https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article Prevalence of Cancer-related Fatigue among Women with Breast Cancer in Erbil City ABSTRACT INTRODUCTION Cancer is a global health issue regardless of a country’s economic status. The inci- dence and mortality of cancer are continu- ously increasing universally, and in 21st century cancer is a major health concern that decreases the life continuum of peo- ple all over the world. In 2015, cancer was expected to be the first and second lead- ing reason of death among adults in 91 countries before age 70[1], In 2017, the second cause of death in United States was cancer [2], and the cancer rate in the United States is estimated to be 1,762,450 new cases, and breast cancer is predicted to be third most common can- cer for women with approximately 62,930 new cases in 2019 [3].Breast cancer (BC) is the most frequent cancer diagnosis among women worldwide, and incidence BC is steadily increasing, but-the rate of Background and objective: Cancer-related fatigue is greatest frequent upsetting sense of tiredness or exhaustion can happen regardless of cancer type and could be experienced physically or emotionally, and or cognitively, that is associated with the tumor or its treat- ment. The current study aimed at assessing prevalence of cancer related fatigue among women with breast cancer. Method: A descriptive cross- sectional study design was conducted from 8th of October 2018 to 8th October 2019. To find out the prevalence of cancer-related fatigue among fe- male breast cancer patients at Nankali Hospital in Erbil city. A sample of 60 breast cancer patient was obtained through non-probability purposive convenience sampling tech- niques. Data were analyzed using Statistical Package for the Social Sciences version 23 for windows. Results: The results showed that the highest percentage of participants (45%) were from age group between 39-54, most of them were from urban area, graduated from primary school, married, however; 53.3% of breast cancer women they had family history of breast cancer. Regarding breast cancer stages, 40% of participants were in third stage. Most of the breast cancer patients were receiving chemotherapy treatment and they had surgery (81.7% and 71.7% respectively). Concerning cancer related fatigue 75% of participants suffered from fatigue, nonetheless; fatigue severity among participants range from severe 53.3% to moderate 48.3%. Also, physical fatigue was a common type of fatigue among women with breast cancer. Conclusion: One of the most common complains symptom of patient with cancer is fa- tigue. Cancer related fatigue impact physical, emotional, cognitive domains of patients’. Moreover, cancer-related fatigue has undesirable effect on patients, mood, daily task per- formance, and the patient’s life. Keywords: prevalence; cancer related fatigue; breast cancer; severity of fatigue; types of fatigue. Shinwy Bakhtyiar Radha; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. )Correspondence: shinwy.radha@hmu.edu.krd) Yousif Muhammed Younis ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 108 Received: 09/11/2019 Accepted:15/1/2020 Published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article mortality is declining in developed coun- tries in contrast to developing countries[4], BC accounts for 14% to 42% of all cancer cases in women younger than 50 years, which indicates that BC has occurred a dec- ade earlier in Arab women when compared with women in developed countries that a half of BC women are aged, older than 65 years [5].In Turkey BC is the leading type of cancer among women, which accounts for 40.6% of all cancer cases, and it is predict- ed that annually, up to 10,000 women are diagnosed with BC in Turkey [6], In Iran BC was the fifth most common cause of death among women [7], and in Iran, BC was ac- counted for 24.6% which was less than the incidence of BC in Iraq and Turkey. The mean age of women living with BC in Iran was 49.7 years [8], the incidence of BC among Iraqi population has been rising over the last 20 years. However, BC is now the most common type of cancer, and among women approximately 33.3% of all cancer diagnosis were BC [9]. Treatment of BC includes utilizing different treatment approaches. Either a single treatment or combination. Treatment options consist of surgery, radiation, systematic treatment with chemotherapy, hormonal therapy, biological and immune therapy. The selec- tion of treatment regimen depends on tu- mor type and stage, hormone receptor, and clinical health state of patients[10]. One of the most symptom complaints re- ported among cancer patients and survi- vors is fatigue, regardless the cancer type [11], Cancer related fatigue (CRF) is a com- plex and multifactorial symptom that affect around 70% to 100% of cases with the moderate to severity intensity for the peri- od of receiving treatment, and impact 30% of all survivors[12]. Cancer related fatigue (CRF) is defined by NCCN (National Com- prehensive Cancer Network) as a, “ is a dis- tressing, persistence, subjective