also found to engage in distancing to preserve self-esteem.
This study was hence done among HNC patients to assess their fatigability, depression, and self-esteem before start, during, and postconcurrent chemoradiotherapy (CCRT) period and to find out the determinants of these parameters.
| > Materials and Methods|| |
This comparative controlled cohort study was done from June to December 2015 in a private tertiary care hospital in Mangalore, Karnataka, India. The study was approved by the Ethics Committee of the Institute. Permission was then obtained from the medical superintendent.
Sample size was calculated using the formula: N = (Zα√2PQ+Zβ√P1Q1+P2Q2) 2/(P1–P2) 2. Here, P1 and P2, the proportion of cancer study group and controls with severe fatigue, were taken as 38% and 11%, respectively, based on the observations of a previous study. Sample size was calculated as 70 each among study and control groups, keeping the power of the study as 95%.
The study group comprised of all incident cases of head-and-neck squamous cell carcinomas from Stage I to Stage IV B admitted at this hospital for radical chemo-radiotherapy. Only cases aged above 18 years were enrolled in this study by convenience sampling method. Cases which were very advanced/metastatic, terminally ill, with cognitive impairments, and unable to talk were excluded from this study.
Patients received weekly cisplatin at 40 mg/m 2 or carboplatin area under the curve 1.5 as a radiation sensitizer. There were 2 patients in this study group who were not eligible for receiving cisplatin/carboplatin due to poor performance status/poor renal function, who received oral gefitinib instead.
Patients were treated on ELEKTA COMPACT Linear accelerator using three-dimensional conformal radiotherapy technique. Treatment was given 5 days per week using conventional fractionation. No unscheduled breaks were planned and 67 patients were able to complete their treatment. Two patients refused further treatment midway during the therapy and one patient expired toward the end due to treatment-related complications.
The total dose administered was 70 Gy in 35 fractions over 7 weeks.
All patients received the same symptomatic and nutritional support. Pain control was delivered as per the WHO pain ladder.
For each case, a matched control from the same hospital was enrolled in this study. Controls were ascertained for absence of cancer by ruling out danger symptoms and signs of the disease among them. Controls with a past history of cancer or with any history of mental illness were excluded from this study. Once a case was enrolled in this study, a 5-year age- and gender-matched control was identified from the outpatient register (purposive sampling method). This patient was then approached by the investigator in the patient waiting area and, if eligible and consenting, he/she was interviewed in a private room.
All participants be it in study or control group gave a written informed consent before being enrolled in this study.
Fatigue was assessed for the current period using revised Piper Fatigue Scale. It comprises 22 items in different dimensions to assess subjective fatigue: behavioral/severity dimension (items 2–7), affective dimension (items 8–12), and sensory/psychological dimension (items 13–23). Each item is scored from 0 to 10, with higher scores indicating greater fatigue. To reach the total score, the average of items 2–23 was calculated. Besides these 22 items, there were five additional open questions (item 1 and items 24–27), which were not included in instrument score calculations.
Scores zero indicated none, 1–3 mild, 4–6 moderate, and 7–10 as severe level of fatigue.
Depression was assessed using Patient Health Questionnaire-9 for the period pertaining to the previous 2 weeks. It was a 9-item questionnaire. Each item was scored from 0 (”not at all”) to 3 (”nearly every day”). Depression levels of none, minimal, mild, moderate, moderately severe, and severe were assessed at cutoff scores 0, below 5, below 10, below 15, below 20, and between 20 and 27, respectively.
Self-esteem for the current period was assessed using the Rosenberg Self Esteem scale which comprised 10 items. Each item was designed in a Likert scale with 3 points for “strongly agree,” 2 for “agree,” 1 point for “disagree,” and no point for “strongly disagree.” Reverse scoring was done for the negatively worded items. Cumulative score below 15 was suggestive of low self-esteem among participants.
These scales were content and language validated for the settings by experts. Data were collected by interviewing each patient in the local language “Kannada” using the “Kannada” version of all instruments. The interview schedule was pretested before its use in the study.
The Cronbach's alpha value of internal consistency of the fatigue, depression, and self-esteem assessment questionnaires was 0.821, 0.774, and 0.81, respectively, indicating good reliability.
The study group were interviewed on three occasions, namely at the start of CCRT before the 1st week, midway during the course of CCRT in the 4th week, and after completion of CCRT in the 7th week. The study group took consultation initially from the treating radiation oncologist. Following enrollment, the investigator interviewed them in the ward after the doctor's visit. All responses were given by the patient himself/herself in person and not by surrogates, and no “ad hoc” translation of questions or items was permitted.
