The Impact of Fatigue on Role Functioning During Radiation Therapy

Patricia Poirier

fatigue, radiation therapy, radiation tolerance
ONF 2011, 38(4), 457-465. DOI: 10.1188/11.ONF.457-465

Purpose/Objectives: To identify the impact of fatigue, site-specific side effects, and individual characteristics on role activities during radiation therapy.

Design: Secondary data analysis.

Setting: A community radiation therapy department in the northeastern region of the United States.

Sample: 77 patients receiving radiation therapy for adjuvant or curative intent.

Methods: Items from the Piper Fatigue Scale and the Brief Fatigue Inventory were grouped into primary (i.e., basic activities of daily living), secondary (i.e., work and school activities), and tertiary (i.e., socialization with family and friends) roles according to the Roy Adaptation Model. Paired t tests and multiple regression were used to analyze performance of roles.

Main Research Variables: Primary, secondary, and tertiary roles.

Findings: Functioning in all three roles declined during treatment, with greater disruption in secondary roles than primary or tertiary roles. Patients maintained their primary and tertiary roles. Patients had greater difficulty maintaining secondary roles such as work and school activities. Treatment to the lung, pelvis, or head and neck; living alone; and an increase in total side-effect scores were associated with increased disruption in role functioning.

Conclusions: Radiation therapy-related fatigue can affect role functioning at the primary, secondary, and tertiary levels.

Implications for Nursing: Oncology nurses are in an ideal position to design interventions to help patients maintain activities at greatest risk for disruption. Future research where performance of specific activities is the primary outcome of interest is indicated.

