Outcome Measures of Fatigue in Adults with Cancer Receiving Radiation Therapy: A Scoping Review

Outcome Measures of Fatigue in Adults with Cancer Receiving Radiation Therapy: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Outcome Measures of Fatigue in Adults with Cancer Receiving Radiation Therapy: A Scoping Review Courtney Apostol, Danielle Hitch This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6917939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cancer-related fatigue (CRF) is a debilitating symptom experienced by many people undergoing radiation therapy, significantly impacting daily functioning and quality of life. Occupational therapists play a vital role in managing CRF, yet the lack of standardised outcome measures tailored to occupational therapy practice hinders effective assessment and intervention. This scoping review aimed to identify and map validated fatigue outcome measures suitable for outpatient radiotherapy settings and discuss their relevance to occupational therapy. Following the Arksey and O’Malley framework, a comprehensive search was conducted across MEDLINE, CINAHL, Embase, and PubMed, identifying 445 records. After screening, 12 studies published between 2010 and 2022 from seven countries were included. Breast, head and neck, and prostate cancers were commonly studied, most often using prospective cohort designs. Most studies used multidimensional, self-reported outcome measures, administered at multiple time throughout radiotherapy and at follow up. While these measures assessed physical, emotional, and cognitive fatigue, few addressed activity or participation in daily life. The findings highlight a gap in outcome measures that comprehensively evaluate activity and participation, which limits their utility in tailoring interventions or demonstrating the impact of occupational therapy. This review underscores the need for developing or adapting CRF outcome measures that better align with occupational therapy goals, to enhance clinical decision-making and research in outpatient radiotherapy settings. Health Economics & Outcomes Research Oncology Cancer Cancer-Related Fatigue Fatigue Outcome Measures Radiation Therapy Figures Figure 1 1. Introduction Cancer-related fatigue (CRF) is a pervasive, debilitating symptom that affects many adults with cancer, particularly those undergoing radiation therapy. It is defined as a distressing, persistent sense of tiredness or exhaustion linked to cancer or its treatment, which is disproportionate to recent activity (Andic et al., 2020 ). CRF is distinct from typical fatigue, being experienced as more severe and unrelieved by rest. It is reported by approximately 84% of patients receiving radiation therapy (Lam et al., 2022 ). The multidimensional nature of CRF encompasses profound energy depletion, mental exhaustion, and muscle aches (often alongside pain), emotional distress, and sleep difficulties (Andic et al. 2020 ). It can vary across the radiation therapy journey, meaning its impact on meaningful occupations may evolve over time. Therefore, it causes many people significant disruption to quality of life and daily functioning, posing important occupational challenges for outpatients striving to maintain participation in meaningful activity of daily life. 1.1 Radiotherapy and Cancer Related Fatigue Radiotherapy, also known as radiation therapy, uses high-energy radiation like X-rays, gamma rays, or charged particles, to target and destroy cancer cells (Hoskin, Ajithkumar, and Goh 2021 ). It may be administered using external beam radiation (where a machine directs radiation at the tumour), or internal methods (where radioactive sources are placed near or inside the tumour) (Hoskin, Ajithkumar, and Goh 2021 ). Radiotherapy may be used as a stand-alone treatment or in combination with surgery, chemotherapy, or immunotherapy. CRF is noted to accumulate gradually over the course of radiotherapy treatment and have a more significant impact on quality of life than that resulting from chemotherapy (Karthikeyan et al. 2012 ; Schwartz et al. 2000 ). Radiotherapy treatment for cancer may have a significant impact on the patients' ability to participate in daily life, particularly for older adults (Nehlsen et al. 2021 ). Patients often experience disruptions in eating, social interactions, and overall quality of life during and after treatment (Wells, 1998; Larsson et al., 2003; Larsson et al., 2007). Occupational engagement tends to decrease during treatment, with nearly half of patients not returning to baseline one month after radiotherapy (Efverman 2024 ). However, the occupational impact on social roles and activities varies due to the individual circumstances of patients, adjuvant chemotherapy regimens and cancer type (Han et al. 2020 ). 1.2 Occupational Therapy for Cancer Related Fatigue Occupational therapy is uniquely positioned to address these challenges, through the assessment of activity and participation to inform tailored interventions that enhance occupational performance (World Federation of Occupational Therapists 2012 ). Emerging evidence highlights the promise of several occupational therapy interventions, with exercise, physical activity programs and psychosocial interventions associated with reduced CRF and improved functional outcomes (Hunter et al. 2017 ; Urlic and Bennett 2010; Newman et al. 2024 ). The evidence for aerobic exercise is strong, while more moderate evidence exists for other occupational therapy interventions (Hunter et al. 2017 ). Group based occupational therapy has also been found to increase occupational performance and decrease fatigue (Udovicich et al. 2020 ). Energy conservation and activity pacing interventions are also utilised as part of broader fatigue management approaches by occupational therapists to support people experiencing CRF. A pilot study of energy conservation training followed by telephone monitoring sessions (Yuen, Mitcham, and Morgan 2006) found significant improvement in only the sensory aspects of fatigue and evaluated its efficacy as modest. All of these interventions may be combined with educational programs, relaxation techniques, problem solving strategies, environmental modifications and strategies for managing breathlessness as part of a package of rehabilitation or care (Vockins 2004 ; Akel, Şahin, and Zarif 2017). 1.3 Outcome Measures for Cancer Related Fatigue There are many assessment methods and outcome measures available for CRF, however best practice or a gold standard measure is yet to be identified (Pearson et al. 2021 ). The National Comprehensive Cancer Network (NCCN) (Berger et al. 2015 ) of the United States definition of CRF encompasses physical, emotional, cognitive and spiritual dimensions. However, current measures inconsistently evaluate variables such as fatigue occurrence, severity, or specific domains. Recent recommendations from Gentile et al. ( 2022 ) noted that no currently available measures encompass all domains of the NCCN definition, and their psychometric qualities are also less than optimal. Of relevance to occupational therapists is the ability of these outcome measures to evaluate activity and participation. The Fatigue Severity Scale (FSS) includes 2 out of 9 items about participation in activities of daily living (Krupp et al. 1989 ), while 4 out of 20 items on the Multidimensional Fatigue inventory (MFI) (Smets et al. 1995 ) assess reduced activity. The Patient Reported Outcomes Measurement Information System, Fatigue – Short Form (PROMIS F-SF) (Ameringer et al. 2016 ) only includes participation in social activities. All of these scales are patient rated outcome measures, and it remains unclear what other forms of evaluation occupational therapists undertake when enabling patients to manage CRF. This lack of standardisation complicates clinical decision-making and research, particularly in the context of radiation therapy where fatigue is a common concern. For occupational therapists, the scarcity of outcome measures focused on meaningful engagement in daily activities, roles, and routines creates a critical gap, which hinders their ability to monitor the impact of their interventions on enhancing their patients’ ability to maintain participation despite CRF. Without suitable outcome measures, occupational therapists are unable to assess the effectiveness of their interventions, tailor treatments to individual needs, or demonstrate the value of occupational therapy in improving outcomes for cancer survivors. 1.4 Rationale for this review CRF has a significant effect on adults undergoing radiotherapy and occupational therapy plays a critical role in maintaining participation and quality of life for these patients. The use of outcome measures which were not developed from an occupational perspective may be a barrier to gathering robust data that enables the monitoring of intervention effectiveness, informs the tailoring of interventions to individual needs and demonstrates the impact of occupational therapy interventions. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted to explore current evidence on this issue but found no existing or ongoing systematic or scoping reviews. This scoping review aimed to systematically identify and map validated fatigue outcome measures suitable for outpatient radiotherapy settings, with a particular emphasis on their relevance to occupational therapy practice. By synthesising the available evidence, the review sought to bridge the gap between current assessment tools and the practice needs of occupational therapists, ultimately enhancing their capacity to assess and manage CRF effectively. The review question guiding this investigation is: What validated outcome measures are available to guide occupational therapists working with people receiving radiotherapy and experiencing cancer-related fatigue? 2. Methods This scoping review proceeded in accordance with the methodological framework outlined by Arksey and O’Malley (2005), as adapted by the Joanna Briggs Institute ( 2015 ). This approach involved five sequential steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. A scoping review methodology was chosen due to its ability to map expansive and multifaceted evidence bases and pinpoint evidence gaps for future development. Ethics approval is not required, as this review includes previously published literature. The protocol for this review was registered on the Open Science Framework prior to its commencement ( https://doi.org/10.17605/OSF.IO/9XBQK ). 2.1. Eligibility Criteria The inclusion and exclusion criteria for this review were designed to ensure it captured relevant, contemporary evidence specific to adults with cancer undergoing radiation therapy. Articles were eligible for inclusion if they involved adults aged 18 years or older with a confirmed cancer diagnosis who were currently receiving radiotherapy or combined chemoradiation therapy. Outcome measures previously validated to assess CRF were included, provided they were published in English due to the language profile of the review team. All included studies had to have applied their outcome measure/s in a clinical practice setting. Only primary studies were reviewed, published after 1st January 2010 to ensure currency of findings. Evidence from any country and outpatient radiotherapy context was included, as the findings were anticipated to be broadly relevant to most patients receiving radiotherapy. Studies involving paediatric patients, children, young adults, or adolescents (under 18 years) were excluded, given the reviews focus on the adult population. Similarly, research focused solely on pain, quality of life (QoL), psychological distress, psycho-social factors (e.g., depression), chronic fatigue without a cancer diagnosis was excluded, as these variables are related to but do not directly assess fatigue in the context of radiotherapy. This ensures the included evidence remains centred on CRF as experienced during treatment, rather than broader symptomology or unrelated fatigue conditions. Studies examining outcome measures only in non-clinical settings or those focused exclusively on psychometric testing (e.g., validity or reliability) without application in clinical practice were also omitted, as these do not reflect the practical utility of measures in outpatient radiotherapy contexts. Finally, research exploring fatigue as a secondary outcome in relation to other variables was excluded to maintain a focus on outcome measures designed and validated primarily for CRF assessment, to ensure the findings were directly translatable to practice. 2.2. Search Strategy A comprehensive search strategy was employed to identify both published and unpublished studies (such as preprints). A draft search strategy was developed in consultation with a specialist hospital librarian and a limited search (see supplementary material) conducted in MEDLINE to refine keywords and Medical Subject Headings (MeSH) terms. These terms were then adapted for the final search conducted on 26th March 2025 across four databases: MEDLINE, CINAHL, Embase, and PubMed. The search used terms such as “cancer,” “fatigue,” “cancer-related fatigue,” “radiation therapy,” and “outcome measures,” combined with Boolean operators. The reference lists of included studies were also searched using the Connected Papers platform (Eitan et al. 2024 ), with 3 further potentially eligible studies identified. 2.3. Study Selection Citations identified through the search were imported into the Covidence platform (Veritas Health Innovation), which automatically removes duplicates. Two independent reviewers (CA, DH) independently screened the remaining 345 titles and abstracts against the eligibility criteria. Potentially relevant studies were retrieved in full text and re-assessed against the criteria by the same reviewers, with a small number of discrepancies resolved through discussion and consensus. All reasons for exclusion at the full-text stage were documented, and the overall selection process was reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram (Tricco et al., 2018 ). 