The controls were assessed for fatigue, depression, and self-esteem only once by the investigator.
Information on sociodemographic details, medical history, and treatment details were also inquired from all the participants. Data were entered and analyzed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA).
Bivariate analysis was done using Chi-square test, two-tailed paired t-test, two-tailed unpaired t-test, Gamma test, analysis of variance, Bonferroni t-test, and Karl Pearson's coefficient of correlation. Multivariate analysis using Binary logistic regression analysis and generalized linear model were used to identify the independent association of determinants. P ≤ 0.05 was taken as cutoff for significant association.
| > Results|| |
The mean age of the study group in this study was 55.1 ± 11.3 years with age ranging from 27 to 80 years. The mean age among controls was 54.9 ± 11.5 years with age ranging from 25 to 80 years. About three-fourth of the study group were males 52 [74.3%] and most of them (65 [92.9%]) were married. Illiteracy status (P < 0.001) and unskilled occupational status (P = 0.001) were seen significantly more among the study group. Close to three-fourth of the study group 51[72.9%] were from rural areas (P = 0.001) [Table 1].
The mean duration of carcinoma among the study group was 4.1 ± 2.3 months. More than one-third of the HNC study group (26 [37.1%]) had carcinoma of the lip and oral cavity. Majority of the study group 45 [64.3%] were in Stage IV A of the disease. All the study group participants underwent CCRT. The six patients who were in early-stage HNC (Stage I or II) were either medically inoperable or had refused surgery as a treatment option and therefore were given chemo-radiation as a curative treatment [Table 2].
Among the 70 controls, majority suffered from hypertension (37 [52.9%]) followed by diabetes mellitus (16 [22.9%]). Greater proportion of the study group had higher level of fatigue, depression, and low self-esteem than controls even before the start of CCRT. The proportion of study group with severe fatigue, depression, and poor self-esteem was found to increase among the study group with progress of CCRT over the 7-week treatment period [Table 3].
|Table 3: Association between duration and level of fatigue, depression, and self-esteem between cases and controls before, during, and after concurrent chemoradiotherapy|
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The baseline mean fatigue scores among the study group was 2.8 ± 2.4 compared to 0.4 ± 0.8 among controls (t = 7.697, P < 0.001). The baseline mean depression scores among the study group was 3.6 ± 4.5 compared to 0.97 ± 1.3 among controls (t = 4.767, P < 0.001). The baseline mean self-esteem scores among the study group was 19.8 ± 3.2 compared to 21.6 ± 3.98 among controls (t = 2.954, P = 0.004).
Mean fatigue and depression scores were found to significantly increase, while self-esteem score was found to significantly decrease (P < 0.001) between 4th and 0th week and between 7th and 0th week of treatment [Table 4].
|Table 4: Distribution of fatigue, depression, and self-esteem scores before, during, and after the course of concurrent chemoradiotherapy among head and neck carcinoma patients|
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There was a significant positive correlation (P < 0.001) of fatigue scores with depression scores before (r = 0.696), during (r = 0.698), and after the course of CCRT (r = 0.778). There was a significant negative correlation (P < 0.001) of fatigue scores with self-esteem scores before (r = −0.424), during (r = −0.443), and after the course of CCRT (r = −0.608). There was a significant negative correlation (P < 0.001) of depression scores with self-esteem scores before (r = −0.425), during (r = −0.503), and after the course of CCRT (r = −0.578).
There was no association of mean fatigue scores (F = 0.693, P = 0.630), mean depression scores (F = 0.191, P = 0.965), and mean self-esteem scores (F = 0.691, P = 0.632) with age distribution among study group before the start of CCRT.
Similarly, there was no significant gender-wise distribution of fatigue (t = 1.25, P = 0.216), depression (t = 1.488, P = 0.141), or self-esteem scores (t = 0.695, P = 0.489) before the start of CCRT.