sense of physical, emotional and cognitive tiredness and/or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” [13].CRF rates frequently vary among patients receiving different treat- ments, and occurs among nearly 90% pa- tients with radiotherapy and 80% of pa- tient receiving systematic treatment. CRF has a great impact on physical, emotional, cognitive, and over patients quality of life [14], It can remains for months or even years after completing of cancer treat- ment, and as a result this symptom has a significant influence on patients quality of life [15]. Management of CRF includes both pharmacological and non-pharmacological ways. There are a wide range of non- pharmacological options including patient education, exercise, psychosocial educa- tion, suitable nutrition and hydration, cog- nitive behavior, and relaxation[16].Cancer related fatigue decreases patient quality of life, capacity, and possibly decreases pa- tient chance for survival [17], and also CRF affects emotional and spiritual suffering for both patients and their families [18].In the Kurdistan region of Iraq patients do not have sufficient information regarding can- cer and their consequence, as a result, pa- tients face issues with many tasks including incapacity to perform normal daily tasks to restricted and devastated from society. There is a big gap between patients and health care providers concerning and utiliz- ing the various ways of treatment side effect management, patients are still be- lieve that they should not assume any physical exercise as well as they do not have information regarding valuable nutri- tion, except the patients insufficient infor- mation, also health providers are kind of careless to saturate patient with recent and available dietary and exercise guide- lines to eliminate patients suffering, and they do not use any specific guideline. It is crucial to determine the prevalence of CRF 109 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article cancer who were at least 18 years old and who suffered from cancer stages 0 through four. The exclusion criteria included female patients with end stage breast cancer and patients with mental disorders. Ethical consideration Ethical approval was ob- tained from the Ethical and Scientific Com- mittees in the College of Nursing, Hawler Medical University (Code No.72 in 2019.06.20). The researcher also obtained official approval from the Nanakaly Hospi- tal in Erbil city. Oral informed consent was obtained from patients after a detailed ex- planation about the aim of the study. Data were coded maintain anonymity. Data Col- lectionA face-to-face interview technique was used to gather information about so- cio-demographics, patient medical infor- mation, and CRF. Data collection was start- ed from the period of 1st April to 1st June 2019, using a questionnaire that was de- signed by the researcher through literature review. The data of each sample has been separately obtained that spent at least 20 minutes; the interview took place in an outpatient oncology unit. The reliability of the questionnaire was obtained through review by medical experts in the fields of nursing, medicine, oncology, and psychia- try. The researcher assessed the relevant socio-demographic characteristics includ- ing age, residential area, education level, marital status, employment statue, family income, and family history of breast can- cer. The Medical history, information was collected through six questions that as- sessed disease status, disease stage, types of breast cancer treatment regimen, Infor- mation on usual and current body mass index. According to American Cancer Soci- ety (ACS) in 2016, BMI for adult person are illustrate below [19]: among breast cancer patients to encourage health care providers to develop an educa- tional program to educate patients for better self- care, how manage adverse effects, including CRF. A descriptive cross-sectional study was un- dertaken to determine the prevalence of CRF among female breast cancer patients at Nankali hospitals in Erbil City, Iraq. Study setting and participant The study was con- ducted at outpatient oncology department of Nanakali Hospital, a government hospi- tal located near Nine Shahed mosque in Azady Q, Erbil, which provides specialty care for blood diseases and cancer. Nana- kali Hospital, opened in 2004, comprises of two essential departments including ad- ministration and the scientific/art depart- ment. The hospital has a staff of 246 pro- fessionals including, 103 medical staff (51 occupied nurses, 52 volunteers) and 60 specialized physicians (oncologist, hematol- ogist, pediatrician, anesthetist, dentist, ra- diologist, pharmacist). The hospital has 95 beds. Each oncologic cases is admitted at either the in-patient and out-patient oncol- ogy department. There are 11 oncology staff including two shifts (morning, even- ing). During the morning shift, there are eight nurses and during the evening shift, there are three nurses. On average, six nurses work during the morning shift and there are 25 