review

Annals of Oncology 20: 1725, 2009

doi:10.1093/annonc/mdn537
Published online 4 August 2008

A systematic review of the scales used

for the measurement of cancer-related
fatigue (CRF)
O. Minton* & P. Stone
Division of Mental Health, St Georges University of London, London, UK

Received 9 April 2008; revised 16 May 2008; revised 27 June 2008; accepted 30 June 2008

Background: Fatigue in cancer is very common and can be experienced at all stages of disease and in survivors.

introduction
Cancer-related fatigue (CRF) is a subjective symptom
experienced by patients at all stages of disease. It can occur
during treatment [1], in advanced disease [2] and in diseasefree survivors [3]. However, the prevalence of fatigue can vary
widely depending on which measurement tool is used [4]. This
is in part a reflection of the lack of an agreed definition of CRF.
Diagnostic criteria for a syndrome of CRF have been proposed
for inclusion in the International Classification for Diseases
(ICD 10) (Cella ref). These criteria can be applied using a short
semistructured interview [5]. The widespread adoption of
a syndrome approach using agreed diagnostic criteria would
help with the interpretation of prevalence figures in different
populations and across different studies. However, the
syndrome approach has not yet been widely used, probably
*Correspondence to: Dr O. Minton, Division of Mental Health, 6th Floor Hunter Wing,
St Georges University of London, Cranmer Terrace, London SW17 ORE, UK.
Tel: +44 02087252620; Fax: +44 02087255358; E-mail: ominton@sgul.ac.uk

because a strict application of the criteria requires the use of

a semistructured psychiatric interview to ensure that
symptoms of CRF are not related to underlying psychiatric
co-morbidity.
The European Association of Palliative Care has
developed a working definition [6] of CRF on the basis
of the European Organisation for Research and Treatment of
Cancer Quality of Life Questionnaire (EORTC QLQ C30).
This defines fatigue as a subjective feeling of tiredness,
weakness or lack of energy. This is a pragmatic approach
which provides a working understanding of CRF for
clinicians. However, other organisations and authorities have
defined CRF in their own ways, e.g. the National
Comprehensive Cancer Network [7], and there is no universally
accepted definition.
The lack of consensus in this area has led to the development
of a number of scales to measure CRF. These scales have usually
been validated originally in cancer patients. Other investigators
have used scales that were originally validated in non-cancer

The Author 2008. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org

review

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There is no accepted definition of cancer-related fatigue (CRF) and no agreement on how it should be measured. A
number of scales have been developed to quantify the phenomenon of CRF. These vary in the quality of psychometric
properties, ease of administration, dimensions of CRF covered and extent of use in studies of cancer patients. This
review seeks to identify the available tools for measuring CRF and to make recommendations for ongoing research
into CRF.
Methods: A systematic review methodology was used to identify scales that have been validated to measure CRF.
The inclusion criteria required the scale to have been validated for use in cancer patients and/or widely used in this
population. Scales also had to meet a minimum quality score for inclusion.
Results: The reviewers identified 14 scales that met the inclusion criteria. The most commonly used scales and best
validated were the Functional Assessment of Cancer Therapy Fatigue (FACT F), the European Organisation for
Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) (fatigue subscale) and the Fatigue
Questionnaire (FQ).
Conclusions: Unidimensional scales are the easiest to administer and have been most widely used. The authors
recommend the use of the EORTC QLQ C30 fatigue subscale or the FACT F. The FQ gives a multidimensional
assessment and has also been widely used. A substantial minority of the scales identified have not been used
extensively or sufficiently validated in cancer patients and cannot be recommended for routine use without further
validation.
Key words: cancer-related fatigue, measurement scales, systematic review

review
populations and have then independently validated their use in
patients with cancer. These scales can differ widely in the
number of items that they contain, the dimensions of CRF that
they cover (e.g. physical, affective and cognitive) and their
psychometric properties.
In the light of this multiplicity of different assessment
methods, we undertook a review to identify which scales have
been best validated and to make recommendations about which
instruments should be used in research and/or in routine
clinical practice.

methods
A systematic methodology was used. The following terms were used
to search Medline, CINAHL and Psychinfo (1950week 1
February 2008):