The gap between fatigue, depression, and self-esteem scores was found to be maximum between beginning and completion of CCRT, indicating significant impact of chemoradiation. Intercomparison of these factors between the various observation intervals was done using Bonferroni t-test [Table 5].
|Table 5: Distribution of mean difference in fatigue scores at different time intervals of concurrent chemoradiotherapy in head-and-neck carcinoma patients|
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After adjusting the confounding effect of depression (P = 0.659) and poor self-esteem (P = 0.991) using binary logistic regression analysis, only fatigability was found to be significant among the study group before the start of CCRT (adjusted odds ratio = 1.481, 95% CI 1.337–1.686, P < 0.001) [Table 6].
|Table 6: Binary logistic regression analysis of fatigue, depression, and self-esteem scores before the onset of concurrent chemoradiotherapy among head-and-neck carcinoma patients (n = 70)|
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Using generalized linear model, pretreatment levels of depression probably induced by cancer were found to influence the levels of depression in the post-CCRT period (at the end of 7th week) among study group (P = 0.011). However, pretreatment levels of fatigability and poor self-esteem induced by cancer did not influence post-CCRT levels of any of these parameters [Table 7].
|Table 7: Multivariate analysis showing the association of concurrent chemoradiotherapy on fatigability, depression, and self-esteem after adjusting the confounding effect of carcinoma-induced effect on these parameters among cases (n=67)|
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| > Discussion|| |
CRF has been reported any time after diagnosis till about 10-year period postdiagnosis., Therefore, the number of survivors with CRF has been found to increase as the treatment for cancer advances. The distress caused by fatigue has been reported to obscure the hope toward recovery in patients on treatment for cancer.
In this study, 46 (65.7%) patients had fatigue and 50 (71.4%) patients suffered from depression before the start of treatment. This could probably be disease induced due to the hypermetabolic state created by it, resulting in inadequate energy supply to organ systems. The associated muscle wasting could also contribute to baseline fatigability. Associated symptoms seen commonly among HNC patients such as pain, dysphagia, and dysphonia, in addition to the diagnosis itself, might have contributed to the onset of baseline depression in the study group.
In this study, fatigue scores were found to significantly increase during and after CCRT. This was similar to observations made among HNC study group in other studies, where fatigue increased during the course of treatment.,,, Wan Leung et al. also observed that fatigue was the most prevalent symptom among HNC after radiotherapy. This is probably a consequence of radiation-induced DNA damage.
In order to cope up with fatigue, educating patients on strategies to conserve energy, practicing relaxation breathing, balancing activity, and rest, incorporating good nutritional practices, and using distractors such as listening to music are suggested rather than dependence on medications.,,
Moreover, treating the underlying comorbidities such as anemia, malnutrition, infection, dehydration, pain, depression, insomnia, and hormonal insufficiency added with the management of side effects of CCRT which contributes to fatigue should also be considered. Training patients in self-monitoring of fatigue levels using a diary would also help them to realize time intervals when their energy levels tend to reduce so that they plan their day accordingly.
In this study, depression scores were also found to increase with the course of CCRT as also reported among HNC cases in a study done in Brazil. This can be attributed to cumulative effect of difficulties in swallowing (due to chemoradiation-induced mucositis/pain) and breathing and communication difficulties along with other CCRT side effects, which are progressive in nature during the course of treatment.
Depression in cancer can lead to further problems such as poor treatment adherence, thereby complicating treatment and resulting in less desirable outcomes. Therefore, periodic screening of depression followed by psychological counseling for the affected should be offered during the course of treatment.
A study done in Japan  reported 16.8%, while a Canadian study  reported 20% of HNC study group to be depressed during the course of treatment, which was lesser than our observations. The greater proportion in these settings compared to developed countries could be due to late stage of diagnosis, usage of substances of abuse, lower education and socioeconomic background, and poor social networking behavior. Role of social support is very vital as it improves emotional adaptation  and reduces depressive symptoms  in HNC study group.
In a systematic review involving studies on HNC study group from different parts of India, use of exercise interventions was found to alleviate anxiety and depression, thereby improving QoL during their course of treatment. These exercise interventions constituted yoga, speech therapy, and physiotherapy-based interventions. Yoga-based interventions focus on breathing control and on integration of mind and body. This could be thus useful in reducing complications of primary cancer-related therapies among HNC survivors. The speech therapy involves use of various exercises to be used even before initiation of CCRT among HNC study group. This was found to improve speech and language proficiency, intelligibility, voice quality, and oromotor and deglutition functions.
Use of complementary therapies and pharmacological therapies with antidepressants and tranquilizers should be considered finally after a thorough assessment of physical, emotional, and social condition of patients. Palliative care with its physical, psychological, social, and spiritual dimensions fulfills all these requirements and hence would be ideal in control of depression and to optimize QoL among cancer patients.
