Abstract
Cancer-Related Fatigue, Psychological Symptoms (Anxiety and depression), and poor sleep quality are prevalent among patients with cancer undergoing chemotherapy. These psychological symptoms can significantly impair the overall well-being and treatment adherence of patients. To examine cancer-related fatigue, anxiety, depression, and sleep quality among patients receiving chemotherapy, and to determine how these symptoms vary according to selected demographic and clinical characteristics. A quantitative, cross-sectional study was conducted at An Najah National University Hospital. A convenience sample of 150 cancer patients receiving chemotherapy was recruited. Among 150 cancer patients receiving chemotherapy, fatigue was the most prevalent symptom (24.93 ± 13.05), with higher levels reported by males compared to females, t(147) = 2.49, P = .014, and by married patients (P < .001). Anxiety and depression affected 69.3% and 67.1% of patients, respectively, with 25.2% experiencing moderate to severe anxiety and 28.1% experiencing moderate to severe depression. 52.7% of patients reported poor sleep quality. Fatigue was strongly correlated with sleep quality (r = .644, P < .001) and moderately correlated with anxiety (r = .390, P < .01) and depression (r = .372, P < .01). Symptom severity varied significantly according to cancer stage (P < .01), type (P < .05), duration (P < .01), income, and education (P < .05). The findings underscore the critical need for comprehensive cancer care that addresses not only the physical aspects of fatigue and sleep disturbances but also the psychological impacts of anxiety and depression.
Background
Cancer patients receiving chemotherapy often endure a range of debilitating symptoms, including cancer-related fatigue (CRF), anxiety, depression, and sleep difficulties, which significantly impair functional status and quality of life. 1 Understanding the interplay between these factors is crucial for improving the overall well-being and quality of life of cancer patients. 2
Cancer-Related Fatigue (CRF)
CRF is one of the most prevalent and debilitating symptoms experienced by individuals undergoing chemotherapy. It disrupts physical functionality, treatment adherence, and psychosocial well-being. 3 Fatigue in cancer patients is multifactorial, with contributors including the disease itself, treatment-related factors (such as chemotherapy drugs and radiation therapy), psychological distress, sleep disturbances, anemia, nutritional deficiencies, and other comorbidities. 2 CRF, in particular, has been found to be closely associated with psychological and physical burden. 3 In a cross-sectional study, Charalambous and Kouta 4 found that approximately 67% of patients with advanced prostate cancer reported CRF, which was strongly linked to decreased quality of life.
Fatigue and depression are commonly co-occurring symptoms. A study by Lobefaro et al 5 found a strong correlation between cancer-related fatigue and depressive symptoms in patients with advanced solid tumors, with multivariate analysis confirming that depression and poor performance status were key predictors of fatigue. These findings underscore the importance of integrated symptom management in oncology care.
Anxiety and Depression
Anxiety and depression are common psychological symptoms experienced by patients with cancer, with prevalence rates varying depending on factors such as cancer type, stage, and individual characteristics. 6 Numerous factors, including the patient’s coping mechanisms, social support, previous psychiatric history, and perceived control over the illness, can influence the experience of cancer-related anxiety and depression. 7 Anxiety and depression can exacerbate fatigue and vice versa, creating a cycle of distress that impacts overall well-being and quality of life. 8
Sleep Disturbances
Sleep disturbances are prevalent among cancer patients undergoing chemotherapy. 9 These disturbances may include difficulty falling asleep, frequent awakenings during the night, early morning awakening, and non-restorative sleep. 10 Pain, medication effects, psychological distress, and circadian disruptions all contribute to poor sleep quality. 11 Poor sleep can further exacerbate fatigue, anxiety, and depression, reinforcing a cycle of symptom burden. 9
Growing evidence highlighted the interconnected nature of fatigue, psychological distress, and sleep disturbance form an interrelated symptom cluster affecting physical functioning, emotional well-being, and overall quality of life.4,5,9,12
Study Objectives
The present study aims to (1) assess the prevalence and severity of cancer-related fatigue, anxiety, depression, and sleep quality among patients undergoing chemotherapy; (2) examine the interrelationships among these symptoms; and (3) evaluate how demographic and clinical characteristics influence symptom severity.