5
6
7
8
9
10
11
12
13
14
15
16

exp Outcome Assessment (Health Care)/

exp Psychometrics/
exp Outcome and Process Assessment (Health Care)/
(fatigue adj (scale or inventory or instrument or measurement or
assessment)).mp. [mp = title, original title, abstract, name of
substance word, subject heading word]
(fatigue adj2 (scale or inventory or instrument or measurement or
assessment)).mp.
(fatigue adj3 (scale or inventory or instrument or measurement or
assessment)).mp.
(fatigue adj4 (scale or inventory or instrument or measurement or
assessment)).mp.
exp Questionnaires/
or/1-8
exp Fatigue/
fatigue (ti,ab,kw)
((lack$ or loss or lost) adj2 (energy or vigour or vigor)).mp.
(tired$ or weary or weariness or exhaustion or exhausted or
lacklustre or astheni$).mp.
(apathy or apathetic or lassitude or letharg$ or (feeling adj3 (drained
or sleepy or sluggish or weak4))).mp.
or/10-14
9 and 15

The titles and abstracts of the papers identified using this search strategy
were screened by one of the authors (O.M.) and where necessary the
full text articles were retrieved. The reference lists of included articles
were also examined. O.M. was responsible for the search strategy and
retrieving studies. An ad hoc quality score was created before searching to
ensure that included scales reached a minimum level of psychometric
properties on the basis of the ideal characteristics of measurement scales
described in detail by Norman and Streiner [6, 8]. These characteristics
are detailed in Table 1. The final list of included studies was agreed by
both authors.
Scales were included only if they met the following a priori criteria:
1) Self-assessment scales originally validated in cancer patients and/or
subsequently widely used in cancer populations (n > 50 patients).
2) Scales must have been used in a second test population for independent
validation of their use in cancer patients.
3) 90% of participants must be >18 years.
4) Scales obtained a minimum quality score. The paper describing the scale
must have contained information on at least three of the following:

18 | Minton & Stone

Table 1. Explanation of psychometric properties of an ideal scale (on the

basis of Norman & Streiner [6, 7])
Psychometric evaluation
Internal consistency

Do items within the scale correlate

with each other and with the total score?
This is usually measured by Cronbachs
alpha. A low value indicates a poor
consistency of items; a very high score
indicates item redundancy.
Testretest reliability
Does the scale provide a similar score
when administered to the same population
in the same setting at different times?
Discriminant validity
Does the scale distinguish between groups
expected to have differing levels of
fatigue, e.g. cancer patients and a
control population.
Responsiveness to change Does the scale measure change during the
course of an intervention that alters the
level of fatigue, e.g. during chemotherapy.
Convergent validity
Does the scale provide a similar measure
to previously validated fatigue tools? This
is usually measured by the degree of
correlation of the scores. The value
usually given is Pearsons r correlation.

internal consistency, testretest reliability, known group validity

(discriminant validity), responsiveness to change or convergent
validity (against other scales).
5) Scales must be in English or translated and validated for English
language use.
There were also explicit exclusion criteria:
1) Objective rating scales testing power/strength, etc. as opposed to
subjective fatigue.
2) Single-item scales, including visual analogue scale (VAS)
3) Fatigue subscales as part of a broader quality-of-life measure. Unless
specific data were available relating to the psychometric properties of
the subscale.
In addition, the original reference was cross-referenced for citating articles
via Medline and Web of Knowledge. This was carried out to quantify the
number of times the scales had been used and the type of populations
studied. This procedure allowed us to approximately quantify the number
of participants who had been tested with each scale. For ease of reference,
populations of cancer patients were divided into three groups:
1) Activeon treatment with curative intent.
2) Palliativeon treatment with palliative intent or supportive care only.
3) Disease freemedium to long-term survivors.
This methodology allowed us to make firmer recommendations for
ongoing research into CRF by being able to compare different levels of scale
usage as well as the scales psychometric properties.

results
The search strategy identified 7889 abstracts in total.
These were screened and 116 studies were identified where
the main focus of the paper was on fatigue measurement. This

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1
2
3
4

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review

Annals of Oncology

7889 studies
screened on title
and abstract

116 papers identified as

primarily measuring fatigue

22 separate scales for

fatigue measurement
identified

14 scales included

5 unidimensional
scales

9 multidimensional
scales

Figure 1. Flow chart of study identification and selection.