beds in the oncology depart- ment including, ten beds for male outpa- tients, ten bed for female outpatients, and five for in-patients cases. The study sample includes female breast cancer patients who were admitting outpatient oncology de- partment and the study used a non- probability, purposive convenience sam- pling techniques to collect the relevant study data. A total of 60 women participat- ed. The inclusion criteria included adult female patients diagnosed with breast 110 Erbil Journal of Nursing & Midwifery METHODS BMI Range Underweight <18.5 Normal body weight 18.5-24.9 Overweight 25-29.9 Obese ≥30 https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article Demographic and questionnaire data was coded and entered Statistical Package for the Social Sciences (SPSS) version 23 for windows, for descriptive statistics (Frequency and Percentage). Sociodemographic characteristics of the study sampleThe table 1 shows the socio- demographic characteristics of partici- pants. The highest percentage of sample were between 39-54 years old (45%), and 23.3% were between 23-38 years old. Most (70%) were from urban areas. The highest percentage had graduated from primary school (38.8%), meanwhile only 3.3% were graduated from the high school. More than half of participants were mar- ried (66.7%), and only one was divorced. Most (86.7%) were unemployed, and 13.3% were employed. More than half (63.3%) have sufficient economic status. Regarding the family history half of study samples had family history of breast can- cer (50.3%), from first degree relevant. 111 Erbil Journal of Nursing & Midwifery Current Hgb level, According to National Institute of Health (NIH) in 2019 adult women who Hgb level less than 12.0 g/dl were identified anemic as following [20]: Chronic diseases assessing, and treatment regimen data consist of whether the pa- tient had undergone chemotherapy, radio- therapy, surgical therapy, biology therapy, and hormonal therapy. The CRF assess- ment consisted, of seven unique questions to determine CRF over the prior two weeks, and the scoring included (0) for none, (1) for not much, (2) for some, (3) for a great deal. Question two and six were recoded as following: (0) for none, (1) for a great deal, (2) for some, (3) for not much. Fatigue severity was assessed using two questions about asking patients to rate fatigue severity levels during two different times (once in previous weeks vs. current fatigue). Regarding NCCN in 2018 the fa- tigue severity level is rating on numerical rating scale from 0 to 10 as (0 for no fa- tigue and 10 for worst fatigue can be imag- ine),also fatigue has been divided as The different types of fatigue during can- cer were also assessed. Physical fatigue questions included contains five questions; emotional fatigue included seven ques- tions, and cognitive fatigue included five questions. Each type was assessed, that using a four scale level (none, not much, some, a great deal), the scoring were as (0) for none, (1) for not much, (2) for some, and (3) for a great deal. Data analysis Hgb Range Mild anemia 10g/dl Moderate anemia 8-9.9g/dl Severe anemia 6.5-7.9g/dl Life-threatening >6.5g/dl Fatigue Score Mild fatigue 1-3 Moderate fatigue 4-6 Sever fatigue 7-10 RESULTS Table 1: Socio-demographic characteris- tics of the study sample Socio-demographic characteristics F. (%) Age group (years) 23-38 14 (23.3) 39-54 27 (45) 55-70 19 (31.7) Residential area Urban 42 (70) Rural 18 (30) Level of education Illiterate 19 (31.7) Primary School 23 (38.3) Secondary School 7 (11.7) Institute graduate 6 (10) College graduate 5 (8.3) Marital status Single 10 (16.7) Married 40 (66.7) Divorced 1 (1.7) Widowed 9 (15) Employment status Employed 8 (13.3) Unemployed 52 (86.7) Family income Sufficient 38 (63.3) Insufficient 22 (36.7) Family history of breast cancer No 28 (46.7) Yes 32 (53.3) Total 60 (100) https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 112 Erbil Journal of Nursing & Midwifery Past medical history of women with breast cancer Table 2 shows medical history. The highest percentages (73.3%) of partici- pants’ breast cancer condition were pro- gress. Concerning the breast cancer stage, 40% of the patients were in the third stage, 31.7% were in second stage, and one in the zero stage of breast cancer. Most of the breast cancer patients were under the treatment of chemotherapy and surgery (81.7% and 71.7% respectively), moreover only 18.3%, 16%, and 15% were under the biology, hormonal, and radiation therapies respectively, and some cases were under more than one therapy. About body mass index, 48.33% of participants were obese, meanwhile; only one case was under- weight. Regarding anemia, the majority of patients (83.3%) had mild anemia and 16.7% had moderate anemia. On the sub- ject of having comorbid diseases 68.3% did not have any comorbid diseases, while; 31.7% had comorbid diseases including, 16.7%, 6.7%, and 3.3% came beyond dia- betes mellitus and hypertension, Hypothy- roidism, and heart failure respectively. Cancer related fatigue among breast can- cer