Accurate diagnosis of CRF is important to guide treatment. Researchers propose that 4 criteria be considered to establish the diagnosis of CRF, including (1) a period of 2 weeks or longer within the preceding month during which significant CRF or diminished energy was experienced each day or almost every day along with additional CRF-related symptoms; (2) the experience of CRF resulting in significant distress or impairment of function; (3) the presence of clinical evidence suggesting that CRF is a consequence of cancer or cancer therapy; and (4) fatigue is not primarily a consequence of a concurrent psychiatric condition, such as major depression.12 Before the diagnosis of CRF is made, it is important that the results of a full medical workup rule out other causes of fatigue such as anemia, endocrine dysfunction, or fatigue directly related to prescription medication. The standardization and comprehensive fatigue assessment guidelines and criteria for clinical practice developed by National Comprehensive Cancer Network (NCCN) were prepared to improve assessment and management of CRF. This review provides evidence to consider when determining the most valid and reliable tools to screen for and assess CRF.
This systematic review resulted in 3 highly recommended unidimensional tools and a single multidimensional tool to screen for or measure CRF. These tools have strong psychometric properties in the population of interest and can be easily used by clinicians. Several other tools are recommended; these have good psychometric properties in the population of interest and are clinically feasible.
Among the unidimensional tools that are either rated 3 or 4 by this task force, the use of a 10-point Rating Scale of Fatigue stands out as the most efficient method to screen for the presence of CRF. An understanding of Numeric Rating Scales (NRSs) and Visual Analog Scales (VASs) is warranted when considering this tool. Numeric Rating Scales, where 0 (absence of a construct) and 10 (worst imaginable experience of a construct) are commonly used clinically to assess the severity of symptoms and most commonly used for pain assessment. The VAS, too, is a frequently employed tool to measure severity of symptoms and consists of a 100-mm line, with markings from 0 to 100 every 10 mm along the line. In evaluating the literature, the authors found a total of 11 studies that used either the NRS or the VAS in examining psychometric qualities of instruments evaluating fatigue. Further analysis of these research studies reveals that the term “NRS” is often used to mean VAS (a written expression of severity); in one case, the VAS was converted to an NRS for telephone interviewing yet was not identified as an NRS in study methodology. While this overlap of terms and rating techniques results in inconsistencies in administration, the overall intent of both methods is based on the premise of rating severity as low to high on a 10-point scale. In the literature search completed by this task force, these 10-point scales had multiple names: NRS for Fatigue, VAS for Fatigue, the One-Item Fatigue Scale, the Single-Item Screening Tool, and the Fatigue Numerical Scale.
The simplicity of a 10-point Numeric Rating Scale for Fatigue makes it an ideal screening tool. The question, “How would you rate your fatigue on a scale of 0 to 10, with 0 being no fatigue and 10 being the worst possible fatigue?” whether verbally or along a 100-mm line, is quick and focused. This simple question captures the presence and intensity of fatigue and can be easily used to drive a referral for greater assessment.2 The simplistic nature of the question belies the strength of the psychometric properties, which demonstrate good test-retest reliability (r = 0.88) and convergent validity with the Fatigue Symptom Index, the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F), and the Multidimensional Fatigue Inventory (general fatigue).31–33 This tool also demonstrates moderate to good sensitivity (0.70-0.85) and specificity (0.61-0.71).31 , 34 The NCCN Guidelines for CRF recommend a referral with a score of 4 or greater.2 While the NCCN Guidelines are most frequently followed, an empirical cutoff score of 5 was derived by taking into consideration an analysis of specificity and sensitivity and based on the area under the curve (0.71).34 Given that the ease and level of efficiency in administration is high, a 10-point Rating Scale for Fatigue receives a highly recommended score by the task force and is an ideal screening tool.
Both the mBFI and the Cancer-Related Fatigue Distress Scale, while unidimensional, are more time-intensive, which may discourage their use to screen for fatigue. The mBFI examines the severity and effect of fatigue on daily functioning in the previous 24 hours through a 9-item questionnaire that can be administered via self-report, interview, or interactive voice recording. Each item is rated 0 to 10, and a global score of fatigue is the average of all items. The mBFI has good to excellent test-retest reliability (0.89-0.95)81 and demonstrates both construct validity with the Multidimensional Fatigue Inventory (Short Form) (r = 0.814)81 and concurrent validity with the FACIT-F scale (r = −0.838 to 0.903).82 The Cancer-Related Fatigue Distress Scale assesses the dimension of distress related to fatigue and examines this in terms of physical, social, psychological, cognitive, and spiritual areas. This 20-item self-report scale evaluates statements on a 0 to 10 scale; higher numbers indicate greater distress.28 The Cancer-Related Fatigue Distress Scale demonstrates excellent item consistency (α = 0.98), good convergent validity with the Wu Cancer Fatigue Scale (r = 0.84), as well as good predictive validity (r = 0.83).83 Understanding the effect of fatigue and the distress experienced can guide clinicians in treatment decisions.
The MD Anderson Symptom Inventory and the Wu Cancer Fatigue Scale, while recommended by the task force, do not possess the strengths of psychometric properties or ease of use that the highly recommended measures possess. The MD Anderson Symptom Inventory is a 19-item self-report scale that examines severity and interference of CRF; higher scores indicate greater levels of fatigue.35 This scale demonstrates acceptable levels of convergent validity with the Brief Fatigue Inventory (r = 0.84) but lower levels with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30 (EORTC QLQ-C30) (r = −0.60) and lacks sensitivity to change.36 The Wu Cancer Fatigue Scale scores 9 items on a 1- to 5-point Likert scale, with higher values indicating greater fatigue.29 The internal consistency of items is high (α = 0.95),30 but the convergent, concurrent, and predictive validity levels are lower (see Tables 5 and 6). Both are acceptable for use, as they take less than 10 minutes to complete; however, a 10-point Rating Scale for Fatigue remains a better screening tool and the mBFI a stronger unidimensional tool for assessing CRF.
The only highly recommended multidimensional fatigue tool recommended by the Cancer EDGE Task Force, the Multidimensional Fatigue Symptom Inventory (Short Form), examines fatigue in the context of global, somatic, cognitive, and behavioral manifestations across general, physical, emotional, and mental domains.38 , 39 This scale, with 30 self-reported items, takes less than 10 minutes to complete, with each item scored on a 5-point Likert scale; higher numbers indicate greater fatigue. The Multidimensional Fatigue Symptom Inventory provides a comprehensive examination of fatigue across multiple domains, with a high sensitivity to change and an ability to discriminate not only between those with and without fatigue but also among those with differing levels of function due to fatigue,38 and demonstrates moderate to high correlations with other established scales (Fatigue Symptom Inventory, r = 0.82 and SF-36 [36-item Medical Outcomes Questionnaire Short Form], r = −0.82).39
Limitations to this review need to be noted as the clinician uses this information to inform practice. As with all reviews, new data may become available after completion of the literature search and are not included here. This review does not assess study quality, and it is possible that psychometric evaluation is based on small sample sizes or studies with methodological flaws. Finally, while this review is intended to evaluate measures to assess CRF, some fatigue instruments lack validation in the cancer population.
Cancer-related fatigue remains one of the most prevalent comorbidities of a cancer diagnosis along the survivorship continuum. As such, knowing the fatigue status of survivors is essential to design appropriate and comprehensive treatment plans and to monitor patient status and the effectiveness of those treatment programs. While this review defines reliable, valid, and clinically useful tools for use in screening for and assessing CRF, clinicians need to consider whether the tool will be used for screening or for assessment. By combining the findings from this investigation with patient needs, appropriate referral and intervention can occur.
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