Professional Documents
Culture Documents
doi:10.1093/annonc/mdn537
Published online 4 August 2008
Received 9 April 2008; revised 16 May 2008; revised 27 June 2008; accepted 30 June 2008
Background: Fatigue in cancer is very common and can be experienced at all stages of disease and in survivors.
There is no accepted definition of cancer-related fatigue (CRF) and no agreement on how it should be measured. A
review
into CRF.
Methods: A systematic review methodology was used to identify scales that have been validated to measure CRF.
The inclusion criteria required the scale to have been validated for use in cancer patients and/or widely used in this
population. Scales also had to meet a minimum quality score for inclusion.
Results: The reviewers identified 14 scales that met the inclusion criteria. The most commonly used scales and best
validated were the Functional Assessment of Cancer Therapy Fatigue (FACT F), the European Organisation for
Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) (fatigue subscale) and the Fatigue
Questionnaire (FQ).
Conclusions: Unidimensional scales are the easiest to administer and have been most widely used. The authors
recommend the use of the EORTC QLQ C30 fatigue subscale or the FACT F. The FQ gives a multidimensional
assessment and has also been widely used. A substantial minority of the scales identified have not been used
extensively or sufficiently validated in cancer patients and cannot be recommended for routine use without further
validation.
Key words: cancer-related fatigue, measurement scales, systematic review
ª The Author 2008. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
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review Annals of Oncology
populations and have then independently validated their use in Table 1. Explanation of psychometric properties of an ideal scale (on the
patients with cancer. These scales can differ widely in the basis of Norman & Streiner [6, 7])
number of items that they contain, the dimensions of CRF that
they cover (e.g. physical, affective and cognitive) and their Psychometric evaluation
psychometric properties. Internal consistency Do items within the scale correlate
In the light of this multiplicity of different assessment with each other and with the total score?
methods, we undertook a review to identify which scales have This is usually measured by Cronbach’s
been best validated and to make recommendations about which alpha. A low value indicates a poor
instruments should be used in research and/or in routine consistency of items; a very high score
clinical practice. indicates item redundancy.
Test–retest reliability Does the scale provide a similar score
when administered to the same population
in the same setting at different times?
methods Discriminant validity Does the scale distinguish between groups
A systematic methodology was used. The following terms were used expected to have differing levels of
to search Medline, CINAHL and Psychinfo (1950—week 1 fatigue, e.g. cancer patients and a
February 2008): control population.
Responsiveness to change Does the scale measure change during the
1 exp ‘‘Outcome Assessment (Health Care)’’/ course of an intervention that alters the
Scale name BFI [18] EORTC QLQ FSS [20] FACT F [21] POMS F [22]
(FS) [19]
Number of items 9 3 9 13 7
Scale type Numerical Likert Numerical Numerical Likert
Population studied in Mixed cancer Three populations: Chronic illness Mixed cancer Mixed work
original validation study lung cancer, bone population patients on population and
marrow transplant, treatment psychiatric patients
metastatic cancer
Internal consistency 0.96 0.80–0.85 0.96 0.95 0.90–0.94
Dimensions fatigue Physical Physical Physical Physical Physical functioning
covered functioning functioning functioning functioning
Test & retest reliability – – Subset 87 patients, r = 0.90 r = 0.66 (12–16
3/52 later (3–7 days later) weeks later)
measurement,
error 4.7 units
Known group comparison Distinguished Distinguished Distinguished CRF Distinguished Distinguished between
(discriminant validity) CRF from between local versus healthy between three known chronic fatigue
Where internal consistency—Cronbach’s alpha unless otherwise stated; convergent validity—Pearson’s correlation value unless otherwise stated. A, active
treatment population; P, palliative care population; S, disease-free survivors; CRF, cancer-related fatigue. Scale abbreviations: BFI, Brief Fatigue Inventory;
EORTC QLQ C30 FS, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Fatigue subscale; FSS, Fatigue Severity
Scale; FACT F, Functional Assessment of Cancer Therapy Fatigue subscale; POMS F, Profile of Mood States Fatigue subscale.
a
This involved cross-referencing studies in Medline and Web of Science and identifying studies in cancer where the scale has been used
subsequently.
The Profile of Mood States [29] was originally used as The Chalder Fatigue Scale—also known as the Fatigue
a measure of workforce health. It contains a number of scales Questionnaire (FQ) [33]—is an 11-item scale that was
including a fatigue subscale of seven items which has been originally validated in a general practice setting. However, its
independently examined in both a non-cancer [30] and main use has been in the investigation of chronic fatigue
a cancer population [31]. It has also been used to provide syndrome. It is brief and easy to administer while still covering
convergent validity in the validation of a number of other scales two aspects of fatigue (mental and physical). It has been used in
used in CRF. It has a defined minimum clinically significant population studies and so has normative data available for
difference [32]. Its extensive use in studies has meant there comparison with cancer patients [34, 41].
are ample data available to recommend its continued use in The Fatigue Symptom Inventory (FSI) [35] is a 13-item scale
this setting. that was originally validated in a breast cancer population. A
subsequent validation study involved 342 mixed cancer patients
multidimensional scales [42]. It has reasonable psychometric properties but there is
There were nine scales included in this category. Full details of a question over its test–retest reliability. It has been used in
these scales can be found in Table 3. a number of studies but with overall small numbers of patients.