Hypotheses
Methods
Study Design
The study was conducted using cross-sectional quantitative design.
Clinical Trial Number
Not applicable
Sample Population and Sampling
The sample population of this study is a patient with cancer undergoing chemotherapy at An Najah National University Hospital using convenience sampling. The sample size was calculated by G*power software, considering a medium effect size (0.3), a power of 0.95, with 10% attrition rate, then the required sample was 148.
Patients who were aged more than 18 years, diagnosed with cancer disease, undergoing chemotherapy, with normal mental and cognitive status in targeted hospital were included in the study. Patients who were admitted to the respected hospital for seeking treatment other than chemotherapy were excluded from the study.
Data Collection Tools and Process
The study instrument consisted of 3 parts: First part about demographic data, which include patient’s information about gender, marital status, educational background, type of chemotherapy, duration and disease stage. Second part about Functional Assessment of Chronic Illness Therapy – Fatigue Scale (FACIT-Fatigue), the scale had an internal consistency of 0.93. 13 Third Part about Hospital Anxiety and Depression Scale (HADS), the scale had good internal consistency (α = .7-.83). 14 In the fourth part, about Pittsburgh Sleep Quality Index (PSQI), the scale had acceptable internal consistency (α = .65). 15
Pilot Study
A pilot study with a sample of 15 patients was conducted to evaluate the reliability of the study instruments. The internal consistency, as evaluated by Cronbach’s alpha (α), demonstrated good to excellent reliability. The FACIT-Fatigue Scale showed good internal consistency (α = .826). The Hospital Anxiety and Depression Scale (HADS) subscales yielded excellent internal consistency, with α = .910 for the Anxiety subscale and α = .950 for the Depression subscale. Additionally, the Pittsburgh Sleep Quality Index (PSQI) demonstrated good reliability (α = .848). These results support the appropriateness of the instruments for use in the main study.
Statistical Analysis
The Statistical Package for Social Sciences (SPSS) software was used to analyze the responses in a quantitative manner, providing both descriptive and frequency results. The data analyzed without imputation. Descriptive analysis involved summarizing patient demographics, cancer diagnosis, and treatment status, as well as calculating response frequencies, means, and percentages. The study’s hypotheses were tested using appropriate correlational tests based on the types of each independent and dependent variable for the analytical results. Specifically, the analysis utilized descriptive statistics and frequencies, an independent t-test was used to compare means between 2 groups, ANOVA was used to compare means across multiple groups, the chi-square test was used to assess associations between categorical variables, and Spearman’s rank correlation test to investigate relationships between continuous variables. A Two-Way MANOVA was conducted to explore the combined effects of gender, marital status, education level, monthly income, cancer type, treatment type, cancer stage and duration of cancer on cancer related fatigue, anxiety, depression, and sleep quality.
Ethical Consideration
This study has been performed in accordance with the declaration of Helsinki and research ethical committee at An Najah National University Hospital. The Institutional Review Board (IRB) approval at An Najah National University was obtained before commencing the study (Nurs. Nov.2024/33). In addition, a written informed consent has been obtained from each participant. They have been assured that anonymity, confidentiality and the right to withdraw from study at any time is allowed. The participants have been asked to give their consent, and they have been assured that the information that was provided was not used against them. In addition, they have been assured that their right of confidentiality and anonymity was protected.
Findings
Demographic Data
A total of 150 patients undergoing chemotherapy participated in this study. The majority were female (62.7%), while 37.3% were male. Most participants were single (51.3%) and held a university degree (43.3%), followed by those with a secondary school education (32.7%). Regarding income level, 63.3%, 20.7%, and 16.0% reported a middle-income, high-income, and low-income status, respectively.