2.4. Data Extraction Data was extracted by two independent reviewers (CA, DH) using a customized extraction tool developed within Covidence (Veritas Health Innovation). Extracted data included study characteristics (e.g., author, year, design), participant details (e.g., sample size, cancer type), context (e.g., outpatient radiotherapy setting), outcome measures (e.g., name, domains, administration method), and key findings relevant to CRF assessment. No modifications were required to the extraction form after it was applied to the review, and it was not necessary to contact any authors of included studies to request missing data. 2.5. Data Analysis and Presentation Consistent with scoping review methodology, the quality of included studies was not formally appraised, given focus is on mapping the evidence rather than synthesising effectiveness. Data was analysed descriptively, using numerical summaries to detail the quantity, design, and characteristics of included studies. A descriptive thematic analysis was also undertaken to identify key themes and concepts related to CRF outcome measures. All results are presented in tabular form accompanied by a narrative synthesis to highlight patterns, gaps, and implications for occupational therapy practice and future research. 3. Results The search and study selection process for this scoping review is summarized in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram (Fig. 1 ). The search initially identified 445 records, from which 100 duplicates were automatically deleted. Of the remaining studies, 39 were retrieved for full-text review, with 12 ultimately meeting the inclusion criteria and being included in the final analysis. The primary reasons for exclusion at the full-text stage included ineligible participant populations (e.g., paediatric or non-radiotherapy patients), outcome measures not validated for CRF, or studies lacking application in clinical practice settings. Additional hand-searching of reference lists via Connected Papers (Eitan et al. 2024 ) identified 3 potentially eligible studies, however all were screened out in the review process. 3.1 Study Characteristics As displayed in Table 1 , the included studies were published between 2010 and 2022 and originated from seven countries (United States n = 3; Canada and Sweden n = 2; Germany, Norway, Brazil and India n = 1). Current research is therefore concentrated in Western, high-income countries limiting presentations from global perspectives. Half the published studies adopted a prospective cohort method (n = 6, 50%), and a further four (33%) utilised descriptive or longitudinal designs. These methodologies indicate these outcome measures are being used to track changes in CRF over time, which aligns with their use in clinical contexts. However, the lack of experimental designs suggests they are not currently applied to studies of intervention efficacy. Sample sizes ranged between 36 to 881 participants, with a median of 88. Gender distribution was reported in 8 studies, showing a slight male predominance (47% female, 53% male across 1,676 participants with gender data). Mean or median ages, where reported, ranged from 57 to 64 years, which is consistent with general demographics for cancer patients in outpatient RT settings. Inclusion criteria varied between studies, exclusion criteria were not always reported, and the overall level of detail was inconsistent. All included studies recruited participants from clinical settings, the majority of which were drawn from general clinic populations. Breast cancer was the most frequently studied type (n = 5, 42%), followed by head and neck cancers (n = 3, 25%) and prostate cancer (n = 2%). While this reflects the prevalence of certain cancers at the study sites, the lack of participants with other common cancers (such as colorectal, lung and stomach cancer), may impact on the generalisability of these findings. The aims of included studies most frequently assessed the nature and course of CRF (n = 9, 75%), with some also investigating factors which cause CRF (n = 5, 42%). Some looked at the links between CRF and function or quality of life (n = 4, 33%), but only one (Andic et al. 2020 ) sought to guide clinical practice. While the first two themes provided data which can support tailored interventions, the limited focus on functional impact and translation to practice is an important gap in current knowledge for occupational therapists. Table 1 Characteristics of included studies Citation & Country Aim/s Design Recruitment / Sample Inclusion / Exclusion Type of Cancer Abel et al. ( 2022 ) Sweden Analyse patient-reported fatigue in patients with HNC receiving RT and explore possible association with organ-at-risk doses. Prospective Cohort Study Discussed at a regional tumour board n = 126 29 F (23%) 97 M (77%) Mean age: 60 Inclusion: Patients with newly diagnosed HNC referred for curative RT from 2008–2010. Exclusion: Not documented. HNC Oral n = 16 Oropharynx n = 80 Hypopharynx n = 9 Nasopharynx n = 11 Unknown primary n = 10 Andic et al. (2020) United States Determine RT-related changes in CRF across 3 timepoints and identify optimal MFI-20 thresholds warranting intervention. Prospective Cohort Study Clinic patients n = 88 88 F (100%) Age range: 26–75 Inclusion: Surgery with or without neoadjuvant/adjuvant chemotherapy followed by RT with or without hormone therapy. Exclusion: History of major psychiatric disorders or substance abuse / dependence in past 12 months. Breast Cheon et al. ( 2015 ) Canada Examine changes in fatigue scores for patients receiving RT for bone metastases and its impact on quality of life. Prospective Cohort Study Rapid Response Radiotherapy Program patients N = 881 Group 1: n = 399 191 F (48%) 208 M (52%) Mean age: 68 Group 2: n = 482 331 F (69%) 151 M (31%) Mean age: 60 Inclusion: Documented fatigue scores at baseline and one month follow up. Exclusion: Not documented. Bone metastases De Paula Avelar, Nicolussi, Toneti, Sonobe & Sawada (2019) Brazil Identify fatigue frequency and affected domains in patients with HNC undergoing RT, at the beginning, middle, and end of treatment. Longitudinal and prospective study of quasi-experimental design Clinic patients n = 60 7 F (12%) 53 M (88%) Age Groups: 18–20 (n = 2, 3%) 21–40 (n = 27, 45%) 41–60 (n = 28, 47%) 61–80 (n = 3, 5%) Inclusion: 18 + years, HNC diagnosis, at beginning of RT. Exclusion: Unable to answer simple questions HNC Dickinson, Kupzyk & Saligan ( 2021 ) United States Describe the multidimensional fatigue experience of men with prostate cancer before, during, and after RT Descriptive longitudinal study Clinic patients n = 57 (n = 47 RT + ADT), n = 10 = RT only) 57 M (100%) Mean age: 66 Inclusion: 21 + years, scheduled to receive ERBT Exclusion: Inflammatory condition, infection, other types of cancer, history of major psychiatric disorders or substance abuse / dependence in past 5 years, chemotherapy before EBRT, taking steroids, nonsteroidal anti-inflammatories or tranquilizers. Prostate Fransson ( 2010 ) Sweden Determine the frequency, severity and changes in fatigue during external beam RT and up to 5 years afterward, and whether this was a predictor for increased fatigue during treatment. Prospective Cohort Study Clinic patients n = 407 407 M (100%) Mean age: 66 Inclusion: Prostrate cancer diagnosis Exclusion: Not documented. Prostate Hauth et al. ( 2021 ) Germany Investigate the impact of RT on CRF and overall QoL in breast cancer patients Prospective Cohort Study Clinic patients n = 66 66 F (100%) Median age: 57 Inclusion: Breast cancer diagnosis, indication for adjuvant curative RT, completion of baseline and follow up outcome measures. Exclusion: Not documented. Breast Lam et al. ( 2022 ) Canada Identify trends and risk factors in patient-reported fatigue associated with breast RT. Prospective Cohort Study Clinic patients n = 651 651 F (100%) Median age: 59 Inclusion: ESAS completed before or during RT. Exclusion: Not documented. Breast Poirier ( 2011 ) United States Identify the impact of fatigue, site-specific side effects, and individual characteristics on role activities during RT. Secondary Data Analysis Clinic patients n = 77 45 F (58%) 32 M (42%) Mean age: 54 Inclusion: Minimum 4 weeks of curative or adjuvant RT, Karnofsky Performance Status Scale (KPSS) > 70, working at the time of cancer diagnosis. Exclusion: Receiving brain RT or for palliative intent, coexisting unstable medical or psychiatric diagnoses. Multiple Breast n = 34 Lung n = 13 HNC n = 10 Abdomen / pelvis n = 9 Pulenzas et al. ( 2014 ) Canada Determine changes in fatigue score following whole brain RT. Retrospective Cohort Study Clinic patients n = 264 Group 1: n = 36 22 F (61%) 14 M (39%) Mean age: 64 Group 2: n = 228 77 F (34%) 151 M (66%) Mean age: 63 Inclusion: Only receiving WBRT. Exclusion: Patients receiving other treatments. Metastatic Brain Raju, Crasta, Rodrigues, Johny, D’Souza & Denitha(2022) India Assess fatigue in cancer patients who receive RT. Quantitative descriptive research design Admitted and community RT patients. n = 138 70 F (51%) 68 M (49%) Age range: 20–65 Inclusion: Aged 20–65 years, any malignancy diagnosis, receiving RT only. Exclusion: Not documented. Multiple Reproductive n = 50 Gastrointestinal n = 20 Respiratory n = 4 Haematological n = 3 HNC n = 61 Reidunsdattter et al. (2013) Norway Explore whether modern RT, alone and in combination with adjuvant treatments, influenced the level and the course of fatigue in breast cancer patients during RT and over 12 months. Prospective longitudinal study Clinic patients n = 245 (n = 231 at follow up) 245 F (98%) Mean Age: 58 Inclusion: Referred for post-operative local or locoregional RT either alone or in addition to CT, no metastatic disease, no physical or psychological disorders that would interfere with participation, able to speak and understand Norwegian. Exclusion: Patients who developed metastatic disease during follow up. Breast Note: ADT = Androgen Deprivation Therapy, CRF = Cancer Related Fatigue, CT = Chemotherapy, F = Female, HNC = Head and Neck Cancer, M = Male, MFI = Multidimensional Fatigue Inventory, QoL = Quality of Life, RT = Radiotherapy / Radiation Therapy, U/K = Unknown 3.2 Outcome Measures Table 2 presents a summary of the outcome measures identified in the included studies which specifically targeted fatigue, along with those measuring other outcomes. Thirteen different fatigues tools were employed, including various formats, content, and administration schedules. The majority were multidimensional outcome measures (n = 10, 83%) where fatigue was measured on a subscale or subset of questions. Three tools (e.g., the Brief Fatigue Inventory (BFI), the Fatigue-Intensity Rating (FIR), the Fatigue Assessment Scale (FAS)) were unidimensional and measured fatigue as a single construct. Four multidimensional fatigue tools were identified - the European Organisation for Research and Treatment of Cancer Fatigue scale (EORTC FA12), the Multidimensional Fatigue Inventory 20 (MFI-20), the Piper Fatigue Scale (PFS), and the Revised Piper Fatigue Scale (RPFS). These outcome measures offered insight into CRF across several domains, including general fatigue, physical fatigue, activity participation, and cognition. The populations in which these outcome measures were originally validated also varied. While some measures were developed for multiple cancer populations (such as the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30 item (EORTC QLQ-C30)) others were originally designed for specific cancer or other populations. For example, the RPFS was originally validated with breast cancer patients (e.g., RPFS), while the FAS was developed for people with systemic lupus erythematosus. This may have implications for the generalisability to populations with which they have not been validated and may also decrease their sensitivity to detecting fatigue in patients with other cancers. Most measures were self-reported and completed in clinical settings at multiple timepoints—usually baseline, during treatment, and at follow-up following RT. Some studies completed postal surveys (e.g., Abel et al. 2022 ; Fransson 2010 ), while others utilised interviews to administer their tools (e.g., De Paula Avelar et al. 2019 ). However, several included studies did not clearly report how their outcome measures were administered. Most were administered alongside other outcome measures, which typically assessed overall quality of life or symptom burden. Commonly co-administered tools were other tools included in the EORTC suite of outcome measures, and the Edmonton Symptom Assessment System (ESAS). The number of fatigue-related items included on each outcome measure ranged from as few as 1 (FIR) to as many as 22 (RPFS), indicating significant diversity in how CRF is contextualised across the outcome measures. However, only 6 (46%) of the included fatigue measures or subscales included items specific to activity, participation, or role performance – the BFI, EORTC QLQ-C, the European Organisation for Research and Treatment of Cancer Core 15 Palliative (EORTC 15-PAL), MFI-20, RPFS, the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue subscale and the FAS. Table 2 Outcome Measures Citation & Country CRF tool Dim. Original population # Fatigue Items / Domains Administration in study Other tools Abel et al. ( 2022 ) Sweden EORTC FA12 Multi Diverse cancer patients 12 items, 3 domains – physical, emotional and cognitive fatigue Mailed for completion at baseline and 1, 3, 6, 12, 24, and 60 months after RT. EORTC QLQ-C30 Andic et al. (2020) United States