shortlist generated data on 22 different scales that have

been used in the assessment of CRF (see Figure 1). Eight of
these scales did not meet our minimum quality requirements.
The specific reasons for excluding these instruments are
itemised below.
The Fatigue Symptom Control Checklist [9]: Although used
in some studies of CRF (e.g. by Morrow et al. [10]), this scale
has neither been validated in English nor been specifically
validated for use in cancer patients.
The Swedish Occupational Fatigue Inventory [11]: This scale
has been used in one study of patients undergoing radiotherapy
[12] but was found to have limitations and has not been further
evaluated.
The original Piper Fatigue Scale (PFS) [13]: This scale was
not included as it was found to have a number of flaws in its
use. It also required the use of an initial screening tool to
identify patients with fatigue. The revised version of the scale
was included (see below).
The Cancer Fatigue Scale [14] and the Fatigue Assessment
Questionnaire [15] were both excluded as validated English
language versions have not been published.
The Fatigue Management Barriers Questionnaire [16], the
Clinical Survey for CRF (QFAS) [17] and the Cancer-Related
Fatigue Distress scale [18] were all excluded because although
they have undergone pilot evaluation in cancer patients no
further published reports regarding their validity could be
identified.
This left 14 scales which met our criteria and have been
included in the review. The scales have been divided into

Volume 20 | No. 1 | January 2009

unidimensional scales
We found five scales that reached our minimum quality
standard. Full details of their psychometric properties and areas
of use are detailed in Table 2.
The Brief Fatigue Inventory (BFI) [23] is a nine-item VAS
that was validated for use in a mixed cancer population. It has
reasonable psychometric properties but has had limited
ongoing use. The scale has cut-off scores to differentiate
between mild, medium and severe fatigue but these have not
been validated and are likely to be of use for screening purposes
only.
The EORTC QLQ C30 [24] is a 30-item quality-of-life
questionnaire. The full tool has been used extensively as
a quality-of-life instrument. The three-item fatigue subscale has
been independently validated as a separate fatigue measure.
While the psychometric properties are weaker than more
extensive scales, their brevity and ease of administration may
outweigh this disadvantage. There have also been two largescale studies (>2000 patients in each) independently assessing
its use [20, 21], so there are extensive data in a variety of
settings. However, it has been noted to have a ceiling effect in
advanced cancer patients [20] and is not recommended as
a single measure in this group.
Another advantage of this measure is that it is possible to
extract fatigue data from studies that have used the full
quality-of-life scale. This includes the large number of
studies that have used this scale in cancer chemotherapy
trials (note: these studies have not been included in the current
analysis).
The Fatigue Severity Scale [25] is a nine-item scale that was
originally validated in a chronic illness (non-cancer)
population and while it has been extensively used in
neurological disease and chronic fatigue, it has had very
limited use in cancer patients. It has only been used and
validated by one author in a few related studies [1, 26].
However, no other studies were identified and it is not
recommended for use in the measurement of CRF.
The Functional Assessment of Cancer Therapy Fatigue
(FACT F) subscale [27] is a 13-item stand-alone scale but is one
of a range of the FACIT series of quality-of-life and tumourspecific symptom questionnaires [22]. It has been used in
a number of intervention studies to treat CRF, and the original
authors have been able to derive change in scale scores that
correspond to minimum clinically significant differences [28].
This application makes it an especially useful measure for
intervention studies.

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8 excluded on quality
criteria

unidimensional and multidimensional for ease of presentation.

The unidimensional scales invariably cover the physical aspects
of fatigue only. The multidimensional scales cover anywhere
between two and five different aspects of fatigue. This
division is possibly artificial as CRF has been shown in
a recent study to be a unidimensional construct, even after
measuring all relevant dimensions of fatigue [19]. However,
this method of categorising measurement scales is still
widely used and has been adopted in this review in order to
structure the presentation and discussion of the different
instruments.

review

Annals of Oncology

Table 2. Unidimensional scales

Scale name

BFI [18]

EORTC QLQ
(FS) [19]

FSS [20]

FACT F [21]

POMS F [22]

Number of items
Scale type
Population studied in
original validation study

9
Numerical
Mixed cancer

9
Numerical
Chronic illness
population

13
Numerical
Mixed cancer
patients on
treatment

7
Likert
Mixed work
population and
psychiatric patients

Internal consistency
Dimensions fatigue
covered
Test & retest reliability

0.96
Physical
functioning

3
Likert
Three populations:
lung cancer, bone
marrow transplant,
metastatic cancer
0.800.85
Physical
functioning

0.95
Physical
functioning
r = 0.90
(37 days later)

0.900.94
Physical functioning

Known group comparison

(discriminant validity)

Responsiveness to change

Distinguished
CRF from
community
adults
Not done

Distinguished
between local
and regional
disease
On the basis of
performance status
deterioration

0.96
Physical
functioning
Subset 87 patients,
3/52 later
measurement,
error 4.7 units
Distinguished CRF
versus healthy
controls