In terms of cancer type, 22.1% of the participants had breast cancer, 16.8% had lung cancer, 4.0% had digestive system cancers, and 57% were classified as having other types. Most participants (66.0%) were receiving chemotherapy, while the remainder received other forms of treatment. Regarding cancer stage, 46.3% had Stage I cancer, followed by Stage II (34%) cancer. The duration of cancer was reported as 1 to 6 months in 47.3% of cases, 6 months to 1 year in 27.7%, 1 to 2 years in 17.6%, and more than 3 years in 7.4%. Further details are shown in Table 1.
Demographic Characteristics of Participated Patients (n = 150).
Fatigue-Related Cancer
The mean fatigue score among the participants was 24.93 (SD = 13.05), the highest score indicating higher fatigue.
Anxiety and Depression
Regarding anxiety (Table 2), about 30.8% of participants were categorized as having normal anxiety levels, 44.1% had borderline anxiety, and 25.2% experienced moderate to severe anxiety symptoms. For depression, 32.9% of the participants were in the normal range, 39% were at a borderline level, and 28.1% reported moderate to severe depressive symptoms. These findings suggest that a significant number of patients experience heightened levels of psychological distress (anxiety and depression) while undergoing chemotherapy.
Severity of Anxiety and Depression.
Sleep Quality
More than half of participated patients (52.7%) experienced poor sleep quality.
Coloration between Fatigue, Anxiety, Depression, and Sleep Quality
Depression was strongly correlated with anxiety (r = .852, P < .01) and moderately correlated with sleep quality (r = .390, P < .01) and fatigue (r = .372, P < .01). Anxiety was moderately correlated with sleep quality (r = .401, P < .01) and fatigue (r = .390, P < .01). Fatigue was strongly correlated with sleep quality (r = .644, P < .01).
The Relationship Between Study Outcomes and Independent Variables
Fatigue
Male patients (M = 28.30, SD = 13.83) reported significantly higher levels of fatigue compared to female patients (M = 22.90, SD = 12.19), t(147) = 2.49, P = .014. Marital status was also associated with fatigue levels, with married individuals (M = 29.28, SD = 11.93) reporting higher fatigue scores than single individuals (M = 20.87, SD = 12.89), t(147) = 4.14, P < .001.
A one-way ANOVA revealed that income level had a significant effect on fatigue, F(2, 146) = 7.34, P = .001. Post hoc Tukey HSD testing showed that patients with high income reported significantly lower fatigue than those with moderate income (P = .001), while no significant differences were found between the other income groups.
Fatigue scores also significantly differed by cancer stage, F(3, 145) = 30.60, P < .001. Post hoc comparisons indicated that patients with stage I cancer had significantly lower fatigue scores than those with stage II (P = .001), stage III (P < .001), and stage IV (P < .001). Additionally, fatigue scores in stage II were significantly lower than those in stage III (P < .001) and stage IV (P = .001).
Duration of cancer was significantly associated with fatigue, F(3, 145) = 35.36, P < .001. Post hoc analysis indicated that patients with a longer illness duration reported significantly higher fatigue scores compared to those with a shorter duration (P < .05).
Anxiety
The income level was significantly associated with anxiety, F(2, 148) = 3.19, P = .044; however, post hoc Tukey HSD tests did not reveal significant differences between specific income groups. Anxiety levels varied significantly by cancer type, F(3, 147) = 4.43, P = .005, with patients diagnosed with gastrointestinal (GI) cancer reporting significantly lower anxiety than those with breast cancer (P = .002) and lung cancer (P = .002). Anxiety was also significantly associated with cancer stage, F(3, 147) = 30.60, P < .001. Post hoc tests indicated that patients in stage I had significantly lower anxiety than those in stage IV (P = .027).
Depression
A significant relationship was found between depression and cancer type, F(3, 141) = 3.22, P = .025. Post hoc tests revealed that patients with GI cancer had significantly lower depression scores than those with breast cancer (P = .019) and lung cancer (P = .050).
