The Fatigue Pictogram: Psychometric evaluation of a new clinical tool

Margaret I. Fitch, Terry Bunston, Debra Bakker, Deborah Mings, Pat Sevean


Fatigue is one of the most prevalent side effects of cancer, yet clinicians may not focus on it during busy clinic appointments. The purpose of this project was to evaluate the psychometric properties of a new two-item instrument designed to quickly identify patients experiencing difficulties with fatigue. The evaluation was conducted with 190 lung cancer patients attending ambulatory clinics. The Fatigue Pictogram had good reliability for test-retest over a 24-hour period (Weighted Kappa 0.71 for Question 1 and 0.72 for Question 2) and for equivalence of method (in person versus phone) (Weighted Kappa 0.64 for Question 1 and 0.65 for Question 2). Validity was assessed by comparing results of the new tool against the Multidimensional Fatigue Inventory and the SF-36. Overall, patients who indicated high fatigue levels did so on all respective scales.

The new Fatigue Pictogram was easy to administer and score in a busy clinical setting. It provides a standardized reliable and valid instrument to identify patients experiencing difficulty with fatigue.

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Ahlberg, K., Ekman, T., Gaston-Johansson, F., & Mock, V. (2003).

Assessment and management of cancer-related fatigue in adults.

Lancet, 362(9384), 640–50.

Ancoli-Israel, S., Liu, L., Marler, M., Parker, B., Jones, B., Sadler, G., …

Fiorentino, L. (2006). Fatigue, sleep and circadian rhythms prior to

chemotherapy for breast cancer. Supportive Cancer in Care, 14(3),


Berglund, G., Bolund, C., Fornander, T., Rutqvist, L.E., & Sjoden, P.

(1991). Late effects of adjuvant chemotherapy and post operative

radiotherapy on quality of life among breast cancer patients.

European Journal of Cancer, 27(9), 1075–1081.

Cella, D. (1997). The Functional Assessment of Cancer Therapy Anemia

(FACT-AN) Scale: A new tool for the assessment of outcomes in

cancer anemia. Seminars in Haematolology, 34(3, Suppl. 2), 13–19.

Cella, D., Lai, J.S., Chang, C.H., Peterman, A., & Slavin, M. (2002).

Fatigue in cancer patients compared with fatigue in the general

United States population. Cancer 94(2), 528–538.

Chan, C.W., & Molassiotis, A. (2001). The impact of fatigue on

Chinese cancer patients in Hong Kong. Supportive Care in

Cancer, 9(1), 18–24.

Cleeland, C.S. (2001). Cancer-related fatigue: New directions for

research (introduction). Cancer, 92(6 Suppl.), 1657–1661.

Curt, G.A., & Johnson, P.G. (2003). Cancer fatigue: The way forward.

Oncologist, 8(Suppl. 1), 27–30.

Danjoux, C., Gardner, S., & Fitch, M.I. (2007). Prospective evaluation

of fatigue during a course of curative radiotherapy for localized

prostate cancer. Supportive Care in Cancer, 15(1), 1169–1176.

Davis, K.M., Lai, J., Hahn, E.A., & Cella, D. (2008). Conducting routine

fatigue assessment for use in oncology practice: Patient and

provider perspective. Supportive Care in Cancer, 16(4), 379–386.

Fitch, M.I. (2010). Supportive care needs of patients with advanced

disease undergoing radiotherapy for symptom control.

Manuscript accepted for publication.

Fitch, M.I., & Steele, R. (2010). Supportive care needs of individuals with

lung cancer. Canadian Oncology Nursing Journal, 20(1), 15–22.

Fitch, M., Gowing, J., Murray, A., McKillop, I., Schertzer, L., & Deane,

K. (2002). Measuring supportive care needs over time: How well

are we doing?” Supportive Care in Cancer, 10.

Irvine, D., Vincent, L., Grayson, J.E., Bubela, N., & Thompson, L.

(1994). The prevalence and correlates of fatigue in patients

receiving treatment with chemotherapy and radiotherapy: A

comparison with the fatigue experienced by healthy individuals.

Cancer Nursing, 17(5), 367–378.

Mitchell, S., Beck, S.L., Hood, L.E., Moore, K., & Tanner, E.R. (2007).