FIR MFI-20 Uni Multi FIR Not reported MFI-20 Breast cancer FIR 1 item (1–3 mild, 4–6 moderate, 7–10 severe) MFI-20 20 items, 5 domains - general fatigue, physical fatigue, mental fatigue, reduced activity, and reduced motivation Method of administration unclear. Both outcome measures completed at baseline, last week of RT and 6 weeks post RT. N/A Cheon et al. ( 2015 ) Canada ESAS EORTC QLQ C-15-PAL Multi Multi ESAS Diverse cancer patients in palliative care EORTC QLQ-C15-PAL Diverse cancer patients in palliative care ESAS 2/9 items EORTC QLQ-C15-PAL 2/15 items Completed in the clinic at baseline, 1-, 2-, and 3-months following RT. QLQ-C30 ESAS – all other questions QCQ-C15-PAL – all other questions De Paula Avelar et al. ( 2019 ) Brazil RPFS Multi Breast cancer 22 items, 4 domains - behavioural/severity, sensory, cognitive/mood, affective Administered by interview, at baseline, middle and end of RT. N/A Dickinson et al. ( 2021 ) United States RPFS Multi Breast cancer 22 items, 4 domains - behavioural/severity, sensory, cognitive/mood, affective Method of administration: Medical records and self-reported questionnaires. Administered at baseline, before RT initiation, RT midpoint, RT completion, and at 1, 3, 6, and 12-months post RT. Hamilton Depression Rating Scale (HAM-D) Patient-Reported Outcomes Measurement Information System v1.0-Sleep Disturbance (PROMIS-SD) Fransson ( 2010 ) Sweden EORTC QLQ-C30 Multi Diverse cancer patients 3/30 items Administered in clinic initially, and then by mail at later time points. Completed before RT, 3 months, 1 year, 3 years and 5 years post RT. EORTC QLQ-C30 - all other questions Hauth et al. ( 2021 ) Germany FACIT - fatigue Multi Diverse cancer patients 13/40 items (Fatigue subscale only) Administered in clinic before post operative RT, end of RT and 10-month follow-up. FACIT-G – all other questions Lam et al. ( 2022 ) Canada ESAS Multi Diverse advanced cancer patients 2/9 items Administered weekly in clinic visits or by follow up phone calls at baseline, weekly during RT, 6 weeks, 1 month and 3 months post RT. ESAS – all other questions Poirier ( 2011 ) United States RPFS BFI Multi Uni PFS Breast cancer BFI Diverse cancer patients PFS 4/22 items BFI 9 items Administered in clinic at baseline, weekly during RT, and 1 month post RT. N/A Pulenzas et al. ( 2014 ) Canada ESAS BASIQ EORTC QLQ-C30 EORTC QLQ-C15-PAL FACT-G Multi Multi Multi Multi Multi ESAS Diverse cancer patients in palliative care BASIQ Brain metastases population EORTC QLQ-C30 Diverse cancer patients EORTC QLQ-C15-PAL Diverse cancer patients in palliative care FACT-G Diverse cancer patients ESAS 2/9 items BASIQ 2/18 items QLQ-C30 3/30 items EORTC QLQ-C15-PAL 2/15 items FACT-G 2 /27items Method of administration unclear as reused from previously conducted studies. Administered at baseline and follow up between 1- and 3-months post RT. All other questions on: ESAS BASIQ EORTC QLQ-C30 EORTC QLQ-C15-PAL FACT-G Spitzer Quality of Life Index (SQLI) EORTC Quality of Life-Brain module (EORTC QLQ-BN20 + 2) Raju et al. ( 2022 ) India FAS Uni Fatigue in individuals with systemic lupus erythematosus (SLE) and general chronic conditions 10 items Administered in the clinic, but timepoints were unclear. N/A Reidunsdattter et al. (2013) Norway EORTC QLQ-C30 Multi Diverse cancer patients QLQ-C30 3/30 items Administered in clinic at baseline, end of RT, 3, 6 and 13-months post RT. N/A Note: BASIQ = Brain Symptom and Impact Questionnaire, BFI = Brief Fatigue Inventory, Dim. = Dimensionality, EORTC = European Organisation for Research and Treatment of Cancer, EORTC-FA12 = EORTC Cancer Related Fatigue, EORTC QLQ C-15-PAL = EORTC Core 15 Palliative, EORTC-QLQ-C30 = EORTC Quality of Life Questionnaire 30 item, ESAS = Edmonton Symptom Assessment System, FACIT-F = Functional Assessment of Chronic Illness Therapy - Fatigue, FACT-G = Functional Assessment of Cancer Therapy-General, FAS = Fatigue Assessment Scale, FIR = Fatigue-Intensity Rating, MFI-20 = Multidimensional Fatigue Inventory 20, N/A = Not Applicable, PFS = Piper Fatigue Scale, RFS = Revised Piper Fatigue Scale 4. Discussion This scoping review identified 12 studies that employed validated outcome measures to assess CRF in adults receiving RT, with a total of 13 unique tools utilized across diverse cancer populations and outpatient settings. Most of these measures were multidimensional, although the range of items included in the tools indicates inconsistencies in how CRF is conceptualised. Methods of administration also lacked standardisation across the studies, with no two taking the same approach to evaluating CRF. Most tools do not specifically address the impact of CRF on activity and participation, which significantly hinders our ability to evaluate its functional impact on daily life and social roles. These results provide an important insight into the current landscape of CRF assessment and their relevance to occupational therapy practice, particularly regarding supporting cancer patients to manage fatigue while engaging in meaningful occupations. The predominance of multidimensional outcome measures aligns with the National Comprehensive Cancer Network’s (NCCN) definition of CRF, which includes physical, emotional, cognitive, and spiritual dimensions (Berger et al. 2015 ). However, the few items specifically targeting participation in daily activities across these tools (e.g., only 2/9 items in ESAS or 3/30 in EORTC QLQ-C30) is a barrier to taking advantage of their comprehensive approach to CRF when assessing the functional impact of CRF. Participation in meaningful occupations make a fundamental contribution to overall quality of life, however, health professionals often underestimate its prevalence and importance to health and wellbeing (Williams et al. 2016 ). Occupational therapists should consider how directly their chosen measure evaluates the links between activity, participation and CRF, and multidimensional fatigue specific outcome measures are recommended for holistic assessment. The selection of fatigue related items from scales designed to evaluate other outcomes (such as quality of life) is also a problematic approach. Item-level analysis can improve predictive performance in some cases (Pratiwi et al. 2023 ), and may also be a pragmatic approach which reduces respondent burden. However, choosing items which are not part of a designated fatigue subscale can limit their validity, reliability and sensitivity (Cohen and Swerdlik 2017 ), and also may challenge interpretation if the degree to which the item overlaps with other constructs (like pain or distress) is not clear. If isolated items are used, occupational therapists should acknowledge they are a proxy measure of fatigue and justify why a validated fatigue scale is inappropriate in their context. In occupational therapy practice, CRF scales are utilised as both screening tools and outcome measures. Both approaches are important, however there is little available research into the use of these tools as outcome measures in healthcare (Cohn et al. 2022 ). Given the prevalence of CRF, patients should be regularly screened following diagnosis to avoid undertreatment and inform occupational therapy care plans (Blickle et al. 2023 ). CRF can accumulate over the course of RT, and its dynamic nature is further confirmed by the often longitudinal, repeated application of these outcome measures in the included studies (Karthikeyan et al. 2012 ). Tracking CRF over time provides valuable information for occupational therapists, that enables the tailoring of interventions like energy conservation and activity pacing to specific phases of treatment. However, the absence of experimental designs indicates these tools are primarily used for descriptive purposes currently, and further exploration of their ability to evaluate intervention efficacy is needed to demonstrate the value of occupational therapy interventions (Newman et al. 2024 ). The findings of this review reflect the National Comprehesive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Cancer-Related Fatigue (2025), which are updated annually. This guideline draws on the most up to date research and clinical experience in the field and confirms that fatigue in patients with cancer is underreported, underdiagnosed, and undertreated. As a result, these guidelines commend the screening of all patients for fatigue using a numeric scale of 0–10 (where 0–3 is mild, 4–6 is moderate, and 6–10 is severe). The guidelines also propose a treatment algorithm to regularly re-evaluate patients for fatigue using a brief screening instrument to guide individualise treatment guided by their fatigue level. The guidelines also provide a list of 14 recommended tools for assessing cancer-related fatigue (five of which were identified in this review) but acknowledges there are multiple barriers to screening in practice settings for various reasons (National Comprehesive Cancer Network 2025 ). Comprehensive assessment of CRF also requires observational evaluations along with data from patient rated outcome measures like those described here. Objective measures of sleep and rest-activity cycles have been found to correlate with fatigue severity in cancer survivors (Martin et al. 2021 ). However, the broad scope of items in the reviewed outcome measures (which often refer only to ‘daily life’) doesn’t account for nuanced differences in the impact of fatigue on different occupations. They don’t provide RT patients much opportunity to reflect on the full range of meaningful occupations in their lives and may therefore lead to an underestimation of its impact. Occupational therapists should therefore combine these outcome measures with observational or objective assessment techniques to obtain a comprehensive understanding of how CRF affects occupational engagement for everyone. Variance in reporting of the included studies also poses challenges for occupational therapists wishing to understand the evidence base. Gender is not reported in some studies, and age is described using means, medians, age groups and ranges, both of which limits sample comparison between groups. Some study aspects, including administration procedures are poorly described. For example, the content and format of the FIR (Andic et al. 2020 ) is not clearly described and there are few other references in the broader literature to provide additional information. Occupational therapists must therefore critically appraise supporting evidence to properly assess its relevance to their own practice. 4.1 Implications of the findings The findings of this scoping review highlight several practical considerations for occupational therapists using CRF outcome measures in their practice. Self-reported tools appear to be feasible in outpatient RT contexts, but their co-administration with other measures may increase patient burden, particularly for people already experiencing fatigue. Unidimensional tools offer simplicity but lack the depth of exploration needed to inform tailored interventions. Multidimensional tools are more time-intensive but are generally more suited to the requirements of high-quality assessment. Cancer diagnosis can lead to significant distress and overwhelm, and patients early in their cancer journey may struggle to fully participate in their care (Boyes et al. 2022 ). Occupational therapists must balance the advantages and disadvantages of each approach to find tools which enable a focus on activity and participation while also remaining practical for clinical use. The absence of a gold standard for CRF assessment, as noted by Gentile et al. ( 2022 ), remains a challenge. While tools like the MFI-20 and FSS include some items related to activity and participation, no measure fully aligns with the multidimensional definition of CRF proposed by the National Comprehensive Cancer Network (NCCN) or comprehensively addresses occupational therapy’s focus on functional outcomes. This underscores the need for future development of CRF outcome measures that prioritise functional outcomes, such as engagement in daily activities and social roles, to better support clinical decision-making and intervention planning in RT settings. The triangulation of multiple forms of assessment (i.e., patient rated, observational, objective) at various stages of RT treatment and follow up remains the recommended approach for now. 4.2 Limitations Limitations related to both the included studies and the scoping methodology itself should be considered when interpreting these findings for practice. Geographical and cancer type biases in the studies highlight significant gaps in the evidence base. Most published research originates from high-income Western countries, which limits the generalisability of findings to diverse global populations, where cultural and healthcare system factor may be influential on CRF experiences and needs (Pearson et al. 2021 ). Similarly, the overrepresentation of breast, head and neck, and prostate cancers (collectively 83% of studies) omits other prevalent cancers, such as colorectal or lung cancer, which may have unique fatigue profiles. For occupational therapists, this lack of diversity complicates the selection of outcome measures that are broadly applicable across patient populations, indicating a need for inclusion of underrepresented groups and settings in future research. The studies also reflect choice made by researchers, within a research context. For example, the original (40 item) and revised (22 item) versions of the PFS were utilised in three studies (de Paula Avelar et al. 2019 ; Dickinson, Kupzyk, and Saligan 2021 ; Poirier 2011 ). However, a brief 12 item version of the tool has been available for over a decade (Reeve et al. 2012 ) and covers all four dimensions of CRF – general, physical, cognitive and emotional fatigue (Rothmund et al. 2024 ). Confusingly, both the 12 and 22 item version of this scale are called the revised PFS in the literature. Its brevity may make it more suitable to clinical contexts, but it may not collect sufficient information from the research point of view. This gap between what appears in the evidence based and the actuality of clinical practice adds complexity to translating these findings into occupational therapy practice. Regarding the review methodology adopted, the restriction to English-language publications also contributes to the previously noted geographical bias. The inclusion of studies published after January 2010 ensured currency but may have omitted earlier foundational work on CRF outcome measures including tools which remain in clinical use. The exclusion of studies focused solely on psychometric testing or non-clinical settings ensured a focus on practical utility but may have overlooked emerging tools in development or those validated in controlled settings. In addition, the lack of formal quality appraisal, while consistent with scoping review methodology (Arksey and O'Malley 2005 ), means that the rigour of included studies was not evaluated which may affect the reliability of the findings. 