women Table 3 shows overall history of CRF during the last two weeks. No partici- pants reported no fatigue it. The highest percentage of study samples (75%) suffered from a great deal of fatigue, while; 20% assumed some degree of fa- tigue, and 5% were not much fatigued. Severity of fatigue among participants Table four illustrates the severity of fatigue among study samples. Concerning the se- verity of fatigue since last week, almost half of breast cancer patients 53.3% were experience severe degree, 30% were mod- erately fatigued, and 16.7% had mild fa- tigue. Current fatigue included moderate (48.3%), severe (25%), and mild (26%). Cancer related fatigue domains Table five shows the domains of fatigue. Concerning the findings all women patients were experienced physical, emotional, and cog- nitive with some degree of fatigue as 60%, 40%, and 40% respectively. Table 2: Past medical history of women with breast cancer Past medical history F (%) Breast cancer condition Recurrent 16 (26.7) Progress 44 (73.3) Breast cancer stage Zero stage 1 (1.7) First stage 8 (13.3) Second stage 19 (31.7) Third stage 24 (40) Four stage 8 (13.3) Chemotherapy use No 11 (18.3) Yes 49 (81.7) Radiation thera- py No 51 (85) Yes 9 (15) Surgery No 17 (28.3) Yes 43 (71.7) Biology therapy No 49 (81.7) Yes 11 (18.3) Hormonal thera- py No 50 (83.3) Yes 10 (16.7) Body Mass Index Underweight 1 (1.7) Norm weight 10 (16.7) Overweight 20 (33.3) Obese 29 (48.3) Anemia Moderate 10 (16.7) Mild 50 (83.3) Comorbid dis- ease No 41 (68.3) Yes 19 (31.7) DM No 50 (83.3) Yes 10 (16.7) HT No 50 (83.3) Yes 10 (16.7) Hypothyroidism No 56 (93.3) Yes 4 (6.7) HF No 58 (96.7) Yes 2 (3.3) Total 60 (100) Table 3: In-depth fatigue history since two weeks ago Fatigue history F (%) Not much 3 (5) Some 12 (20) A great deal 45 (75) Total 60 (100) https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 113 Erbil Journal of Nursing & Midwifery Breast cancer is a major global health con- cern for women. One of the concerning of cancer and its treatment is CRF that leads to decline person capabilities of physical, or emotional, and/ or mental capability. The present study aimed to assessing the prevalence of cancer related fatigue among women with breast cancer Ghiasvand et al , 2011 in Iran, found that the mean age of cancer occurrence was 41 years old, while ; research in the United Kingdom among illustrated that 24.8% of BC occurred in age among women aged 20 to 39 years [21]. In this study, Breast can- cer occurred a in younger women because Kurdistan a developing country that eco- nomic status, health care system, are un- der the development. Meanwhile; Kurdish civilian constantly suffer from stress, war, they have poor education, all are being the reason of BC occurring in young age which is supported by a research that says BC occurs earlier in younger age women in Asian’s and African’s countries which is more forceful and tense, mostly metasta- sis.[22]. The present study found that the majority of samples were from urban areas, the explanation for that is be- cause in urban area the number of, in- dustrial companies, cars, manufacturing wastes are increased randomly without taking public health in consideration, and most of urban civilians have seden- tary lifestyle, all are helping factors for developing different kind of cancers, that is why the incidence of cancer are growing up. Correspond to research in China, that found as a result of changing global claiming cancer generally has been increased the entire world and is being an urbanizing disease [23]. Low education levels are associated with poor disease progress and affect the sur- vival rate too [24]. Current study results showed that most participants graduat- ed from primary school. In Kurdistan, migration and financial crisis have con- tributed to people not being able to complete their education. This study’s results are supported by findings from a cross-sectional study among patients receiving anti-neoplastic treatment Table 4: Fatigue severity level Severity of fatigue F. (%) Level of fatigue on the average during the past week Mild 10 (16.7) Moderate 18 (30) Severe 32 (53.3) Current fatigue level Mild 16 (26) Moderate 29 (48.3) Severe 15 (25) Total 60 (100) Table 5: Cancer related fatigue domains Fatigue domains None Not much Some A great deal Total F. (%) F. (%) F. (%) F. (%) F. (%) Physical fatigue 6 (10) 12 (20) 36 (60) 6 (10) 60(100) Emotional fatigue 11 (18.3) 2 (3.3) 24 (40) 23 (38.4) 60(100) Cognitive fatigue 11 (18.3) 21 (35) 24 (40) 4 (6.7) 60(100) DISCUSSIONS https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 114 Erbil Journal of Nursing & Midwifery in India in 2012, which demonstrated that participants were mainly from primary school too. [25]. Regarding marital status more than half of present study partici- pants were married, the similar result found in the research performed among 60 Breast Cancer patients in United State at 2012; represented that most of study sample were married [26]. Most patients were in the third stage of their cancer. This is likely