Table 3. (Continued)
Convergent validity VASF, r = 0.77 Short form 36, MFI subscale POMS F—not Schwartz CFS,
(against other scales) r = 0.55; FSI, r = 0.74 r = 0.84 quantified r = 0.84
Number of participants 111 cancer patients 275 382 166 82
tested in original (1200 controls)
validation
Populations studied A/P/S A/S (breast only) A/S (breast only) A only A (breast only)
(active/palliative/
survivors)
Approximate number >20 (2000) 3 (380) 9 (800) 2 (300) 1 (170)
of further cancer
studies and participantsa
Where internal consistency—Cronbach’s alpha unless otherwise stated; convergent validity—Pearson’s correlation value unless otherwise stated.
MCID, minimum clinically important difference; POMS F, Profile of Mood States Fatigue subscale; A, active treatment population; P, palliative
care population; S, disease-free survivors. Scale abbreviations: FQ, Fatigue Questionnaire; FSI, Fatigue Severity Inventory; VASF, Visual Analogue
Scale for Fatigue; MAF, Multidimensional Assessment of Fatigue; MFI-20, Multidimensional Fatigue Inventory; MFSI-30, Multidimensional Fatigue
Symptom Inventory short form; PFS, Piper Fatigue Scale (revised); Schwartz CFS, Schwartz Cancer Fatigue Scale; Wu CFS, Wu Cancer
Its areas of measurement have been limited to patients properties; however, its use in clinical studies has been
undergoing active treatment and survivors. somewhat limited. There have only been two additional studies
The Lee fatigue scale (or Visual Analogue Scale for reporting its use in breast cancer survivors.
Fatigue—VASF) [36] is an 18-item tool that was originally Its use beyond this group will require further validation.
validated in a group of patients with sleep disorders. It has had The revised PFS [45] is a shorter version of the original scale
very limited use in cancer patients. Its psychometric properties [13]. Piper reported some limitations to her original fatigue
were assessed in a sample of 212 mixed cancer patients scale [13] and she went on develop a revised version. This
undergoing treatment [31]. However, because of a potential revised scale consists of 22 items and has been validated in
overlap with measures of sleep disturbance it is not a group of breast cancer survivors [45]. There are limited data
recommended for use in CRF measurement. on the psychometric properties of the revised scale for use in
The Multidimensional Assessment of Fatigue (MAF) [43] is cancer patients although data are available in other
a 16-item scale that was originally validated in rheumatoid populations. While the scale has since been used in a small
arthritis patients. Its psychometric properties were assessed in number of studies of cancer patients, the majority of these
the same sample of cancer patients previously discussed with studies have been undertaken in breast cancer patients
respect to the VASF [31]. It was also used (as one of a number undergoing treatment and in breast cancer survivors. There are
of fatigue measures) by Morrow and colleagues in two little or no data in other cancer populations.
subsequent intervention studies examining the role of The Schwartz Cancer Fatigue Scale [46] is a 28-item scale
antidepressants in treating fatigue [10, 37]. Compared with that was validated in a mixed cancer population undergoing
other fatigue instruments included in this review, it has been treatment. Its psychometric properties were further examined
relatively poorly validated and its use in further studies cannot (along with the VASF and the MAF) in the study of 212 mixed
be recommended unless further validation work is undertaken. cancer patients discussed previously [31]. Schwartz has also
The Multidimensional Fatigue Inventory (MFI-20) [44] is determined the minimum clinically significant difference in
a 20-item scale that was designed for use in cancer patients. Its a further study [32] on 103 mixed cancer patients undergoing
original validation had a number of group comparisons treatment. We did not find any other studies that have used this
including both healthy controls and groups of subjects who at scale. Its usefulness despite extensive psychometric data must
various time points were expected to be fatigued. This included therefore be questioned.
army trainees and doctors undertaking shift work. This means The Wu Cancer Fatigue Scale [47]: The original scale had 16
there are normative data available for reference. It was further items but a secondary validation study found redundant items
validated for use in cancer in a subsequent study of 275 patients and the scale was revised to include only nine items [48]. The
undergoing radiotherapy [38]. It has since been used in instrument has undergone limited psychometric evaluation and
a number of studies but with small numbers of patients in each has not been used in any subsequent studies. The relative lack
study. of data means that it cannot be recommended for further use.
The Multidimensional Fatigue Symptom Inventory short
form (MFSI-30) [39] is a 30-item scale that was originally
investigated in a group of breast cancer patients undergoing
discussion
treatment. It was further validated in a mixed cancer This review has demonstrated the range and number of scales
population of 304 patients [40]. It has favourable psychometric available to specifically measure CRF. A number of other tools
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