5. Conclusion This scoping review systematically mapped validated outcome measures for assessing CRF in adults receiving radiation therapy, with a focus on their relevance to occupational therapy practice. The 12 included studies predominantly utilised self-reported multidimensional fatigue outcome measures. These measures were primarily administered in clinical settings across multiple timepoints, with most studies completed with people with breast, head and neck, or prostate cancers. The findings highlight a lack of outcome measures designed to capture the occupational impact of CRF on participation in meaningful activities, roles, and routines. Future research should prioritise the development and validation of outcome measures that specifically assess the occupational dimensions of CRF and capture its impact on daily life. These tools should align with the NCCN’s multidimensional framework (Gentile et al. 2022 ) and incorporate patient-centred domains relevant to occupational therapy practice. Studies exploring CRF in underrepresented cancer types and diverse cultural contexts are also needed to enhance the generalisability of findings. To address practical challenges, future development should also focus on standardising administration protocols and ensuring measures are feasible for routine use in outpatient RT settings where patients received only a single session of occupational therapy. Engaging occupational therapists, patients and/or cancer survivors in the co-design of these tools could ensure they meet clinical needs and facilitate tailored interventions. Experimental studies evaluating the efficacy of occupational therapy interventions, such as energy conservation, activity pacing, and psychosocial programs, are also needed to establish their utility in clinical practice. Finally, longitudinal studies tracking CRF beyond the immediate post-radiotherapy period could provide insights into its sustained occupational impact, informing rehabilitation strategies that support lifelong participation and quality of life for cancer survivors. By addressing these gaps, occupational therapists can better assess and manage CRF and enhance their ability to support adults undergoing RT in maintaining meaningful engagement in daily life. Declarations 7. Data availability Data sharing not applicable to this article as no datasets were generated or analysed during the current study. 8. Conflicts of interest The authors declare that there is no conflict of interest regarding the publication of this article. 9. Funding statement This review was completed as part of the employment of the authors at Western Health, Melbourne, Australia. 10. Acknowledgements We acknowledge the Traditional Owners of country on which this work was produced - the Wurundjeri Woi Wurrung peoples of the Kulin Nation. We recognise their continuing connection to land, waters and culture, and we pay our respects to their Elders past, present and emerging. Authors would also like to acknowledge the contribution of the Western Health Allied Health Strategy, Planning, Innovation, Research and Education (ASPIRE) unit Stepping into Research program to the completion of this review. References Abel E, Silander E, Nordström F, Olsson C, Brodin NP, Nyman J, Björk-Eriksson T, Hammerlid E (2022) Fatigue in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Prospective Study of Patient-Reported Outcomes and Their Association With Radiation Dose to the Cerebellum. Adv Radiat Oncol 7(5):100960. https://doi.org/10.1016/j.adro.2022.100960 Akel B, Semin S, Şahin, Zarif M (2017) Occupational Therapy in Oncology and Palliative Care. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6917939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":472797844,"identity":"1ae6f97a-84cc-4966-b127-0fc2d2231ba1","order_by":0,"name":"Courtney Apostol","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABF0lEQVRIiWNgGAWjYBAC/gYYixlCyfAz8ODXInEASIAwAztIcwIDj2QDAS0GDjAtPAcgWgwOENLC3mP2+eMOm8QGidyDD3/+sOExvpF7gOHjnloG/hkJ2LXwnDGecfBMGlBLXrIxT0Iaj9mNvATGGc+OM0jcwKFFIseY4WDbYaCWHDNphoTDPGa3cwyYeQ4cY2DAr+V/YoP8GzPJH0AtxrOhWuRxaYkAazkAtkWCB6jFQBqspYbBAIcWiTPHihnOtiUbt4H9kpbGI3H/jcHBGQcO8BieeYBVC39782aGyjY72X5QiP2wsZHj7zlj+ODDgTo5uePYbYEBxzbkSD/AwHCYQOwwMNgzoKWTOkI6RsEoGAWjYOQAACcXX9bmx7VOAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0006-3343-3904","institution":"Western Health","correspondingAuthor":true,"prefix":"","firstName":"Courtney","middleName":"","lastName":"Apostol","suffix":""},{"id":472797845,"identity":"9995fa41-3e5a-4bb5-ad07-07f099854393","order_by":1,"name":"Danielle Hitch","email":"","orcid":"https://orcid.org/0000-0003-2798-2246","institution":"Deakin University / Western Health","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"Hitch","suffix":""}],"badges":[],"createdAt":"2025-06-18 01:19:55","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6917939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6917939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84946061,"identity":"e24c4963-75da-4c56-854c-7fbaeb954119","added_by":"auto","created_at":"2025-06-19 06:12:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65714,"visible":true,"origin":"","legend":"\u003cp\u003eStudy Selection Process (Tricco et al. 2018)\u003c/p\u003e","description":"","filename":"ApostolFig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6917939/v1/9ea2b9e0093da51c224de5e1.png"},{"id":84946732,"identity":"10c0b643-5178-457c-a3be-330e498912a0","added_by":"auto","created_at":"2025-06-19 06:28:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":996041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6917939/v1/672534c8-ccdf-4471-84ef-ffb86430eb80.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eOutcome Measures of Fatigue in Adults with Cancer Receiving Radiation Therapy: A Scoping Review\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCancer-related fatigue (CRF) is a pervasive, debilitating symptom that affects many adults with cancer, particularly those undergoing radiation therapy. It is defined as a distressing, persistent sense of tiredness or exhaustion linked to cancer or its treatment, which is disproportionate to recent activity (Andic et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). CRF is distinct from typical fatigue, being experienced as more severe and unrelieved by rest. It is reported by approximately 84% of patients receiving radiation therapy (Lam et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe multidimensional nature of CRF encompasses profound energy depletion, mental exhaustion, and muscle aches (often alongside pain), emotional distress, and sleep difficulties (Andic et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). It can vary across the radiation therapy journey, meaning its impact on meaningful occupations may evolve over time. Therefore, it causes many people significant disruption to quality of life and daily functioning, posing important occupational challenges for outpatients striving to maintain participation in meaningful activity of daily life.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Radiotherapy and Cancer Related Fatigue\u003c/h2\u003e \u003cp\u003eRadiotherapy, also known as radiation therapy, uses high-energy radiation like X-rays, gamma rays, or charged particles, to target and destroy cancer cells (Hoskin, Ajithkumar, and Goh \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It may be administered using external beam radiation (where a machine directs radiation at the tumour), or internal methods (where radioactive sources are placed near or inside the tumour) (Hoskin, Ajithkumar, and Goh \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Radiotherapy may be used as a stand-alone treatment or in combination with surgery, chemotherapy, or immunotherapy. CRF is noted to accumulate gradually over the course of radiotherapy treatment and have a more significant impact on quality of life than that resulting from chemotherapy (Karthikeyan et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Schwartz et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2000\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRadiotherapy treatment for cancer may have a significant impact on the patients' ability to participate in daily life, particularly for older adults (Nehlsen et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Patients often experience disruptions in eating, social interactions, and overall quality of life during and after treatment (Wells, 1998; Larsson et al., 2003; Larsson et al., 2007). Occupational engagement tends to decrease during treatment, with nearly half of patients not returning to baseline one month after radiotherapy (Efverman \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, the occupational impact on social roles and activities varies due to the individual circumstances of patients, adjuvant chemotherapy regimens and cancer type (Han et al. \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Occupational Therapy for Cancer Related Fatigue\u003c/h2\u003e \u003cp\u003eOccupational therapy is uniquely positioned to address these challenges, through the assessment of activity and participation to inform tailored interventions that enhance occupational performance (World Federation of Occupational Therapists \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Emerging evidence highlights the promise of several occupational therapy interventions, with exercise, physical activity programs and psychosocial interventions associated with reduced CRF and improved functional outcomes (Hunter et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Urlic and Bennett 2010; Newman et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The evidence for aerobic exercise is strong, while more moderate evidence exists for other occupational therapy interventions (Hunter et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Group based occupational therapy has also been found to increase occupational performance and decrease fatigue (Udovicich et al. \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEnergy conservation and activity pacing interventions are also utilised as part of broader fatigue management approaches by occupational therapists to support people experiencing CRF. A pilot study of energy conservation training followed by telephone monitoring sessions (Yuen, Mitcham, and Morgan 2006) found significant improvement in only the sensory aspects of fatigue and evaluated its efficacy as modest. All of these interventions may be combined with educational programs, relaxation techniques, problem solving strategies, environmental modifications and strategies for managing breathlessness as part of a package of rehabilitation or care (Vockins \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Akel, Şahin, and Zarif 2017).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Outcome Measures for Cancer Related Fatigue\u003c/h2\u003e \u003cp\u003eThere are many assessment methods and outcome measures available for CRF, however best practice or a gold standard measure is yet to be identified (Pearson et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The National Comprehensive Cancer Network (NCCN) (Berger et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) of the United States definition of CRF encompasses physical, emotional, cognitive and spiritual dimensions. However, current measures inconsistently evaluate variables such as fatigue occurrence, severity, or specific domains. Recent recommendations from Gentile et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) noted that no currently available measures encompass all domains of the NCCN definition, and their psychometric qualities are also less than optimal.\u003c/p\u003e \u003cp\u003eOf relevance to occupational therapists is the ability of these outcome measures to evaluate activity and participation. The Fatigue Severity Scale (FSS) includes 2 out of 9 items about participation in activities of daily living (Krupp et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1989\u003c/span\u003e), while 4 out of 20 items on the Multidimensional Fatigue inventory (MFI) (Smets et al. \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) assess reduced activity. The Patient Reported Outcomes Measurement Information System, Fatigue \u0026ndash; Short Form (PROMIS F-SF) (Ameringer et al. \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) only includes participation in social activities. All of these scales are patient rated outcome measures, and it remains unclear what other forms of evaluation occupational therapists undertake when enabling patients to manage CRF.