Distinguished between
chronic fatigue
syndrome and
controls (N = 6275)
MCID derived
(5.6 points)

Convergent validity
(against other scales)

POMS F,
r = 0.84

Number of participants
tested in original
validation study
Populations studied
(active/palliative/
survivors)
Approximate number
of further cancer
studies and participantsa

305

Fatigue
Questionnaire,
r = 0.490.75
366

227

Distinguished
between three known
haemoglobin levels
(>13, 1113 and <11)
Minimum clinical
important difference
(MCID) derived
(3 points)
Piper Fatigue Scale,
r = 20.75; POMS F,
r = 0.74
50

695

A/P/S

A/P/S

A/P

A/P/S

A/P/S

4 (2300)

>10 (>5000)

1 (100)

>50 (>5000)

>20 (>2000)

EORTC, r = 0.83

Not done

Where internal consistencyCronbachs alpha unless otherwise stated; convergent validityPearsons correlation value unless otherwise stated. A, active
treatment population; P, palliative care population; S, disease-free survivors; CRF, cancer-related fatigue. Scale abbreviations: BFI, Brief Fatigue Inventory;
EORTC QLQ C30 FS, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Fatigue subscale; FSS, Fatigue Severity
Scale; FACT F, Functional Assessment of Cancer Therapy Fatigue subscale; POMS F, Profile of Mood States Fatigue subscale.
a
This involved cross-referencing studies in Medline and Web of Science and identifying studies in cancer where the scale has been used
subsequently.

The Profile of Mood States [29] was originally used as

a measure of workforce health. It contains a number of scales
including a fatigue subscale of seven items which has been
independently examined in both a non-cancer [30] and
a cancer population [31]. It has also been used to provide
convergent validity in the validation of a number of other scales
used in CRF. It has a defined minimum clinically significant
difference [32]. Its extensive use in studies has meant there
are ample data available to recommend its continued use in
this setting.

multidimensional scales
There were nine scales included in this category. Full details of
these scales can be found in Table 3.

20 | Minton & Stone

The Chalder Fatigue Scalealso known as the Fatigue

Questionnaire (FQ) [33]is an 11-item scale that was
originally validated in a general practice setting. However, its
main use has been in the investigation of chronic fatigue
syndrome. It is brief and easy to administer while still covering
two aspects of fatigue (mental and physical). It has been used in
population studies and so has normative data available for
comparison with cancer patients [34, 41].
The Fatigue Symptom Inventory (FSI) [35] is a 13-item scale
that was originally validated in a breast cancer population. A
subsequent validation study involved 342 mixed cancer patients
[42]. It has reasonable psychometric properties but there is
a question over its testretest reliability. It has been used in
a number of studies but with overall small numbers of patients.

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Not done

r = 0.66 (1216
weeks later)

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Annals of Oncology

Table 3. Multidimensional scales

Scale name
Number of items
Scale type
Original validation
sample
Internal consistency
Dimensions fatigue
covered

FQ [30]
11
Likert
General practice
0.880.90
Physical and mental

Not done

Known group
comparison
(discriminant
validity)

Distinguished
between Hodgkins
disease and general
population

Responsiveness
to change

Not done

Convergent validity
(against other scales)

Fatigue item on
clinical interview
schedule
374

VASF [34]
18
Visual analogue scale
Patients with sleep
disorders
0.910.96
Physical and mental

Range of values:
patients,
r = 0.350.75;
controls,
r = 0.100.74
Distinguished between
healthy controls and
breast cancer
patients

Not done

Distinguished between
pre- and posttreatment fatigue
levels
POMS F, r = 0.75

Distinguished between
patients with sleep
disorders and healthy
controls
Limited ability to
detect changes over
treatment period

MAF [35]
16
Numerical
Arthritis patients
0.93
Distress,
interference,
severity, cognitive
Not done

Distinguished
between patients
with arthritis
and healthy
controls
Not done

POMS F,
r = 0.580.78

POMS F, r = 0.78

270

122

50

A/P/S

A/S

A only

A only

Number of participants
tested in original
sample
Populations studied
(active/palliative/
survivors)
Approximate number
of further cancer
studies and
participants
Scale name
Number of items
Scale type
Original validation
sample
Internal consistency
Dimensions fatigue
covered

>10 (>2000)

7 (700)

3 (250)

3 (760)

MFI-20 [36]
20
Likert
Mixed cancer
population
0.84
Cognitive, physical
and emotional

MFSI-30 [37]
30
Likert
Breast cancer
population
0.870.96
Cognitive, physical
and mental

Schwartz CFS [39]