Putting evidence into practice: Evidence-based interventions for

fatigue during and following cancer and its treatment. Clinical

Journal of Oncology Nursing, 11(1), 99–113.

National Comprehensive Cancer Network. (2007). NCCN Guidelines

for Supportive Care. Retrieved from


Nunnally, J.C., & Bernstein, I. (1994). Psychometric theory. Toronto,

ON: McGraw-Hill.

Olson, K. (2007). A new way of thinking about fatigue—A

reconceptualization. Oncology Nursing Forum, 34(1), 90–93.

Olson, K., Krawchuk, A., & Qudussi, T. (2007). Fatigue in individuals

with advanced cancer in active treatment and palliative settings.

Cancer Nurse, 30(6), 1–10.

Piper, B.F. (1990). Piper fatigue scale available for clinical testing.

Oncology Nursing Forum, 17(5), 661–662.

Portenoy, R.K., & Itri, L.M. (1999). Cancer-related fatigue: Guidelines

for evaluation and management. Oncologist, 4(1) 1–10.

Ream, E., Richardson, A., & Alexander-Dann, C. (2006). Supportive

intervention for fatigue in patients undergoing chemotherapy:

A randomized controlled trial. Journal of Pain & Symptom

Management, 31(2), 148–61.

Servaes, P.F., Verhagen, C.F., & Bleijenberg, G. (2002). Fatigue in

cancer patients during and after treatment: Prevalence, correlates

and interventions. European Journal of Cancer, 38(1), 27–43.

Smets, E.M.A., Garssen, B., Cull, A., & deHaes, J.C.J.M. (1996).

Application of the multidimensional fatigue inventory (MFI-20) in

cancer patients receiving radiotherapy. British Journal of Cancer,

(2), 241–245.

Steele, R., & Fitch, M.I. (2008). Supportive care needs of women with

gynecological cancer. Cancer Nursing, 31(4), 284–291.

Tiesinga, L.J., Dassen, T.W.N., & Halfens, R.J.G. (1996). Fatigue—A

summary of the definitions, dimensions and indicators. Nursing

Diagnosis, 7(2), 51–62.

Vogelzang, N.J., Breitbart, W., Cella, D., Curt, G.A., Groopman, J.E.,

Herning, S.J., … Portenoy, R.K. (1997). Patient caregiver and

oncologist perspectives of cancer-related fatigue: Results of a

tripartite assessment survey: The Fatigue Coalition. Seminars in

Haematology, 34(3, Suppl. 2), 4–12.

Ware, J.E. Jr., & Sherbourne, C.D. (1992). The MOS 36-item shortform

health survey (SF-36). I. Conceptual framework and item

selection. Medical Care, 30(6), 473–483.

Wei, J.T., Dunn, R.L., Sandler, H.M., McLaughlin, P.W. Montie, J.E., Litwin,

N.S., … Sanda, M.G. (2002). Comprehensive comparison of healthrelated

quality of life after contemporary therapies for localized

prostate cancer. Journal of Clinical Oncology, 20(2), 557–66.

Windsor, P.M., Nicol, K.F., & Poller, J. (2004). A randomized

controlled trial of aerobic exercise for treatment-related fatigue

in men receiving radical external beam radiotherapy for localized

prostate carcinoma. Cancer, 101(3), 550–57.

Winningham, M.L., Nail, L.M., Burke M.B., Brophy, L., Cimprich, B.,

Jones, L.S., et al. (1994). Fatigue and the cancer experience: The

state of the knowledge. Oncology Nursing Forum, 21(1), 23–35.

Wu, H.S., & McSweeney, M. (2004). Assessing fatigue in persons with

cancer: An instrument development and testing study. Cancer,

(7), 1685–95.

Yellen, S.B., Cella, D.F., Webster, K., Blendowski, C., & Kaplan, E.

(1997). Measuring fatigue and other anemia-related symptoms

with the Functional Assessment of Cancer Therapy (FACT)

Measurement System. Journal of Pain & Symptom Management,

(2), 63–74.

Zubrod, C.G., Schneiderman, M., Frei, E., Brindley, C., Gold, G.L.,

Snider, B., et al. (1960). Appraisal of methods for study of

chemotherapy of cancer in man. Journal of Chronic Diseases,

(1), 7–33.


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