\u003c/p\u003e \u003cp\u003eThis lack of standardisation complicates clinical decision-making and research, particularly in the context of radiation therapy where fatigue is a common concern. For occupational therapists, the scarcity of outcome measures focused on meaningful engagement in daily activities, roles, and routines creates a critical gap, which hinders their ability to monitor the impact of their interventions on enhancing their patients\u0026rsquo; ability to maintain participation despite CRF. Without suitable outcome measures, occupational therapists are unable to assess the effectiveness of their interventions, tailor treatments to individual needs, or demonstrate the value of occupational therapy in improving outcomes for cancer survivors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Rationale for this review\u003c/h2\u003e \u003cp\u003eCRF has a significant effect on adults undergoing radiotherapy and occupational therapy plays a critical role in maintaining participation and quality of life for these patients. The use of outcome measures which were not developed from an occupational perspective may be a barrier to gathering robust data that enables the monitoring of intervention effectiveness, informs the tailoring of interventions to individual needs and demonstrates the impact of occupational therapy interventions.\u003c/p\u003e \u003cp\u003eA preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted to explore current evidence on this issue but found no existing or ongoing systematic or scoping reviews. This scoping review aimed to systematically identify and map validated fatigue outcome measures suitable for outpatient radiotherapy settings, with a particular emphasis on their relevance to occupational therapy practice. By synthesising the available evidence, the review sought to bridge the gap between current assessment tools and the practice needs of occupational therapists, ultimately enhancing their capacity to assess and manage CRF effectively.\u003c/p\u003e \u003cp\u003eThe review question guiding this investigation is: What validated outcome measures are available to guide occupational therapists working with people receiving radiotherapy and experiencing cancer-related fatigue?\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis scoping review proceeded in accordance with the methodological framework outlined by Arksey and O\u0026rsquo;Malley (2005), as adapted by the Joanna Briggs Institute (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This approach involved five sequential steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. A scoping review methodology was chosen due to its ability to map expansive and multifaceted evidence bases and pinpoint evidence gaps for future development. Ethics approval is not required, as this review includes previously published literature. The protocol for this review was registered on the Open Science Framework prior to its commencement (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.17605/OSF.IO/9XBQK\u003c/span\u003e\u003cspan address=\"10.17605/OSF.IO/9XBQK\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Eligibility Criteria\u003c/h2\u003e \u003cp\u003eThe inclusion and exclusion criteria for this review were designed to ensure it captured relevant, contemporary evidence specific to adults with cancer undergoing radiation therapy. Articles were eligible for inclusion if they involved adults aged 18 years or older with a confirmed cancer diagnosis who were currently receiving radiotherapy or combined chemoradiation therapy. Outcome measures previously validated to assess CRF were included, provided they were published in English due to the language profile of the review team. All included studies had to have applied their outcome measure/s in a clinical practice setting. Only primary studies were reviewed, published after 1st January 2010 to ensure currency of findings. Evidence from any country and outpatient radiotherapy context was included, as the findings were anticipated to be broadly relevant to most patients receiving radiotherapy.\u003c/p\u003e \u003cp\u003eStudies involving paediatric patients, children, young adults, or adolescents (under 18 years) were excluded, given the reviews focus on the adult population. Similarly, research focused solely on pain, quality of life (QoL), psychological distress, psycho-social factors (e.g., depression), chronic fatigue without a cancer diagnosis was excluded, as these variables are related to but do not directly assess fatigue in the context of radiotherapy. This ensures the included evidence remains centred on CRF as experienced during treatment, rather than broader symptomology or unrelated fatigue conditions.\u003c/p\u003e \u003cp\u003eStudies examining outcome measures only in non-clinical settings or those focused exclusively on psychometric testing (e.g., validity or reliability) without application in clinical practice were also omitted, as these do not reflect the practical utility of measures in outpatient radiotherapy contexts. Finally, research exploring fatigue as a secondary outcome in relation to other variables was excluded to maintain a focus on outcome measures designed and validated primarily for CRF assessment, to ensure the findings were directly translatable to practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Search Strategy\u003c/h2\u003e \u003cp\u003eA comprehensive search strategy was employed to identify both published and unpublished studies (such as preprints). A draft search strategy was developed in consultation with a specialist hospital librarian and a limited search (see supplementary material) conducted in MEDLINE to refine keywords and Medical Subject Headings (MeSH) terms. These terms were then adapted for the final search conducted on 26th March 2025 across four databases: MEDLINE, CINAHL, Embase, and PubMed. The search used terms such as \u0026ldquo;cancer,\u0026rdquo; \u0026ldquo;fatigue,\u0026rdquo; \u0026ldquo;cancer-related fatigue,\u0026rdquo; \u0026ldquo;radiation therapy,\u0026rdquo; and \u0026ldquo;outcome measures,\u0026rdquo; combined with Boolean operators. The reference lists of included studies were also searched using the Connected Papers platform (Eitan et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), with 3 further potentially eligible studies identified.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Study Selection\u003c/h2\u003e \u003cp\u003eCitations identified through the search were imported into the Covidence platform (Veritas Health Innovation), which automatically removes duplicates. Two independent reviewers (CA, DH) independently screened the remaining 345 titles and abstracts against the eligibility criteria. Potentially relevant studies were retrieved in full text and re-assessed against the criteria by the same reviewers, with a small number of discrepancies resolved through discussion and consensus. All reasons for exclusion at the full-text stage were documented, and the overall selection process was reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram (Tricco et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data Extraction\u003c/h2\u003e \u003cp\u003e Data was extracted by two independent reviewers (CA, DH) using a customized extraction tool developed within Covidence (Veritas Health Innovation). Extracted data included study characteristics (e.g., author, year, design), participant details (e.g., sample size, cancer type), context (e.g., outpatient radiotherapy setting), outcome measures (e.g., name, domains, administration method), and key findings relevant to CRF assessment. No modifications were required to the extraction form after it was applied to the review, and it was not necessary to contact any authors of included studies to request missing data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Data Analysis and Presentation\u003c/h2\u003e \u003cp\u003eConsistent with scoping review methodology, the quality of included studies was not formally appraised, given focus is on mapping the evidence rather than synthesising effectiveness. Data was analysed descriptively, using numerical summaries to detail the quantity, design, and characteristics of included studies. A descriptive thematic analysis was also undertaken to identify key themes and concepts related to CRF outcome measures. All results are presented in tabular form accompanied by a narrative synthesis to highlight patterns, gaps, and implications for occupational therapy practice and future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe search and study selection process for this scoping review is summarized in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The search initially identified 445 records, from which 100 duplicates were automatically deleted. Of the remaining studies, 39 were retrieved for full-text review, with 12 ultimately meeting the inclusion criteria and being included in the final analysis. The primary reasons for exclusion at the full-text stage included ineligible participant populations (e.g., paediatric or non-radiotherapy patients), outcome measures not validated for CRF, or studies lacking application in clinical practice settings. Additional hand-searching of reference lists via Connected Papers (Eitan et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) identified 3 potentially eligible studies, however all were screened out in the review process.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Characteristics\u003c/h2\u003e \u003cp\u003eAs displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the included studies were published between 2010 and 2022 and originated from seven countries (United States n\u0026thinsp;=\u0026thinsp;3; Canada and Sweden n\u0026thinsp;=\u0026thinsp;2; Germany, Norway, Brazil and India n\u0026thinsp;=\u0026thinsp;1). Current research is therefore concentrated in Western, high-income countries limiting presentations from global perspectives. Half the published studies adopted a prospective cohort method (n\u0026thinsp;=\u0026thinsp;6, 50%), and a further four (33%) utilised descriptive or longitudinal designs. These methodologies indicate these outcome measures are being used to track changes in CRF over time, which aligns with their use in clinical contexts. However, the lack of experimental designs suggests they are not currently applied to studies of intervention efficacy.\u003c/p\u003e \u003cp\u003eSample sizes ranged between 36 to 881 participants, with a median of 88. Gender distribution was reported in 8 studies, showing a slight male predominance (47% female, 53% male across 1,676 participants with gender data). Mean or median ages, where reported, ranged from 57 to 64 years, which is consistent with general demographics for cancer patients in outpatient RT settings. Inclusion criteria varied between studies, exclusion criteria were not always reported, and the overall level of detail was inconsistent.\u003c/p\u003e \u003cp\u003eAll included studies recruited participants from clinical settings, the majority of which were drawn from general clinic populations. Breast cancer was the most frequently studied type (n\u0026thinsp;=\u0026thinsp;5, 42%), followed by head and neck cancers (n\u0026thinsp;=\u0026thinsp;3, 25%) and prostate cancer (n\u0026thinsp;=\u0026thinsp;2%). While this reflects the prevalence of certain cancers at the study sites, the lack of participants with other common cancers (such as colorectal, lung and stomach cancer), may impact on the generalisability of these findings.\u003c/p\u003e \u003cp\u003eThe aims of included studies most frequently assessed the nature and course of CRF (n\u0026thinsp;=\u0026thinsp;9, 75%), with some also investigating factors which cause CRF (n\u0026thinsp;=\u0026thinsp;5, 42%). Some looked at the links between CRF and function or quality of life (n\u0026thinsp;=\u0026thinsp;4, 33%), but only one (Andic et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) sought to guide clinical practice. While the first two themes provided data which can support tailored interventions, the limited focus on functional impact and translation to practice is an important gap in current knowledge for occupational therapists.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCitation \u0026amp; Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAim/s\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRecruitment / Sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion / Exclusion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eType of Cancer\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbel et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnalyse patient-reported fatigue in patients with HNC receiving RT and explore possible association with organ-at-risk doses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiscussed at a regional tumour board\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;126\u003c/p\u003e \u003cp\u003e29 F (23%)\u003c/p\u003e \u003cp\u003e97 M (77%)\u003c/p\u003e \u003cp\u003eMean age: 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Patients with newly diagnosed HNC referred for curative RT from 2008\u0026ndash;2010.\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHNC\u003c/p\u003e \u003cp\u003eOral n\u0026thinsp;=\u0026thinsp;16 Oropharynx n\u0026thinsp;=\u0026thinsp;80 Hypopharynx n\u0026thinsp;=\u0026thinsp;9 Nasopharynx n\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e \u003cp\u003eUnknown primary n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndic et al. (2020)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDetermine RT-related changes in CRF across 3 timepoints and identify optimal MFI-20 thresholds warranting intervention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;88\u003c/p\u003e \u003cp\u003e88 F (100%)\u003c/p\u003e \u003cp\u003eAge range: 26\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Surgery with or without neoadjuvant/adjuvant chemotherapy followed by RT with or without hormone therapy.