Sleep Quality
Married patients (M = 14.32, SD = 2.56) reported significantly poorer sleep quality than single patients (M = 12.81, SD = 2.68), t(147) = 3.46, P = .001. Sleep quality also significantly varied by education level, F(3, 143) = 3.43, P = .019, with secondary education level associated with significantly poorer sleep than university education (P = .014). The income level was significantly related to sleep quality, F(2, 144) = 10.04, P < .001. Patients with high incomes reported significantly better sleep quality compared to those with moderate income (P < .001).
Cancer stage significantly influenced sleep quality, F(3, 143) = 23.33, P < .001. Post hoc analysis revealed that patients with stage I cancer had significantly better sleep quality than those in stage II (P < .001), stage III (P < .001), and stage IV (P = .007). Duration of cancer also affected sleep quality, F(3, 143) = 14.39, P < .001. Patients with longer durations of illness reported significantly worse sleep quality than those with shorter durations (P < .05).
Multivariate analysis revealed a significant effect of gender on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality (Wilks’ Lambda = .869, F(4, 78) = 2.94, P = .026). There was a significant effect of marital status on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality (Wilks’ Lambda = .614, F(4, 78) = 12.34, P = .000). Additionally, a significant effect of education level on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality was found (Wilks’ Lambda = .312, F(12, 206.660) = 9.53, P = .000). Also, a significant effect of monthly income on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality was found (Wilks’ Lambda = .410, F(8, 156) = 10.91, P = .000). There was a significant effect of type of cancer on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality (Wilks’ Lambda = .313, F(12, 206.660) = 9.49, P = .000). Also, there was a significant effect of cancer stage on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality (Wilks’ Lambda = .311, F(12, 206.660) = 9.55, P = .000). A significant effect of cancer duration on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality was found (Wilks’ Lambda = .241, F(12, 206.660) = 12.28, P = .000). A significant effect of combined independent variables on the multivariate pattern of cancer-related fatigue, anxiety, depression, and sleep quality was found (Wilks’ Lambda = .014, F(144, 313.335) = 4.17, P = .000). Univariate tests for between-subjects effects were conducted to further examine the individual effects on cancer-related fatigue, anxiety, depression, and sleep quality. Gender exhibited significant effects on sleep quality F(1, 81) = 6.79 P = .011; Wilk’s Λ = .313, partial η 2 = . 077.
Discussion
This study sought to investigate cancer-related fatigue, anxiety, depression, and sleep quality in patients receiving chemotherapy and to understand the relationships between these symptoms and different demographic and clinical factors. A total of 150 participants were included, reflecting a varied sample across different cancer types, stages, and socioeconomic backgrounds.
Fatigue
Fatigue emerged as a prevalent and severe symptom, with a mean score of 24.93, reflecting moderate to high levels of cancer-related fatigue (CRF). This aligns with the findings of Charalambous and Kouta 4 who indicated that 66.9% of cancer patients experience CRF, which significantly impacts their quality of life. Additionally, Hendy et al 9 reported that 99.2% of patients experienced fatigue. The present study found that fatigue was most closely linked to advanced stages of cancer and extended illness durations, reflecting the results of Lobefaro et al 5 who recognized poor performance status and cancer-related distress as significant predictors of fatigue severity.
Fatigue was notably more pronounced among male patients than among females, which contrasts with the findings of Al Maqbali et al 16 This gender-based discrepancy may be attributable to cultural or psychological differences in illness perception, coping mechanisms, or social role expectations, highlighting the importance of gender-sensitive assessment strategies in oncology care.
Additionally, fatigue was significantly higher among married participants and those with moderate income levels. This may reflect increased caregiving responsibilities, psychological strain, or financial stress associated with managing chronic illness—factors known to influence fatigue and emotional distress. In addition, cancer stage was associated with fatigue which is consistent with a meta-analysis that showed that patients with advanced-stage cancer often report more intense fatigue. 17
Anxiety and Depression
Moreover, psychological distress was also notably prevalent in the study population. Approximately 42.0% of patients reported borderline anxiety levels, and 27.3% experienced moderate to severe depression. These findings align with previous research demonstrating the emotional burden of cancer and its treatment.5,9,18 A systematic review and meta-analysis reported that depression and anxiety prevalence among cancer patients. 19 Additionally, the same study discovered a strong correlation between advanced cancer and higher rates of both depression and anxiety.