Jump to a section


    Ahlberg, K., Ekman, T., & Gaston-Johansson, F. (2005). Fatigue, psychological distress, coping resources, and functional status during radiotherapy for uterine cancer. Oncology Nursing Forum, 32, 633-640. doi:10.1188/05.ONF.633-640
    American Cancer Society. (2010). Cancer facts and figures 2010. Retrieved from
    Bansal, M., Mohanti, B.K., Shah, N., Chaudhry, R., Bahadur, S., & Shukla, N.K. (2004). Radiation related morbidities and their impact on quality of life in head and neck cancer patients receiving radical radiotherapy. Quality of Life Research, 13, 481-488. doi:10.1023/B:QURE.0000018491.80646.bc
    Barsevick, A.M., Dudley, W.N., & Beck, S.L. (2006). Cancer-related fatigue, depressive symptoms, and functional status: A mediation model. Nursing Research, 55, 366-372. doi:10.1097/00006199-200609000-00009
    Browall, M., Ahlberg, K., Karlsson, P., Danielson, E., Persson, L.O., & Gaston-Johansson, F. (2008). Health-related quality of life during adjuvant treatment for breast cancer among postmenopausal women. European Journal of Oncology Nursing, 12, 180-189. doi:10.1016/j.ejon.2008.01.005
    Burns, N., & Grove, S. (2005). The practice of nursing research: Conduct, critique, and utilization (5th ed.). Philadelphia, PA: W.B. Saunders.
    Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
    Curt, G.A., Breitbart, W., Cella, D., Groopman, J.E., Horning, S.J., Itri, L.M., … Vogelzang, N.J. (2000). Impact of cancer-related fatigue on the lives of patients: New findings from the Fatigue Coalition. Oncologist, 5, 353-360. doi:10.1634/theoncologist.5-5-353
    Dhruva, A., Dodd, M., Paul, S.M., Cooper, B.A., Lee, K., West, C., … Miaskowski, C. (2010). Trajectories of fatigue in patients with breast cancer before, during, and after radiation therapy. Cancer Nursing, 33, 201-212. doi:10.1097/NCC.0b013e3181c75f2a
    DiMattio, M.J., & Tulman, L. (2003). A longitudinal study of functional status and correlates following coronary artery bypass graft surgery in women. Nursing Research, 52, 98-107. doi:10.1097/00006199-200303000-00006
    Dodd, J.J., Cho, M.H., Cooper, B.A., & Miaskowski, C. (2010). The effect of symptom clusters on functional status and quality of life in women with breast cancer. European Journal of Oncology Nursing, 14, 101-110. doi:10.1016/j.ejon.2009.09.005
    Donovan, K.A., Jacobsen, P.B., Andrykowski, M.A., Winters, E.M., Balducci, L., Malik, U., … McGrath, P. (2004). Course of fatigue in women receiving chemotherapy and/or radiotherapy for early stage breast cancer. Journal of Pain and Symptom Management, 28, 373-380. doi:10.1016/j.jpainsymman.2004.01.012
    Doorenbos, A., Given, B., Given, C., & Verbitsky, N. (2006). Physical functioning: Effect of behavioral intervention for symptoms among individuals with cancer. Nursing Research, 55, 161-171. doi:10.1097/00006199-200605000-00002
    Ekfors, H., & Petersson, K. (2004). A qualitative study of the experiences during radiotherapy of Swedish patients suffering from lung cancer. Oncology Nursing Forum, 31, 329-334. doi:10.1188/04.ONF.329-334
    Garman, K.S., & Cohen, H.J. (2002). Functional status and the elderly cancer patient. Critical Reviews in Oncology/Hematology, 43, 191-208. doi:10.1016/S1040-8428(02)00062-8
    Garman, K.S., Pieper, C.F., Seo, P., & Cohen, H.J. (2003). Function in elderly cancer survivors depends on comorbidities. Journals of Gerontology, Series A—Biological Sciences and Medical Sciences, 58, M1119-M1124.
    Given, B., Given, C., Azzouz, F., & Stommel, M. (2001). Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nursing Research, 50, 222-232. doi:10.1097/00006199-200107000-00006
    Gosselin, T.K. (2010). Principles of radiation therapy. In C.H. Yarbro, D. Wujcik, & B.H. Holmes. (Eds.), Cancer nursing: Principles and practice (7th ed., pp. 250-269). Sudbury, MA: Jones and Bartlett.
    Haas, M.L. (2010). Radiation therapy: Toxicities and management. In C.H. Yarbro, D. Wujcik, & B.H. Holmes. (Eds.), Cancer nursing: Principles and practice (7th ed., pp. 313-352). Sudbury, MA: Jones and Bartlett.
    Haylock, P.J., & Hart, L.K. (1979). Fatigue in patients receiving localized radiation. Cancer Nursing, 2, 461-467. doi:10.1097/00002820-197912000-00005
    Hickey, B.E., Francis, D.P., & Lehman, M.H. (2006). Sequencing of chemotherapy and radiation therapy for early breast cancer. Cochrane Database of Systematic Reviews, 4, CD005212. doi:10.1002/14651856.CD005212.Pub2
    Hoffman, A.J., von Eye, A., Gift, A.G., Given, B.A., Given, C.W., & Rothert, M. (2009). Testing a theoretical model of perceived self-efficacy for cancer-related fatigue self-management and optimal physical functional status. Nursing Research, 58, 32-41. doi:10.1097/NNR.0b013e3181903d7b