\u003c/p\u003e \u003cp\u003eExclusion: History of major psychiatric disorders or substance abuse / dependence in past 12 months.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCheon et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExamine changes in fatigue scores for patients receiving RT for bone metastases and its impact on quality of life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRapid Response Radiotherapy Program patients\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;881\u003c/p\u003e \u003cp\u003eGroup 1:\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;399\u003c/p\u003e \u003cp\u003e191 F (48%)\u003c/p\u003e \u003cp\u003e208 M (52%)\u003c/p\u003e \u003cp\u003eMean age: 68\u003c/p\u003e \u003cp\u003eGroup 2:\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;482\u003c/p\u003e \u003cp\u003e331 F (69%)\u003c/p\u003e \u003cp\u003e151 M (31%)\u003c/p\u003e \u003cp\u003eMean age: 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Documented fatigue scores at baseline and one month follow up.\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBone metastases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Paula Avelar, Nicolussi, Toneti, Sonobe \u0026amp; Sawada (2019)\u003c/p\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentify fatigue frequency and affected domains in patients with HNC undergoing RT, at the beginning, middle, and end of treatment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLongitudinal and prospective study of quasi-experimental design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e \u003cp\u003e7 F (12%)\u003c/p\u003e \u003cp\u003e53 M (88%)\u003c/p\u003e \u003cp\u003eAge Groups:\u003c/p\u003e \u003cp\u003e18\u0026ndash;20 (n\u0026thinsp;=\u0026thinsp;2, 3%)\u003c/p\u003e \u003cp\u003e21\u0026ndash;40 (n\u0026thinsp;=\u0026thinsp;27, 45%)\u003c/p\u003e \u003cp\u003e41\u0026ndash;60 (n\u0026thinsp;=\u0026thinsp;28, 47%)\u003c/p\u003e \u003cp\u003e61\u0026ndash;80 (n\u0026thinsp;=\u0026thinsp;3, 5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: 18\u0026thinsp;+\u0026thinsp;years, HNC diagnosis, at beginning of RT.\u003c/p\u003e \u003cp\u003eExclusion: Unable to answer simple questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHNC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDickinson, Kupzyk \u0026amp; Saligan (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescribe the multidimensional fatigue experience of men with prostate cancer before, during, and after RT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescriptive longitudinal study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;57 (n\u0026thinsp;=\u0026thinsp;47 RT\u0026thinsp;+\u0026thinsp;ADT), n\u0026thinsp;=\u0026thinsp;10\u0026thinsp;=\u0026thinsp;RT only)\u003c/p\u003e \u003cp\u003e57 M (100%)\u003c/p\u003e \u003cp\u003eMean age: 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: 21\u0026thinsp;+\u0026thinsp;years, scheduled to receive ERBT\u003c/p\u003e \u003cp\u003eExclusion: Inflammatory condition, infection, other types of cancer, history of major psychiatric disorders or substance abuse / dependence in past 5 years, chemotherapy before EBRT, taking steroids, nonsteroidal anti-inflammatories or tranquilizers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFransson (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDetermine the frequency, severity and changes in fatigue during external beam RT and up to 5 years afterward, and whether this was a predictor for increased fatigue during treatment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;407\u003c/p\u003e \u003cp\u003e407 M (100%)\u003c/p\u003e \u003cp\u003eMean age: 66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Prostrate cancer diagnosis\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProstate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHauth et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvestigate the impact of RT on CRF and overall QoL in breast cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003cp\u003e66 F (100%)\u003c/p\u003e \u003cp\u003eMedian age: 57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Breast cancer diagnosis, indication for adjuvant curative RT, completion of baseline and follow up outcome measures.\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLam et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentify trends and risk factors in patient-reported fatigue associated with breast RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;651\u003c/p\u003e \u003cp\u003e651 F (100%)\u003c/p\u003e \u003cp\u003eMedian age: 59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: ESAS completed before or during RT.\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoirier (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIdentify the impact of fatigue, site-specific side effects, and individual characteristics on role activities during RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary Data Analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003cp\u003e45 F (58%)\u003c/p\u003e \u003cp\u003e32 M (42%)\u003c/p\u003e \u003cp\u003eMean age: 54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Minimum 4 weeks of curative or adjuvant RT, Karnofsky Performance Status Scale (KPSS)\u0026thinsp;\u0026gt;\u0026thinsp;70, working at the time of cancer diagnosis.\u003c/p\u003e \u003cp\u003eExclusion: Receiving brain RT or for palliative intent, coexisting unstable medical or psychiatric diagnoses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003cp\u003eBreast n\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e \u003cp\u003eLung n\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003cp\u003eHNC n\u0026thinsp;=\u0026thinsp;10\u003c/p\u003e \u003cp\u003eAbdomen / pelvis n\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulenzas et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDetermine changes in fatigue score following whole brain RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective Cohort Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;264\u003c/p\u003e \u003cp\u003eGroup 1:\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e \u003cp\u003e22 F (61%)\u003c/p\u003e \u003cp\u003e14 M (39%)\u003c/p\u003e \u003cp\u003eMean age: 64\u003c/p\u003e \u003cp\u003eGroup 2:\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;228\u003c/p\u003e \u003cp\u003e77 F (34%)\u003c/p\u003e \u003cp\u003e151 M (66%) Mean age: 63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Only receiving WBRT.\u003c/p\u003e \u003cp\u003eExclusion: Patients receiving other treatments.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMetastatic Brain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRaju, Crasta, Rodrigues, Johny, D\u0026rsquo;Souza \u0026amp; Denitha(2022)\u003c/p\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAssess fatigue in cancer patients who receive RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative descriptive research design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdmitted and community RT patients.\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;138\u003c/p\u003e \u003cp\u003e70 F (51%)\u003c/p\u003e \u003cp\u003e68 M (49%)\u003c/p\u003e \u003cp\u003eAge range: 20\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Aged 20\u0026ndash;65 years, any malignancy diagnosis, receiving RT only.\u003c/p\u003e \u003cp\u003eExclusion: Not documented.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003cp\u003eReproductive n\u0026thinsp;=\u0026thinsp;50 Gastrointestinal n\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e \u003cp\u003eRespiratory n\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003eHaematological n\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003cp\u003eHNC n\u0026thinsp;=\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReidunsdattter et al. (2013)\u003c/p\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplore whether modern RT, alone and in combination with adjuvant treatments, influenced the level and the course of fatigue in breast cancer patients during RT and over 12 months.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective longitudinal study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClinic patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;245 (n\u0026thinsp;=\u0026thinsp;231 at follow up)\u003c/p\u003e \u003cp\u003e245 F (98%)\u003c/p\u003e \u003cp\u003eMean Age: 58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInclusion: Referred for post-operative local or locoregional RT either alone or in addition to CT, no metastatic disease, no physical or psychological disorders that would interfere with participation, able to speak and understand Norwegian.\u003c/p\u003e \u003cp\u003eExclusion: Patients who developed metastatic disease during follow up.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNote: ADT\u0026thinsp;=\u0026thinsp;Androgen Deprivation Therapy, CRF\u0026thinsp;=\u0026thinsp;Cancer Related Fatigue, CT\u0026thinsp;=\u0026thinsp;Chemotherapy, F\u0026thinsp;=\u0026thinsp;Female, HNC\u0026thinsp;=\u0026thinsp;Head and Neck Cancer, M\u0026thinsp;=\u0026thinsp;Male, MFI\u0026thinsp;=\u0026thinsp;Multidimensional Fatigue Inventory, QoL\u0026thinsp;=\u0026thinsp;Quality of Life, RT\u0026thinsp;=\u0026thinsp;Radiotherapy / Radiation Therapy, U/K\u0026thinsp;=\u0026thinsp;Unknown\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Outcome Measures\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a summary of the outcome measures identified in the included studies which specifically targeted fatigue, along with those measuring other outcomes. Thirteen different fatigues tools were employed, including various formats, content, and administration schedules. The majority were multidimensional outcome measures (n\u0026thinsp;=\u0026thinsp;10, 83%) where fatigue was measured on a subscale or subset of questions.\u003c/p\u003e \u003cp\u003eThree tools (e.g., the Brief Fatigue Inventory (BFI), the Fatigue-Intensity Rating (FIR), the Fatigue Assessment Scale (FAS)) were unidimensional and measured fatigue as a single construct. Four multidimensional fatigue tools were identified - the European Organisation for Research and Treatment of Cancer Fatigue scale (EORTC FA12), the Multidimensional Fatigue Inventory 20 (MFI-20), the Piper Fatigue Scale (PFS), and the Revised Piper Fatigue Scale (RPFS). These outcome measures offered insight into CRF across several domains, including general fatigue, physical fatigue, activity participation, and cognition.\u003c/p\u003e \u003cp\u003eThe populations in which these outcome measures were originally validated also varied. While some measures were developed for multiple cancer populations (such as the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30 item (EORTC QLQ-C30)) others were originally designed for specific cancer or other populations. For example, the RPFS was originally validated with breast cancer patients (e.g., RPFS), while the FAS was developed for people with systemic lupus erythematosus. This may have implications for the generalisability to populations with which they have not been validated and may also decrease their sensitivity to detecting fatigue in patients with other cancers.\u003c/p\u003e \u003cp\u003eMost measures were self-reported and completed in clinical settings at multiple timepoints\u0026mdash;usually baseline, during treatment, and at follow-up following RT. Some studies completed postal surveys (e.g., Abel et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Fransson \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), while others utilised interviews to administer their tools (e.g., De Paula Avelar et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). However, several included studies did not clearly report how their outcome measures were administered. Most were administered alongside other outcome measures, which typically assessed overall quality of life or symptom burden. Commonly co-administered tools were other tools included in the EORTC suite of outcome measures, and the Edmonton Symptom Assessment System (ESAS).\u003c/p\u003e \u003cp\u003eThe number of fatigue-related items included on each outcome measure ranged from as few as 1 (FIR) to as many as 22 (RPFS), indicating significant diversity in how CRF is contextualised across the outcome measures. However, only 6 (46%) of the included fatigue measures or subscales included items specific to activity, participation, or role performance \u0026ndash; the BFI, EORTC QLQ-C, the European Organisation for Research and Treatment of Cancer Core 15 Palliative (EORTC 15-PAL), MFI-20, RPFS, the Functional Assessment of Chronic Illness Therapy (FACIT) fatigue subscale and the FAS.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome Measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCitation \u0026amp; Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCRF tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDim.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOriginal population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e# Fatigue Items / Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministration in study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOther tools\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbel et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEORTC FA12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 items, 3 domains \u0026ndash; physical, emotional and cognitive fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMailed for completion at baseline and 1, 3, 6, 12, 24, and 60 months after RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndic et al. (2020)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFIR\u003c/p\u003e \u003cp\u003eMFI-20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUni\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFIR\u003c/span\u003e\u003c/p\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMFI-20\u003c/span\u003e\u003c/p\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFIR\u003c/span\u003e\u003c/p\u003e \u003cp\u003e1 item (1\u0026ndash;3 mild, 4\u0026ndash;6 moderate, 7\u0026ndash;10 severe)\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMFI-20\u003c/span\u003e\u003c/p\u003e \u003cp\u003e20 items, 5 domains - general fatigue, physical fatigue, mental fatigue, reduced activity, and reduced motivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMethod of administration unclear. Both outcome measures completed at baseline, last week of RT and 6 weeks post RT. \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCheon et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESAS\u003c/p\u003e \u003cp\u003eEORTC QLQ C-15-PAL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eESAS\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients in palliative care\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEORTC QLQ-C15-PAL\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients in palliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eESAS\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2/9 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEORTC QLQ-C15-PAL\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2/15 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompleted in the clinic at baseline, 1-, 2-, and 3-months following RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQLQ-C30\u003c/p\u003e \u003cp\u003eESAS \u0026ndash; all other questions\u003c/p\u003e \u003cp\u003eQCQ-C15-PAL \u0026ndash; all other questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDe Paula Avelar et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRPFS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 items, 4 domains - behavioural/severity, sensory, cognitive/mood, affective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered by interview, at baseline, middle and end of RT. \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDickinson et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRPFS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22 items, 4 domains - behavioural/severity, sensory, cognitive/mood, affective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMethod of administration: Medical records and self-reported questionnaires. Administered at baseline, before RT initiation, RT midpoint, RT completion, and at 1, 3, 6, and 12-months post RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHamilton Depression Rating Scale (HAM-D)\u003c/p\u003e \u003cp\u003ePatient-Reported Outcomes Measurement Information System v1.0-Sleep Disturbance (PROMIS-SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFransson (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3/30 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered in clinic initially, and then by mail at later time points. Completed before RT, 3 months, 1 year, 3 years and 5 years post RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEORTC QLQ-C30 - all other questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHauth et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFACIT - fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13/40 items (Fatigue subscale only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered in clinic before post operative RT, end of RT and 10-month follow-up.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFACIT-G \u0026ndash; all other questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLam et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiverse advanced cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2/9 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered weekly in clinic visits or by follow up phone calls at baseline, weekly during RT, 6 weeks, 1 month and 3 months post RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eESAS \u0026ndash; all other questions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoirier (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRPFS\u003c/p\u003e \u003cp\u003eBFI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eUni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePFS\u003c/span\u003e\u003c/p\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBFI\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePFS\u003c/span\u003e\u003c/p\u003e \u003cp\u003e4/22 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBFI\u003c/span\u003e\u003c/p\u003e \u003cp\u003e9 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered in clinic at baseline, weekly during RT, and 1 month post RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulenzas et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eESAS\u003c/p\u003e \u003cp\u003eBASIQ\u003c/p\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003cp\u003eEORTC QLQ-C15-PAL\u003c/p\u003e \u003cp\u003eFACT-G\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eESAS\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients in palliative care\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBASIQ\u003c/span\u003e\u003c/p\u003e \u003cp\u003eBrain metastases population\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEORTC QLQ-C30\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEORTC QLQ-C15-PAL\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients in palliative care\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFACT-G\u003c/span\u003e\u003c/p\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eESAS\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2/9 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBASIQ\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2/18 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eQLQ-C30\u003c/span\u003e\u003c/p\u003e \u003cp\u003e3/30 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEORTC QLQ-C15-PAL\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2/15 items\u003c/p\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFACT-G\u003c/span\u003e\u003c/p\u003e \u003cp\u003e2 /27items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMethod of administration unclear as reused from previously conducted studies. Administered at baseline and follow up between 1- and 3-months post RT. \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAll other questions on:\u003c/p\u003e \u003cp\u003eESAS\u003c/p\u003e \u003cp\u003eBASIQ\u003c/p\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003cp\u003eEORTC QLQ-C15-PAL\u003c/p\u003e \u003cp\u003eFACT-G\u003c/p\u003e \u003cp\u003eSpitzer Quality of Life Index (SQLI)\u003c/p\u003e \u003cp\u003eEORTC Quality of Life-Brain module (EORTC QLQ-BN20\u0026thinsp;+\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRaju et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFatigue in individuals with systemic lupus erythematosus (SLE) and general chronic conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered in the clinic, but timepoints were unclear.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReidunsdattter et al. (2013)\u003c/p\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEORTC QLQ-C30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMulti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiverse cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eQLQ-C30\u003c/span\u003e\u003c/p\u003e \u003cp\u003e3/30 items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdministered in clinic at baseline, end of RT, 3, 6 and 13-months post RT.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNote: BASIQ\u0026thinsp;=\u0026thinsp;Brain Symptom and Impact Questionnaire, BFI\u0026thinsp;=\u0026thinsp;Brief Fatigue Inventory, Dim. = Dimensionality, EORTC\u0026thinsp;=\u0026thinsp;European Organisation for Research and Treatment of Cancer, EORTC-FA12\u0026thinsp;=\u0026thinsp;EORTC Cancer Related Fatigue, EORTC QLQ C-15-PAL\u0026thinsp;=\u0026thinsp;EORTC Core 15 Palliative, EORTC-QLQ-C30\u0026thinsp;=\u0026thinsp;EORTC Quality of Life Questionnaire 30 item, ESAS\u0026thinsp;=\u0026thinsp;Edmonton Symptom Assessment System, FACIT-F\u0026thinsp;=\u0026thinsp;Functional Assessment of Chronic Illness Therapy - Fatigue, FACT-G\u0026thinsp;=\u0026thinsp;Functional Assessment of Cancer Therapy-General, FAS\u0026thinsp;=\u0026thinsp;Fatigue Assessment Scale, FIR\u0026thinsp;=\u0026thinsp;Fatigue-Intensity Rating, MFI-20\u0026thinsp;=\u0026thinsp;Multidimensional Fatigue Inventory 20, N/A\u0026thinsp;=\u0026thinsp;Not Applicable, PFS\u0026thinsp;=\u0026thinsp;Piper Fatigue Scale, RFS\u0026thinsp;=\u0026thinsp;Revised Piper Fatigue Scale\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e This scoping review identified 12 studies that employed validated outcome measures to assess CRF in adults receiving RT, with a total of 13 unique tools utilized across diverse cancer populations and outpatient settings. Most of these measures were multidimensional, although the range of items included in the tools indicates inconsistencies in how CRF is conceptualised. Methods of administration also lacked standardisation across the studies, with no two taking the same approach to evaluating CRF. Most tools do not specifically address the impact of CRF on activity and participation, which significantly hinders our ability to evaluate its functional impact on daily life and social roles. These results provide an important insight into the current landscape of CRF assessment and their relevance to occupational therapy practice, particularly regarding supporting cancer patients to manage fatigue while engaging in meaningful occupations.\u003c/p\u003e \u003cp\u003eThe predominance of multidimensional outcome measures aligns with the National Comprehensive Cancer Network\u0026rsquo;s (NCCN) definition of CRF, which includes physical, emotional, cognitive, and spiritual dimensions (Berger et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, the few items specifically targeting participation in daily activities across these tools (e.g., only 2/9 items in ESAS or 3/30 in EORTC QLQ-C30) is a barrier to taking advantage of their comprehensive approach to CRF when assessing the functional impact of CRF. Participation in meaningful occupations make a fundamental contribution to overall quality of life, however, health professionals often underestimate its prevalence and importance to health and wellbeing (Williams et al. \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Occupational therapists should consider how directly their chosen measure evaluates the links between activity, participation and CRF, and multidimensional fatigue specific outcome measures are recommended for holistic assessment.\u003c/p\u003e \u003cp\u003eThe selection of fatigue related items from scales designed to evaluate other outcomes (such as quality of life) is also a problematic approach. Item-level analysis can improve predictive performance in some cases (Pratiwi et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and may also be a pragmatic approach which reduces respondent burden. However, choosing items which are not part of a designated fatigue subscale can limit their validity, reliability and sensitivity (Cohen and Swerdlik \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), and also may challenge interpretation if the degree to which the item overlaps with other constructs (like pain or distress) is not clear. If isolated items are used, occupational therapists should acknowledge they are a proxy measure of fatigue and justify why a validated fatigue scale is inappropriate in their context.\u003c/p\u003e \u003cp\u003eIn occupational therapy practice, CRF scales are utilised as both screening tools and outcome measures. Both approaches are important, however there is little available research into the use of these tools as outcome measures in healthcare (Cohn et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Given the prevalence of CRF, patients should be regularly screened following diagnosis to avoid undertreatment and inform occupational therapy care plans (Blickle et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). CRF can accumulate over the course of RT, and its dynamic nature is further confirmed by the often longitudinal, repeated application of these outcome measures in the included studies (Karthikeyan et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Tracking CRF over time provides valuable information for occupational therapists, that enables the tailoring of interventions like energy conservation and activity pacing to specific phases of treatment. However, the absence of experimental designs indicates these tools are primarily used for descriptive purposes currently, and further exploration of their ability to evaluate intervention efficacy is needed to demonstrate the value of occupational therapy interventions (Newman et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The findings of this review reflect the National Comprehesive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Cancer-Related Fatigue (2025), which are updated annually. This guideline draws on the most up to date research and clinical experience in the field and confirms that fatigue in patients with cancer is underreported, underdiagnosed, and undertreated. As a result, these guidelines commend the screening of all patients for fatigue using a numeric scale of 0\u0026ndash;10 (where 0\u0026ndash;3 is mild, 4\u0026ndash;6 is moderate, and 6\u0026ndash;10 is severe). The guidelines also propose a treatment algorithm to regularly re-evaluate patients for fatigue using a brief screening instrument to guide individualise treatment guided by their fatigue level. The guidelines also provide a list of 14 recommended tools for assessing cancer-related fatigue (five of which were identified in this review) but acknowledges there are multiple barriers to screening in practice settings for various reasons (National Comprehesive Cancer Network \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComprehensive assessment of CRF also requires observational evaluations along with data from patient rated outcome measures like those described here. Objective measures of sleep and rest-activity cycles have been found to correlate with fatigue severity in cancer survivors (Martin et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, the broad scope of items in the reviewed outcome measures (which often refer only to \u0026lsquo;daily life\u0026rsquo;) doesn\u0026rsquo;t account for nuanced differences in the impact of fatigue on different occupations. They don\u0026rsquo;t provide RT patients much opportunity to reflect on the full range of meaningful occupations in their lives and may therefore lead to an underestimation of its impact. Occupational therapists should therefore combine these outcome measures with observational or objective assessment techniques to obtain a comprehensive understanding of how CRF affects occupational engagement for everyone.