There was significant positive correlation between fatigue scores with depression scores among carcinoma patients at start, during, and after treatment with CCRT as also observed among HNC study group by Sawada et al. This meant that interventions to reduce fatigue during management would also reduce depression among HNC study group. On the contrary, Spratt et al. found no correlation of fatigue and depression scores among HNC study group during the course of treatment.
Self-esteem component was observed to be significantly less among carcinoma patients compared to controls in this study. Its level was also found to progressively deteriorate with progress of CCRT. This can be explained by the fact that irradiation causes progressive worsening of skin condition leading to darkening and sometimes desquamations, which catch the attention of these patients every day. Moreover, radiation markers placed over the skin would make them feel “branded.”
The self-esteem scores were also found to deteriorate with increase in fatigue or depression scores among HNC study group before, during, or after CCRT. Similarly, another study done in the Netherlands found self-esteem and social support levels to deteriorate with higher levels of depression, on regression analysis, among cancer patients.
In this study, preradiation fatigue levels were not influencing postradiation fatigue levels on treatment completion among HNC study group in multivariate analysis, which was different from the observations of other studies.,, This could be attributed to the fact that good nutritional status was maintained among the study group at this tertiary care setting. All the patients received nutritional support as per dietician's advice. Wherever oral intake was found inadequate due to any reason including that due to tumors, they were supplemented by Ryle's tube or percutaneous endoscopy gastrostomy tube feeding.
In addition to this symptomatic treatment, psychological support is offered to our patients as and when necessary which has helped in alleviating fatigue levels after treatment.
However, pretreatment depression was found to be a significant predictor of depression in post-CCRT period among HNC study group, which emphasizes the need of psychological counseling services soon after the diagnosis of cancer. A study done in Amsterdam, Netherlands, found that pretreatment depression was also a significant predictor of posttreatment fatigue among patients with different types of cancers including HNCs.
| > Conclusions|| |
Baseline fatigability was significant among the HNC study group. Given the fact that it can affect working capacity and activities of daily living, assessment and management of the same using measures such as cognitive behavioral therapy and graded exercise therapy is a must.
Pretreatment depression was found to be significant predictor of depression post-CCRT among HNC study group. Hence, care providers need to periodically screen HNC patients for depression soon after diagnosis and during the radiotherapy session. This should be followed by provision of treatment and appropriate rehabilitation program targeted at alleviating depression. In addition, patients should be educated to discuss fatigue and depression with medical professionals at the beginning of treatment itself so as to initiate prompt remedial measures to reduce these symptoms during the course of treatment. These measures will enable a better QoL among HNC patients in the settings.
This being a hospital-based study, there may be chances of selection bias. The study and control groups may not be representative of a specified geographic area. Few other factors such as tobacco or alcohol use, comorbidities, sleep pattern, and dietary habits which could also influence parameters such as fatigue could not be assessed due to time constraints. The assessment of study group during follow-up visits after completion of CCRT was not a part of this study. This was because a number of our patients come from far off rural areas who are often lost on follow-up after completion of CCRT. Hence, we are not in a position to comment about the changes in fatigue, depression, and self-esteem scores beyond assessment period of this study.
Since controls were not inpatients, subsequent follow-up during the assessment period could not done among them. Despite these limitations, a unique aspect of this study was that it focuses on a particular type of cancer patients who were on homogeneous treatment modality. The controls were matched both for age and gender with that of study group. These measures resulted in minimal confounding variables influencing the associated risk factors. Furthermore, use of standardized instruments to assess fatigue, depression, and self-esteem further improved the validity of findings. The results of the study are thus believed to contribute to improvement in patient care among HNC study group in the settings.
The authors thank Medical Superintendent of Kasturba Medical College Hospital, Attavar, Mangalore, India, for permitting us to do this study.
Financial support and sponsorship
This study was financially supported by Manipal University research grants.
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A, et al.
Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108.
Mishra A, Meherotra R. Head and neck cancer: Global burden and regional trends in India. Asian Pac J Cancer Prev 2014;15:537-50.
Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al.
Effect of screening on oral cancer mortality in Kerala, India: A cluster-randomised controlled trial. Lancet 2005;365:1927-33.
Hofman M, Ryan JL, Figueroa-Moseley CD, Jean-Pierre P, Morrow GR. Cancer-related fatigue: The scale of the problem. Oncologist 2007;12 Suppl 1:4-10.
Stasi R, Abriani L, Beccaglia P, Terzoli E, Amadori S. Cancer-related fatigue: Evolving concepts in evaluation and treatment. Cancer 2003;98:1786-801.