    Howlander, N., Noone, A.M., Krapcho, M., Neyman, N., Aminou, R., Waldron, W., … Edwards, B.K. (Eds.). (2011). SEER cancer statistics review, 1975-2008. Bethesda, MD: National Cancer Institute.
    Institute of Medicine. (2001). Crossing the quality chasm: A new health care system for the 21st century. Retrieved from
    Kärki, A., Simonen, R., Mälkiä, E., & Selfe, J. (2005). Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal of Rehabilitation Medicine, 37, 180-188. doi:10.1080/16501970410024181
    Kim, E., Jahan, T., Aouizerat, B.E., Dodd, M.J., Cooper, B.A., Paul, S.M., … Miaskowski, C. (2009). Differences in symptom clusters identified using occurrence rates versus symptom severity ratings in patients at the end of radiation therapy. Cancer Nursing, 32, 429-436. doi:10.1097/NCC.0b013e3181b046ad
    Kim, J.E., Dodd, M.J., Aouizerat, B.E., Jahan, T., & Miaskowski, C. (2009). A review of the prevalence and impact of multiple symptoms in oncology patients. Journal of Pain and Symptom Management, 37, 715-736. doi:10.1016/j.jpainsymman.2008.04.018
    Knobf, M.T., & Sun, Y. (2005). A longitudinal study of symptoms and self-care activities in women treated with primary radiotherapy for breast cancer. Cancer Nursing, 28, 210-218. doi:10.1097/00002820-200505000-00010
    Lai, Y.H., Shun, S.C., Hsiao, Y.L., Chiou, J.F., Wei, L.L., Tsai, J.T., & Kao, C.Y. (2007). Fatigue experiences in hepatocellular carcinoma patients during six weeks of stereotactic radiotherapy. Oncologist, 12, 221-230. doi:10.1634/theoncologist.12-2-221
    Lavdaniti, M., Patiraki, E., Dafni, U., Katapodi, M., Papathanasoglou, E., & Sotiropoulou, A. (2006). Prospective assessment of fatigue and health status in Greek patients with breast cancer undergoing adjuvant radiotherapy. Oncology Nursing Forum, 33, 603-610. doi:10.1188/06.ONF.603-610
    Lundberg, P.C., & Rattanasuwan, O. (2007). Experiences of fatigue and self-management of Thai Buddhist cancer patients undergoing radiation therapy. Cancer Nursing, 30, 146-155. doi:10.1097/01.NCC.0000265005.02559.43
    Lundh, H.C., Seiger, A., & Furst, C.J. (2005). Quality of life in terminal care—With special reference to age, gender and marital status. Supportive Care in Cancer, 14, 320-328. doi:10.1007/s00520-005-0886-4
    Mendoza, T.R., Wang, X.S., Cleeland, C.S., Morrissey, M., Johnson, B.A., Wendt, J.K., & Huber, S.L. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85, 1186-1196. doi:10.1002/(SICI)1097-0142(19990301)85:51186::AID-CNCR24>3.0.CO;2-N
    Miaskowski, C., Cooper, B.A., Paul, S.M., Dodd, M., Lee, K., Aouizerat, B.E., … Bank, A. (2006). Subgroups of patients with cancer with different symptom experiences and quality-of-life outcomes: A cluster analysis [Online exclusive]. Oncology Nursing Forum, 33, E79-E89. doi:10.1188/06.ONF.E79-E89
    Miaskowski, C., Paul, S.M., Cooper, B.A., Lee, K., Dodd, M., West, C., … Wara, W. (2008). Trajectories of fatigue in men with prostate cancer before, during, and after radiation therapy. Journal of Pain and Symptom Management, 35, 632-643. doi:10.1016/j.painsymman.2007.07.007
    National Cancer Institute. (2006). Common terminology criteria for adverse events, version 3.0. Retrieved from
    National Comprehensive Cancer Network. 2010. NCCN guidelines for treatment of cancer by site. Retrieved from
    Okuyama, T., Wang, X.S., Akechi, T., Mendoza, T.R., Hosaka, T., Cleeland, C.S., & Uchitomi, Y. (2003). Validation study of the Japanese version of the Brief Fatigue Inventory. Journal of Pain and Symptom Management, 25, 106-117. doi:10.1016/S0885-3924(02)00596-1
    Oncology Nursing Society. (2009). Oncology Nursing Society 2009-2013 research agenda. Retrieved from
    Pandey, M., Thomas, B.C., SreeRekha, P., Ramdas, K., Ratheesan, K., Parameswaran, S., … Rajan, B. (2005). Quality of life determinants in women with breast cancer undergoing treatment with curative intent. World Journal of Surgical Oncology, 3, 63. doi: 10.1186/1477-7819-3-63
    Piper, B.F., Dibble, S.L., Dodd, M.J., Weiss, M.C., Slaughter, R.E., & Paul, S.M. (1998). The revised Piper Fatigue Scale: Psychometric evaluation in women with breast cancer. Oncology Nursing Forum, 25, 677-684.
    Poirier, P. (2005). Policy implications of the relationship of sick leave benefits, individual characteristics, and fatigue to employment during radiation therapy for cancer. Policy, Politics, and Nursing Practice, 6, 305-318. doi:10.1177/1527154405283411
    Poirier, P. (2006). The relationship of sick leave benefits, employment patterns, and individual characteristics to radiation therapy-related fatigue. Oncology Nursing Forum, 33, 593-601. doi:10.1188/06.ONF.593-601
    Poirier, P. (2007). Factors affecting performance of usual activities during radiation therapy. Oncology Nursing Forum, 34, 827-834. doi:10.1188/07.ONF.827-834