because of prevention pro- grams in Iraq. While; the result of a re- search carried out in India at 2017 closed to existence study found that most of breast cancer were diagnosed in advance stage, is that because India like Kurdistan they may not have spent enough budget to health promotion and prevention [27]. Moreover; the current study result is disa- gree with American Association for Cancer Research finding in 2012 that found ut- most of women diagnosed with BC were in first stage, that is because of existence of good and strong health policy in America [28]. Most of the patients were under the treatment of chemotherapy and surgery, nonetheless; the result is supported by a clinical practice guideline published by Ox- ford University, which showed that ap- proximately one eight of BC cases will un- dergo surgery [29], and also a survey of 1954 women patient with BC illustrated that third-fourth of women were used chemotherapy, it is point out that two of the most effective and powerful manage- ment for BC are surgery and chemothera- py [30]. Nearly half the participants were obese, meanwhile; only one case were underweight, on the same time; the study finding is dissimilar with a research con- ducted in Bangladesh in 2015 represented that 69% of participants were had normal body weight. This differences is might re- lated to the Bangladesh’s’ women aware- ness regarding knowing the values of healthy foods and consuming balance in diet to maintain healthy body weight. [31]. On the subject of having comorbid diseases 68.3% of current study did not have any comorbid diseases, while; 31.7% had comorbid diseases, this result is dis- similar with the American Cancer Society prospective surveillance model study for rehabilitation for women with breast can- cer in Georgia at 2012 among 1500 pa- tients discovered that 66% of participant had at list one comorbidities, while; 33% of them were have more than two comorbidities, and the most common comorbid disease was hypertension[37]. Cancer related fatigue assessment Nearly every cancer patients go through some kind of fatigue during cancer treat- ment according to present study finding all the participants were fatigued with different level of fatigue, because there were no participants that were not being fatigue it. The highest percentage of study samples (75%) were suffered from a great deal of fatigue, this is similar with the cross-sectional observational study finding that was performed in Malwa re- gion of Punjab at 2017 under the title “Assessment of Cancer-related Fatigue among Cancer Patients Receiving Various Therapies” among 126 participants the percentage of study fatigue was 83.3% [38].Severity of cancer related fatigue Concerning the severity of fatigue of pre- sent study since last week, almost half of breast cancer patients 53.3% were expe- rience severe degree; whereas 30% got moderate fatigue, and 16.7% were as- sume mild degree of fatigue, the study result is reinforced by the study conduct- ed by Campos et al at 2011 in Brazil among 260 patients demonstrated fa- tigue severity as 47% for sever fatigue, 42% for moderate fatigue, and 10% for mild fatigue[39], while; American Cancer Society accomplished research in 2015 to under the title “screening, evaluation, https://doi.org/10.15218/ejnm.2020.13 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 115 Erbil Journal of Nursing & Midwifery and management of cancer related fa- tigue” illustrated that the most common fatigue severity among cancer patient was severe fatigue ranged 98% [40]. Fatigue domains Fatigue domains finding in cur- rent study all women patients were expe- rienced physical, emotional, and cognitive with some degree of fatigue as 60%, 40%, and 40% respectively, this is supported by review of literature research carried out in Netherland at 2013 stated that physical fatigue was more frequent fatigue among study participants who were under thera- py than the mental (cognitive) fatigue [41]. The study illustrated that the highest per- centage of participants (45%) were ages 39 to 54, most were from urban areas, bad graduated from primary school, and were married. Most of study samples were un- employed (86.7%), however; 53.3% of breast cancer women they had family his- tory of BC, first degree relevant with Breast Cancer history were affected 62.5% of samples. Regarding breast cancer stag- es, 40% of participants were in third stage, Most of the breast cancer patients were under the treatment of chemotherapy and surgery (81.7% and 71.7% respectively, most of them were obese, while; majority of patients had mild anemia (83.3%). On conclusion, as a study result showed every breast cancer patients were assuming some level of fatigue while; concerning fatigue severity among participants were ranging between sever to moderate de- gree of fatigue 53.3% and 48.3% respec- tively coming beyond fatigue level in past week, and fatigue rate right now. Also physical fatigue was common type of fa- tigue among breast cancer women. 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