A significant relationship was identified between anxiety and depression, reinforcing the idea that these symptoms often manifest together. Lobefaro et al 5 indicate that focusing on a specific psychological domain, such as anxiety, can frequently lead to advances in other areas, including depression. Additionally, depression and anxiety were moderately associated with fatigue, highlighting the relationship between psychological and physical symptoms.
The type of cancer was also a significant factor influencing psychological outcomes. Individuals diagnosed with breast or lung cancer exhibited elevated anxiety and depression scores compared to those with gastrointestinal (GI) cancers. The findings align with the research conducted by Van Noyen et al 20 and Zeilinger et al 21 which indicated a significant prevalence of anxiety and depressive disorders among breast cancer patients. This variation may arise from differences in prognosis, treatment intensity, or the societal visibility of specific cancer types. While income showed a statistical correlation with anxiety, subsequent analysis indicated no significant pairwise differences, implying that this relationship could be influenced by unmeasured variables such as coping mechanisms or support systems.
Sleep Quality
Sleep quality has been identified as a significant area of concern, with more than 50% of participants indicating that they experience poor sleep. The study conducted by Hendy et al 9 revealed that 87.4% of the target patients experienced poor sleep. Inadequate sleep exhibited a significant correlation with fatigue and a moderate association with anxiety and depression. The findings align with the study of Hendy et al 9 and Lee and Kim 22 who emphasized notable connections between sleep disturbances and psychological distress in cancer patients.
The quality of sleep was found to be influenced by educational level and income. Individuals with secondary education indicated lower sleep quality in comparison to their counterparts with university degrees—likely attributable to variations in health literacy, coping mechanisms, or availability of supportive resources. In a similar vein, individuals with higher incomes reported improved sleep quality, highlighting the significant influence of socioeconomic status on health outcomes.
Furthermore, individuals with advanced stages of cancer (III and IV) indicated notably worse sleep quality compared to those with earlier-stage conditions. This aligns with fatigue patterns and illustrates the cumulative impact of disease progression on both physical and psychological functioning.
Symptom Interdependence and Clinical Moderators
The study findings collectively illustrate a nuanced relationship between physical and psychological symptoms. The observed correlations among fatigue, anxiety, depression, and sleep quality indicate that these symptoms may mutually reinforce each other, potentially exacerbating patient distress. This dynamic can be analyzed through biopsychosocial model, 23 which indicates that health outcomes arise from the interplay of biological, psychological, and social factors.
Weber and O’Brien 24 established the link between fatigue and depression as well as anxiety, which is consistent with the findings of the current study. Ho et al 25 also demonstrated similar findings, indicating a correlation between depression, fatigue, and sleep disturbances. Several studies have corroborated the correlations noted.9,26
Various demographic and clinical factors impacted the severity of symptoms. Factors such as marital status, gender, education, income, and cancer stage have been identified as significant. For instance, the elevated fatigue levels observed in married patients may indicate role strain or emotional burden, whereas the higher levels of sleep quality noted in university-educated individuals might be associated with more efficient health management or better access to resources. The findings highlight the importance of considering individual differences in symptom burden assessment and management within oncology settings.
The interrelated symptoms can be attributed to overlapping neurobiological mechanisms, including inflammation and cytokine dysregulation induced by chemotherapy, which may concurrently influence mood regulation, sleep patterns, and energy levels. This is consistent with the psychoneuroimmunological perspective on distress related to cancer. For example, chemotherapy can result in painful neuropathies, cause energy depletion, and lead to sleep disturbances as the body tries to recover from the destruction of tumor cells. This pain could contribute to poor sleep resulting in persistent fatigue during day. 27 Psychological stress can result in the dysregulation of the sympathetic nervous system and hypothalamic-pituitary axis pathways, which may enhance the production of pro-inflammatory cytokines. 28 In addition, pro-inflammatory cytokines generated in reaction to tissue damage resulting from chemotherapy and cellular stress can activate central nervous system pathways that lead to hyperalgesia and pain, disturb sleep, and induce fatigue. 27 Also, higher inflammatory biomarkers may contribute to depression. 29
Finally, the geographical setting probably affected symptom experiences and reporting behaviors. Responsibilities to extended family, cultural norms about emotional expression, and the scarcity of psycho-oncology therapies may exacerbate psychological distress and exhaustion. Disparities in access to sleep or mental health therapies, especially within resource-limited healthcare systems, may further exacerbate the duration of these symptoms.