    Pud, D., Ben Ami, S., Cooper, B.A., Aouizerat, B.E., Cohen, D., Radiano, R., … Miaskowski, C. (2008). The symptom experience of oncology outpatients has a different impact on quality-of-life outcomes. Journal of Pain and Symptom Management, 35, 162-170. doi:10.1016/j.jpainsymman.2007.03.010
    Radbruch, L., Sabatowski, R., Elsner, F., Everts, J., Mendoza, T., & Cleeland, C. (2003). Validation of the German version of the Brief Fatigue Inventory. Journal of Pain and Symptom Management, 25, 449-458. doi:10.1016/S0885-3924(03)00073-3
    Rowell, N.P., & O'Rourke, N. (2004). Concurrent chemoradiotherapy in non-small cell lung cancer. Cochrane Database of Systematic Reviews, 4, CD002140. doi:10.1002/14651858.VF0021.40.Pub2
    Roy, C., Sr., & Andrews, H.A. (1999). Roy adaptation model. Stamford, CT: Appleton and Lange.
    Roy, C., Sr., & Zhan, L. (2006). Sister Callista Roy's Adaptation Model and its application. In M.E. Parker (Ed.), Nursing theories and nursing practice (2nd ed., pp. 268-280). Philadelphia, PA: F.A. Davis.
    Schmidt, C.E., Bestmann, B., Küchler, T., Longo, W.E., Rohde, B., & Kremer, B. (2005). Gender differences in quality of life of patients with rectal cancer. A five-year prospective study. World Journal of Surgery, 29, 1630-1641. doi:10.1007/s00268-005-0067-0
    Schwartz, A.H. (2002). Validity of cancer-related fatigue instruments. Pharmacotherapy, 22, 1433-1441. doi:10.1592/phco.22.16.1433.33690
    Schwartz, A.L., Nail, L.M., Chen, S., Meek, P., Barsevick, A.M., King, M.E. & Jones, L.S. (2000). Fatigue patterns observed in patients receiving chemotherapy and radiotherapy. Cancer Investigation, 18, 11-19. doi:10.3109/07357900009023057
    Seifert, M.L. (2010). Fatigue, pain, and functional status during outpatient chemotherapy [Online exclusive]. Oncology Nursing Forum, 37, E114-E123. doi:10.1188/10.ONF.114-123
    Serin, D., Dilhuydy, J.M., Romestaing, P., Guiochet, N., Gledhill, J., Bret, P., … Flinois, A. (2004). ‘Parcours de Femme 2001’: A French opinion survey on overall disease and everyday life management in 1870 women presenting with gynecological or breast cancer and their caregivers. Annals of Oncology, 15, 1056-1064. doi:10.1093/annonc/mdh265
    Stone, P., Richards, M., A'Hern, R., & Hardy, J. (2001). Fatigue in patients with cancer of the breast or prostate undergoing radical radiotherapy. Journal of Pain and Symptom Management, 22, 1007-1015. doi:10.1016/S0885-3924(01)00361-X
    Sultan, S., Fisher, D.A., Voils, C.I., Kinney, A.Y., Sandler, R.S., & Provenzale, D. (2004). Impact of functional support on health-related quality of life in patients with colorectal cancer. Cancer, 101, 2737-2743. doi:10.1002/cncr.20699
    Suwisith, N., Hanucharunkul, S., Dodd, M., Vorapongsathorn, T., Pongthavorakamol, K., & Asavametha, N. (2008). Symptom clusters and functional status of women with breast cancer. Thai Journal of Nursing Research, 12, 153-164.
    Tanaka, K., Akechi, T., Okuyama, T., Nishiwaki, Y., & Uchitomi, Y. (2002). Impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer. Journal of Pain and Symptom Management, 23, 417-423. doi:10.1016/S0885-3924(02)00376-7
    Tchen, N., Bedard, P., Yi, Q.L., Klein, M., Cella, D., Eremenco, S., & Tannock, I.F. (2003). Quality of life and understanding of disease status among cancer patients of different ethnic origin. British Journal of Cancer, 89, 641-647. doi:10.1038/sj.bjc.6601159
    Thanaslip, S., & Kongsaktrakul, P. (2005). Factors predicting quality of life of patients with cancer undergoing chemotherapy. Thai Journal of Nursing Research, 9, 306-315.
    Tulman, L., & Fawcett, J. (1990). A framework for studying functional status after diagnosis of breast cancer. Cancer Nursing, 13, 95-99. doi:10.1097/00002820-199004000-00004
    Tulman, L., & Fawcett, J. (2007). Development of the Comprehensive Inventory of Functioning-Cancer. Cancer Nursing, 30, 205-212. doi:10.1097/01.NCC.0000270713.18156.95
    Uzun, O., Aslan, F.E., Selimen, D., & Koç, M. (2004). Quality of life in women with breast cancer in Turkey. Journal of Nursing Scholarship, 36, 207-213. doi:10.1111/j.1547-5069.2004.04039.x
    Williams, P.D., Lopez, V., Ying, C.S., Piamjariyakul, U., Wenru, W., Hung, G.T., … Williams, A.R. (2010). Symptom monitoring and self-care practices among oncology adults in China. Cancer Nursing, 33, 184-193. doi:10.1097/NCC.0b013e3181c29598
    Williams, P.D., Piamjariyakul, U., Ducey, K., Badura, J., Boltz, K.D., Olberding, K., … Williams, A.R. (2006). Cancer treatment, symptom monitoring, and self-care in adults: Pilot study. Cancer Nursing, 29, 347-355. doi:10.1097/00002820-200609000-00001
    Wu, H.S., & McSweeney, M. (2001). Measurement of fatigue in people with cancer. Oncology Nursing Forum, 28, 1371-1384.