Medical Content

Tired of Cancer starting point for content is strongly scientifically based. Inspired by face-to-face and online therapies of the Helen Dowling Institute (Less fatigue of Cancer), based on both science and proven clinical practice, and aligned with the Standards of Care on CRF by the prestigious National Comprehensive Cancer Network (NCCN) in the USA Untire was developed. At its core, Tired of Cancer has over 30 years of expertise in the field of cancer-related fatigue.

NCCN

In general, Untire is in line with the Standards of Care on Cancer-Related Fatigue (CRF) – the standard is elaborated in table 1 – by the NCCN (National Comprehensive Cancer Network) of the USA in 2017 (1).

Table 1 – Standards of Care NCCN

  • Fatigue is rarely an isolated symptom and most commonly occurs with other symptoms, such as pain, emotional distress, anemia, and sleep disturbances, in symptom clusters. Therefore, patients should be screened for multiple symptoms that may vary according to diagnosis, treatment, and stage of disease.
  • Fatigue is a subjective experience that should be systematically assessed using patient self-reports and other sources of data.
  • Fatigue should be screened, assessed, and managed according to clinical practice guidelines.
  • All patients should be screened using age-appropriate measures for fatigue at their initial visit, at regular intervals during and following cancer treatment, and as clinically indicated.
  • Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease, prior to, during, and following treatment.
  • Patients and families should be informed that management of fatigue is an integral part of total health care and that fatigue can persist following treatment.
  • Implementation of guidelines for fatigue evaluation and management is best accomplished by interdisciplinary teams who are able to tailor interventions to the needs of the individual patient. Consider referral to an appropriate specialist or supportive care provider (eg, survivorship, palliative care, integrative oncology, psychology, psychiatry, physical therapy).
  • Educational and training programs should be implemented to ensure that health care professionals have knowledge and skills in the assessment and management of fatigue.
  • Cancer-related fatigue should be included in clinical health outcome studies as an independent variable and potential moderator of outcome.
  • Quality of fatigue management should be included in institutional continuous quality improvement projects.
  • Medical care contracts should include reimbursement for the management of fatigue.
  • Disability insurance should include coverage for the continuing effects of fatigue.
  • Consider referral to rehabilitation as indicated: physical therapy, occupational therapy, and physical medicine from diagnosis to end of life.

Furthermore, the non-pharmacologic interventions suggested by the NCCN (1) have great overlap with the Untire® App, which is shown in table 2, where most interventions are offered.

Table 2 – Non-pharmacologic Interventions for patients on active treatment

Intervention Untire® App Remarks
Physical activity Available Physical activity (Strenght + Fitness)
Physically based therapies Not available Not possible to deliver digitally
Physcosocial interventions Available Themes (Basics, Worry, Anxiety, Selfcare, Boundaries, Fatigue) + Managing Energy + Tips + Exercises
Nutrition consultation Available Nutrition theme
CBT for sleep Available Sleep theme
Bright light therapy Not available Not possible to deliver digitally

In the next chapter, each content item of the Untire® App is elaborated; how it is composed and by whom.  

 Untire® App Content

Hereunder a list of Untire® App’s content;

Basics, worry, anxiety, selfcare, boundaries, (managing) fatigue

The core of  the Untire’s themes are written by Dr. Bram Kuiper, psycho-oncologist and CEO/founder of Tired of Cancer. Feedback, tips and insights were given many of expert colleagues to establish the current themes

  • dr. R. Sanderman, MSc – Expert in Health Psychology
  • Dr. S. Schagen, MSc – Expert in Cancer and Cognitive Functioning
  • dr. M. van de Lee, Msc – Expert in CRF
  • C. Volker, Msc – Expert in CRF
  • Dr. T. Hagenbeek, MD – Expert in oncology

 Physical activity

Physical activity is an effective component in people with cancer related fatigue. In order to set up the right programme, it is important that this can be done safely. Together with the experts listed below, we have drawn up the programme.

  • M. Wolvers – Expert in CRF and physical activity.
  • Lauret-Roemers – Expert as oedema physiotherapist

 Sleep

Sleep and the problems surrounding sleep is an important theme for many people with cancer related fatigue. For this purpose, an exclusive programme has been drawn up together with sleep experts.

  • H.M.J.C. Verbeek – Somnology (sleep) expert at Kempenhaege sleep institute

Nutrition

Cancer related fatigue and nutrition is still in its infancy. Based on In order to be able to give sound advice, we have put together a program together with the University of Wageningen – the leading University in the Netherlands/World in the field of nutrition.

  • dr.ir. E. Kampman – Nutrition and Disease at Wageningen University.

Tips

In particular based on the insights and outcomes from the Positive Psychology. Besides that based on general wisdoms and oral and written expressions of fatigued cancer patients that helped them to cope effectively with their burden.