\u003c/p\u003e \u003cp\u003eVariance in reporting of the included studies also poses challenges for occupational therapists wishing to understand the evidence base. Gender is not reported in some studies, and age is described using means, medians, age groups and ranges, both of which limits sample comparison between groups. Some study aspects, including administration procedures are poorly described. For example, the content and format of the FIR (Andic et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) is not clearly described and there are few other references in the broader literature to provide additional information. Occupational therapists must therefore critically appraise supporting evidence to properly assess its relevance to their own practice.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Implications of the findings\u003c/h2\u003e \u003cp\u003eThe findings of this scoping review highlight several practical considerations for occupational therapists using CRF outcome measures in their practice. Self-reported tools appear to be feasible in outpatient RT contexts, but their co-administration with other measures may increase patient burden, particularly for people already experiencing fatigue. Unidimensional tools offer simplicity but lack the depth of exploration needed to inform tailored interventions. Multidimensional tools are more time-intensive but are generally more suited to the requirements of high-quality assessment. Cancer diagnosis can lead to significant distress and overwhelm, and patients early in their cancer journey may struggle to fully participate in their care (Boyes et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Occupational therapists must balance the advantages and disadvantages of each approach to find tools which enable a focus on activity and participation while also remaining practical for clinical use.\u003c/p\u003e \u003cp\u003eThe absence of a gold standard for CRF assessment, as noted by Gentile et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), remains a challenge. While tools like the MFI-20 and FSS include some items related to activity and participation, no measure fully aligns with the multidimensional definition of CRF proposed by the National Comprehensive Cancer Network (NCCN) or comprehensively addresses occupational therapy\u0026rsquo;s focus on functional outcomes. This underscores the need for future development of CRF outcome measures that prioritise functional outcomes, such as engagement in daily activities and social roles, to better support clinical decision-making and intervention planning in RT settings. The triangulation of multiple forms of assessment (i.e., patient rated, observational, objective) at various stages of RT treatment and follow up remains the recommended approach for now.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Limitations\u003c/h2\u003e \u003cp\u003eLimitations related to both the included studies and the scoping methodology itself should be considered when interpreting these findings for practice. Geographical and cancer type biases in the studies highlight significant gaps in the evidence base. Most published research originates from high-income Western countries, which limits the generalisability of findings to diverse global populations, where cultural and healthcare system factor may be influential on CRF experiences and needs (Pearson et al. \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Similarly, the overrepresentation of breast, head and neck, and prostate cancers (collectively 83% of studies) omits other prevalent cancers, such as colorectal or lung cancer, which may have unique fatigue profiles. For occupational therapists, this lack of diversity complicates the selection of outcome measures that are broadly applicable across patient populations, indicating a need for inclusion of underrepresented groups and settings in future research.\u003c/p\u003e \u003cp\u003eThe studies also reflect choice made by researchers, within a research context. For example, the original (40 item) and revised (22 item) versions of the PFS were utilised in three studies (de Paula Avelar et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Dickinson, Kupzyk, and Saligan \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Poirier \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). However, a brief 12 item version of the tool has been available for over a decade (Reeve et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) and covers all four dimensions of CRF \u0026ndash; general, physical, cognitive and emotional fatigue (Rothmund et al. \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Confusingly, both the 12 and 22 item version of this scale are called the revised PFS in the literature. Its brevity may make it more suitable to clinical contexts, but it may not collect sufficient information from the research point of view. This gap between what appears in the evidence based and the actuality of clinical practice adds complexity to translating these findings into occupational therapy practice.\u003c/p\u003e \u003cp\u003eRegarding the review methodology adopted, the restriction to English-language publications also contributes to the previously noted geographical bias. The inclusion of studies published after January 2010 ensured currency but may have omitted earlier foundational work on CRF outcome measures including tools which remain in clinical use. The exclusion of studies focused solely on psychometric testing or non-clinical settings ensured a focus on practical utility but may have overlooked emerging tools in development or those validated in controlled settings. In addition, the lack of formal quality appraisal, while consistent with scoping review methodology (Arksey and O'Malley \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2005\u003c/span\u003e), means that the rigour of included studies was not evaluated which may affect the reliability of the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003e This scoping review systematically mapped validated outcome measures for assessing CRF in adults receiving radiation therapy, with a focus on their relevance to occupational therapy practice. The 12 included studies predominantly utilised self-reported multidimensional fatigue outcome measures. These measures were primarily administered in clinical settings across multiple timepoints, with most studies completed with people with breast, head and neck, or prostate cancers. The findings highlight a lack of outcome measures designed to capture the occupational impact of CRF on participation in meaningful activities, roles, and routines.\u003c/p\u003e \u003cp\u003eFuture research should prioritise the development and validation of outcome measures that specifically assess the occupational dimensions of CRF and capture its impact on daily life. These tools should align with the NCCN\u0026rsquo;s multidimensional framework (Gentile et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and incorporate patient-centred domains relevant to occupational therapy practice. Studies exploring CRF in underrepresented cancer types and diverse cultural contexts are also needed to enhance the generalisability of findings. To address practical challenges, future development should also focus on standardising administration protocols and ensuring measures are feasible for routine use in outpatient RT settings where patients received only a single session of occupational therapy.\u003c/p\u003e \u003cp\u003eEngaging occupational therapists, patients and/or cancer survivors in the co-design of these tools could ensure they meet clinical needs and facilitate tailored interventions. Experimental studies evaluating the efficacy of occupational therapy interventions, such as energy conservation, activity pacing, and psychosocial programs, are also needed to establish their utility in clinical practice. Finally, longitudinal studies tracking CRF beyond the immediate post-radiotherapy period could provide insights into its sustained occupational impact, informing rehabilitation strategies that support lifelong participation and quality of life for cancer survivors. By addressing these gaps, occupational therapists can better assess and manage CRF and enhance their ability to support adults undergoing RT in maintaining meaningful engagement in daily life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e7. Data availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e8. Conflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e9. Funding statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review was completed as part of the employment of the authors at Western Health, Melbourne, Australia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10. Acknowledgements \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the Traditional Owners of country on which this work was produced - the Wurundjeri Woi Wurrung peoples of the Kulin Nation. We recognise their continuing connection to land, waters and culture, and we pay our respects to their Elders past, present and emerging. Authors would also like to acknowledge the contribution of the Western Health Allied Health Strategy, Planning, Innovation, Research and Education (ASPIRE) unit Stepping into Research program to the completion of this review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbel E, Silander E, Nordstr\u0026ouml;m F, Olsson C, Brodin NP, Nyman J, Bj\u0026ouml;rk-Eriksson T, Hammerlid E (2022) Fatigue in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Prospective Study of Patient-Reported Outcomes and Their Association With Radiation Dose to the Cerebellum. 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J Allied Health 35 2:121E\u0026ndash;139E\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Western Health","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cancer, Cancer-Related Fatigue, Fatigue, Outcome Measures, Radiation Therapy","lastPublishedDoi":"10.21203/rs.3.rs-6917939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6917939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCancer-related fatigue (CRF) is a debilitating symptom experienced by many people undergoing radiation therapy, significantly impacting daily functioning and quality of life. Occupational therapists play a vital role in managing CRF, yet the lack of standardised outcome measures tailored to occupational therapy practice hinders effective assessment and intervention. This scoping review aimed to identify and map validated fatigue outcome measures suitable for outpatient radiotherapy settings and discuss their relevance to occupational therapy. Following the Arksey and O\u0026rsquo;Malley framework, a comprehensive search was conducted across MEDLINE, CINAHL, Embase, and PubMed, identifying 445 records. After screening, 12 studies published between 2010 and 2022 from seven countries were included. Breast, head and neck, and prostate cancers were commonly studied, most often using prospective cohort designs. Most studies used multidimensional, self-reported outcome measures, administered at multiple time throughout radiotherapy and at follow up. While these measures assessed physical, emotional, and cognitive fatigue, few addressed activity or participation in daily life. The findings highlight a gap in outcome measures that comprehensively evaluate activity and participation, which limits their utility in tailoring interventions or demonstrating the impact of occupational therapy. This review underscores the need for developing or adapting CRF outcome measures that better align with occupational therapy goals, to enhance clinical decision-making and research in outpatient radiotherapy settings.\u003c/p\u003e","manuscriptTitle":"Outcome Measures of Fatigue in Adults with Cancer Receiving Radiation Therapy: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-19 06:12:09","doi":"10.21203/rs.3.rs-6917939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec72755a-ca48-4b1e-956a-3e7bbfcce5a0","owner":[],"postedDate":"June 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50210106,"name":"Health Economics \u0026 Outcomes Research"},{"id":50210107,"name":"Oncology"}],"tags":[],"updatedAt":"2025-06-19T06:12:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-19 06:12:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6917939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6917939","identity":"rs-6917939","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}