Curt GA, Breitbart W, Cella D, Groopman JE, Horning SJ, Itri LM, et al.
Impact of cancer-related fatigue on the lives of patients: New findings from the fatigue coalition. Oncologist 2000;5:353-60.
Piper BF, Borneman T, Sun VC, Koczywas M, Uman G, Ferrell B, et al.
Cancer-related fatigue: Role of oncology nurses in translating national comprehensive cancer network assessment guidelines into practice. Clin J Oncol Nurs 2008;12:37-47.
Sawada NO, de Paula JM, Sonobe HM, Zago MM, Guerrero GP, Nicolussi AC, et al.
Depression, fatigue, and health-related quality of life in head and neck cancer patients: A prospective pilot study. Support Care Cancer 2012;20:2705-11.
Devins GM, Wong JC, Payne AY, Lebel S, Lee RN, Mah K, et al.
Distancing, self-esteem, and subjective well-being in head and neck cancer. Psychooncology 2015;24:1506-13.
Servaes P, Verhagen S, Bleijenberg G. Determinants of chronic fatigue in disease-free breast cancer patients: A cross-sectional study. Ann Oncol 2002;13:589-98.
Wu HS, Davis JE. Definition, prevalence and characteristics of sudden exhaustion: A possible syndrome of fatigue in cancer? Support Care Cancer 2013;21:609-17.
Benzein EG, Berg AC. The level of and relation between hope, hopelessness and fatigue in patients and family members in palliative care. Palliat Med 2005;19:234-40.
Jereczek-Fossa BA, Santoro L, Alterio D, Franchi B, Fiore MR, Fossati P, et al.
Fatigue during head-and-neck radiotherapy: Prospective study on 117 consecutive patients. Int J Radiat Oncol Biol Phys 2007;68:403-15.
de Graeff A, de Leeuw JR, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA, et al.
Pretreatment factors predicting quality of life after treatment for head and neck cancer. Head Neck 2000;22:398-407.
Spratt DE, Sakae M, Riaz N, Lok BH, Essandoh S, Hsu M, et al.
Time course and predictors for cancer-related fatigue in a series of oropharyngeal cancer patients treated with chemoradiation therapy. Oncologist 2012;17:569-76.
Wan Leung S, Lee TF, Chien CY, Chao PJ, Tsai WL, Fang FM, et al.
Health-related quality of life in 640 head and neck cancer survivors after radiotherapy using EORTC QLQ-C30 and QLQ-H &; N35 questionnaires. BMC Cancer 2011;11:128.
Anderson P, Dean G, Piech M. Fatigue. In: Ferrell B, Coyle N, editors. Oxford Textbook of Palliative Nursing. 3rd
ed. New York: Oxford University Press; 2010. p. 187-209.
Jereczek-Fossa BA, Marsiglia HR, Orecchia R. Radiotherapy-related fatigue. Crit Rev Oncol Hematol 2002;41:317-25.
Kugaya A, Akechi T, Okuyama T, Nakano T, Mikami I, Okamura H, et al.
Prevalence, predictive factors, and screening for psychologic distress in patients with newly diagnosed head and neck cancer. Cancer 2000;88:2817-23.
Katz MR, Kopek N, Waldron J, Devins GM, Tomlinson G. Screening for depression in head and neck cancer. Psychooncology 2004;13:269-80.
Rapoport Y, Kreitler S, Chaitchik S, Algor R, Weissler K. Psychosocial problems in head-and-neck cancer patients and their change with time since diagnosis. Ann Oncol 1993;4:69-73.
De Leeuw JR, De Graeff A, Ros WJ, Hordijk GJ, Blijham GH, Winnubst JA, et al.
Negative and positive influences of social support on depression in patients with head and neck cancer: A prospective study. Psychooncology 2000;9:20-8.
Samuel SR, Veluswamy SK, Maiya AG, Fernandes DJ, McNeely ML. Exercise-based interventions for cancer survivors in India: A systematic review. Springerplus 2015;4:655.
Schroevers MJ, Ranchor AV, Sanderman R. The role of social support and self-esteem in the presence and course of depressive symptoms: A comparison of cancer patients and individuals from the general population. Soc Sci Med 2003;57:375-85.
Smets EM, Visser MR, Willems-Groot AF, Garssen B, Oldenburger F, van Tienhoven G, et al.
Fatigue and radiotherapy: (A) experience in patients undergoing treatment. Br J Cancer 1998;78:899-906.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]