Fatigue, Distress, and Quality of Life As Covariates for Early-Stage Chronic Lymphocytic Leukemia

Despite the prevalence of Chronic lymphocytic leukemia (CLL) among the leukemias (American Cancer Society, 2012), little research has examined the psychological and quality of life correlates of this disease. Virtually no research has focused on these factors as related to the experiences of monitoring through active surveillance. Further, it is unknown if the psychological distress of these patients covaries with their reports of symptoms and signs associated with this disease. Research shows that cancer diagnosis is associated with significant distress and immunologic perturbations (Andersen et al., 1998). We hypothesize that the unique nature of coping with CLL diagnosis yet receiving no subsequent therapy may be associated with increased uncertainty, worry, and other symptoms of distress. The present study is one of the first to examine adjustment and quality of life in untreated CLL.

This cross-sectional study examined correlates of physical and psychological quality of life in 115 early-stage untreated CLL patients. Eligibility for this ongoing trial included patients with stage 0–2 disease aged 20 through 80 (inclusive) with no history of treatment for a prior cancer. Patients were accrued through the OSU James Division of Hematology oncology clinic. Following consent, participants completed a 45-minute telephone assessment using standardized and validated measures of psychological and physical symptoms associated with their CLL and general health. Measures included the following: Center for Epidemiological Studies-Depression Scale (CESD; Radloff, 1977) assessed depressive symptomatology; Medical Outcomes Study (MOS) SF-36 Short-Form Health Survey (SF-36; Ware et al., 1993) examined overall physical and mental quality of life. Measures of anxiety and stress were also examined. The Health Anxiety Questionnaire (HAQ; Lucock & Morley, 1996) assessed overall health-related anxiety and the Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979; Weiss & Marmar, 1996) examined stress specifically related to CLL. The Fatigue Symptom Inventory (FSI; Hann et al., 1998) assessed fatigue. Hierarchical linear regression was conducted bidirectionally to examine the covarying relationship between fatigue, psychological distress, and quality of life.

The demographic characteristics of this sample were similar to those found in patients participating in CLL clinical trials at the authors' institution. The majority of the sample was male (55%) with a median age of 62 (range: 37–76 years) and 100% Caucasian. Most participants in the sample had stage 0 (61.4%) disease. Mean time since diagnosis was 4.7 years (range: 0–17 years). Sociodemographic and disease variables were examined to identify appropriate statistical control variables. Age and time since diagnosis were significantly correlated with the physical and psychological variables examined. Hierarchical linear regression demonstrated that fatigue predicted greater depressive symptoms (p<.01), health anxiety manifest through worry (p<.01) and reassurance seeking (p<.05), and CLL-specific stress (p<.01). Fatigue also predicted worse physical (p<.01) and mental (p<.01) quality of life. Each regression was statistically significant when tested bidirectionally; results demonstrated the significance of distress and quality of life predicting fatigue.

Early-stage patients are mostly asymptomatic by definition. As such, these results highlight the importance of identifying the subset of early-stage patients for whom significant physical symptoms may be accompanied by greater distress and poorer quality of life. The bidirectional nature of the present results suggests a covariation of distress and physical symptoms, replicating previous research with other cancer patient groups. These finding also support future longitudinal research to better determine the temporal relationship of physical symptoms and distress. Identification of such predictors of worse adjustment better inform patient care both during active surveillance and treatment. These preliminary data are compelling in that they provide a perspective on the biopsychosocial characteristics of this understudied population. Further exploration on these characteristics of quality of life, distress, and physical functioning is warranted.

No relevant conflicts of interest to declare.