Exercises

Based on general and more specific (mindfulness based cognitive therapy) relaxation/breathing exercises to learn to stand still in a busy and overwhelming world and learn to conserve energy.

References Untire content

The following literature was leading in the creation of Untire’s content:

  • Abrahams HJG, Gielissen MFM, Donders RRT, et al. The efficacy of Internet-based cognitive behavioral therapy for severely fatigued survivors of breast cancer compared with care as usual: a randomized controlled trial. 2017;123(19):3825–3834.
  • Berger A, Mooney K, Banerjee C, et al. Cancer-related fatigue. NCCN Clin Pract Guidel Oncol. 2017;2
  • Bruggeman-Everts FZ, Wolvers MDJ, van de Schoot R, Vollenbroek-Hutten MMR, Van der Lee ML. Effectiveness of Two Web-Based Interventions for Chronic Cancer-Related Fatigue Compared to an Active Control Condition: Results of the “Fitter na kanker” Randomized Controlled Trial. J Med Internet Res. 2017 Oct 19;19(10):e336. doi: 10.2196/jmir.7180. PMID: 29051138; PMCID: PMC5668634.
  • Compen, Félix René & Bisseling, Else & Schellekens, Melanie & Jansen, Ellen & Lee, Marije & Speckens, Anne. (2017). Mindfulness-Based Cognitive Therapy for Cancer Patients Delivered via Internet: Qualitative Study of Patient and Therapist Barriers and Facilitators. Journal of Medical Internet Research. 19. e407. 10.2196/jmir.7783.
  • Goedendorp MM, Gielissen MFM, Verhagen CA, et al. Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database Syst Rev. 2009.
  • Goedendorp MM, Knoop H, Gielissen MFM, et al. The effects of cognitive behavioral therapy for postcancer fatigue on perceived cognitive disabilities and neuropsychological test performance. J Pain Symptom Manage. 2014;47(1):35–44.
  • Interventions for Chronic Cancer-Related Fatigue: The Design and an Analysis Plan of a Three-Armed Randomized Controlled Trial. Journal of Medical Internet Research. 4. 10.2196/resprot.4363.
  • Jager Meezenbroek, Eltica & Pet, Anette & Lee, Marije. (2007). Online training Minder Moe bij Kanker veelbelovend?. Pallium. 9. 22-23. 10.1007/BF03088985.
  • Lee, Marije & Garssen, Bert. (2012). Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: A treatment study. Psycho-oncology. 21. 264-72. 10.1002/pon.1890.
  • May AM, Van Weert E, Korstjens I, et al. Improved physical fitness of cancer survivors: a randomised controlled trial comparing physical training with physical and cognitive behavioural training. Acta Oncol. 2008;47(5):825–834.
  • Meneses-Echávez JF, González-Jiménez E, Ramírez-Vélez R. Effects of supervised exercise on cancer-related fatigue in breast cancer survivors: a systematic review and meta-analysis. BMC Cancer. 2015;15:77.
  • Minton O, Berger A, Barsevick A, et al. Cancer-related fatigue and its impact on functioning. Cancer. 2013;119(Suppl 11):2124–2130
  • Related Fatigue Compared to an Active Control Condition: Results of the “Fitter na kanker” Randomized Controlled Trial. Journal of Medical Internet Research. 19. e336. 10.2196/jmir.7180.
  • Völker, C. & Lee, Marije & Pet, A.. (2011). De angst voor terugkeer van kanker. GZ -Psychologie. 3. 30-38. 10.1007/s41480-011-0029-0.
  • Wang XS, Zhao F, Fisch MJ, et al. Prevalence and characteristics of moderate to severe fatigue: a multicenter study in cancer patients and survivors. 2014;120(3):425–432.
  • Wolvers, M. J., Bussmann, J. J., Bruggeman-Everts, F. Z., Boerema, S. T., Schoot, R., & Vollenbroek-Hutten, M. R. (2017). Physical behavior profiles in chronic cancer-related fatigue. International Journal Of Behavioral Medicine, doi:10.1007/s12529-017-9670-3
  • Wolvers, Marije & Bruggeman-Everts, Fieke & Lee, Marije & Schoot, Rens & Vollenbroek – Hutten, Miriam. (2015). Effectiveness, Mediators, and Effect Predictors of Internet
  • Wolvers, Marije & Vollenbroek – Hutten, Miriam. (2015). An mHealth Intervention Strategy for Physical Activity Coaching in Cancer Survivors.
  • Zhu, Lei & Ranchor, Adelita & Lee, Marije & Garssen, Bert & Sanderman, Robbert & Schroevers, Maya. (2014). The role of goal adjustment in symptoms of depression, anxiety and fatigue in cancer patients receiving psychosocial care: A longitudinal study. Psychology &health. 30. 1-35.10.1080/08870446.2014.969263.