Clinical Implications
Incorporate comprehensive fatigue management into standard care protocols. Healthcare providers may implement structured fatigue management interventions. The programs should include physical activity initiatives, nutritional counseling, and strategies for energy conservation. Incorporate psychological support within oncology services. The significant levels of anxiety and depression reported by participants highlight the need for psychological interventions, such as cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and access to counseling services to improve emotional well-being. Implement therapies related to sleep. Given the widespread sleep disturbances noted, it is crucial for providers to offer education on sleep hygiene, apply behavioral sleep therapies, and incorporate relaxation techniques to improve sleep quality, ultimately reducing fatigue and distress. Healthcare providers are advised to employ validated screening instruments to assess fatigue, anxiety, depression, and sleep quality throughout the cancer care continuum, enabling early identification and prompt intervention. Future research will employ longitudinal designs to monitor symptom progression over time and explore potential mediators such as coping styles, social support, and performance status.
Study Limitations
This study presents several limitations that warrant acknowledgment. The cross-sectional design offers merely a single snapshot of patients’ experiences, which restricts the capacity to analyze the progression of fatigue, anxiety, depression, and sleep quality during the course of cancer treatment. Secondly, the utilization of self-reported questionnaires may lead to reporting bias, as participants might have either overestimated or underestimated their symptoms due to challenges in recall or the influence of social desirability. The lack of a control group consisting of non-cancer individuals limits the ability to directly compare symptom levels with those observed in the general population or other clinical cohorts. Furthermore, while various demographic and clinical variables were examined, other significant factors, including comorbidities, medication usage, and coping strategies, were not evaluated and could impact the observed relationships. The findings may exhibit limited generalizability, as the sample may not comprehensively represent all cancer populations or demographic subgroups. Future research utilizing larger and more diverse samples, in conjunction with more rigorous methodologies, is advised to enhance external validity and offer a more thorough understanding of these interconnected symptoms.
Conclusion
This study offers important details about the multifaceted symptom burden faced by cancer patients, especially concerning fatigue, anxiety, depression, and sleep quality. The varied participant sample indicated a significant occurrence of moderate to severe fatigue, along with considerable levels of anxiety and depression, which together hindered daily functioning and overall quality of life. Fatigue exhibited a significant correlation with inadequate sleep quality, particularly among patients experiencing advanced stages of cancer and extended disease duration. Furthermore, the type of cancer, its stage, and the treatment approach significantly impacted the severity of symptoms, highlighting the intricate relationships that affect the physical and psychological health of patients. The findings highlight the essential requirement for comprehensive symptom management strategies that encompass both psychological and physical aspects to improve overall patient outcomes in oncology care.
Footnotes
Acknowledgements
We would like to thank all patients who agreed to participate in this study.
Ethical Considerations
This study has been performed in accordance with the Declaration of Helsinki and the research ethics committee at An Najah National University and An Najah National University Hospital. The Institutional Review Board (IRB) approval at An Najah National University was obtained before commencing the study (Nurs. Nov.2024/33). Participants are guaranteed anonymity, confidentiality, and the right to withdraw from the study at any time.
Consent to Participate
A written informed consent has been obtained from each participant.
Author Contributions
Study conception and design: NBS, AA
Data collection: NBS
Data analysis and interpretation: NBS
Drafting of the article: NBS, AA
Critical revision of the article: NBS, AA
Both authors reviewed and accepted the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request