28
Likert
Mixed cancer
population
0.96
Physical, emotional
and cognitive

Wu CFS [40]
9
Likert
Breast cancer
population
0.91
Physical and
emotional

Test & retest reliability

Not done

Not done

Not done

Known group
comparison
(discriminant
validity)

Distinguished between
cancer patients,
healthy controls
and doctors
on shift work

Three occasions,
r > 0.50
Distinguished
between cancer
patients and healthy
controls

PFS (revised) [38]

22
Likert
Breast cancer
population
0.97
Temporal, intensity,
cognitive, affective
and sensory
r = 0.98
Significant differences
between lung and
breast cancer
patients

None

Responsiveness to
change

Monitored change
over course of
radiotherapy

Significant
differences in
fatigue preand post-first
chemotherapy
cycle
MCID calculated
on treatment
population
(5 points)

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Not done

Not done

Not done

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Test & retest

reliability

FSI [33]
13
Numerical
Breast cancer on
treatment
0.94
Physical and mental

review

Annals of Oncology

Table 3. (Continued)

Convergent validity
(against other scales)
Number of participants
tested in original
validation
Populations studied
(active/palliative/
survivors)
Approximate number
of further cancer
studies and participantsa

VASF, r = 0.77

Short form 36,

r = 0.55; FSI, r = 0.74
275

MFI subscale
r = 0.84
382

POMS Fnot
quantified
166

Schwartz CFS,
r = 0.84
82

A/P/S

A/S (breast only)

A/S (breast only)

A only

A (breast only)

>20 (2000)

3 (380)

9 (800)

2 (300)

1 (170)

111 cancer patients

(1200 controls)

Its areas of measurement have been limited to patients

undergoing active treatment and survivors.
The Lee fatigue scale (or Visual Analogue Scale for
FatigueVASF) [36] is an 18-item tool that was originally
validated in a group of patients with sleep disorders. It has had
very limited use in cancer patients. Its psychometric properties
were assessed in a sample of 212 mixed cancer patients
undergoing treatment [31]. However, because of a potential
overlap with measures of sleep disturbance it is not
recommended for use in CRF measurement.
The Multidimensional Assessment of Fatigue (MAF) [43] is
a 16-item scale that was originally validated in rheumatoid
arthritis patients. Its psychometric properties were assessed in
the same sample of cancer patients previously discussed with
respect to the VASF [31]. It was also used (as one of a number
of fatigue measures) by Morrow and colleagues in two
subsequent intervention studies examining the role of
antidepressants in treating fatigue [10, 37]. Compared with
other fatigue instruments included in this review, it has been
relatively poorly validated and its use in further studies cannot
be recommended unless further validation work is undertaken.
The Multidimensional Fatigue Inventory (MFI-20) [44] is
a 20-item scale that was designed for use in cancer patients. Its
original validation had a number of group comparisons
including both healthy controls and groups of subjects who at
various time points were expected to be fatigued. This included
army trainees and doctors undertaking shift work. This means
there are normative data available for reference. It was further
validated for use in cancer in a subsequent study of 275 patients
undergoing radiotherapy [38]. It has since been used in
a number of studies but with small numbers of patients in each
study.
The Multidimensional Fatigue Symptom Inventory short
form (MFSI-30) [39] is a 30-item scale that was originally
investigated in a group of breast cancer patients undergoing
treatment. It was further validated in a mixed cancer
population of 304 patients [40]. It has favourable psychometric

22 | Minton & Stone

properties; however, its use in clinical studies has been

somewhat limited. There have only been two additional studies
reporting its use in breast cancer survivors.
Its use beyond this group will require further validation.
The revised PFS [45] is a shorter version of the original scale
[13]. Piper reported some limitations to her original fatigue
scale [13] and she went on develop a revised version. This
revised scale consists of 22 items and has been validated in
a group of breast cancer survivors [45]. There are limited data
on the psychometric properties of the revised scale for use in
cancer patients although data are available in other
populations. While the scale has since been used in a small
number of studies of cancer patients, the majority of these
studies have been undertaken in breast cancer patients
undergoing treatment and in breast cancer survivors. There are
little or no data in other cancer populations.
The Schwartz Cancer Fatigue Scale [46] is a 28-item scale
that was validated in a mixed cancer population undergoing
treatment. Its psychometric properties were further examined
(along with the VASF and the MAF) in the study of 212 mixed
cancer patients discussed previously [31]. Schwartz has also
determined the minimum clinically significant difference in
a further study [32] on 103 mixed cancer patients undergoing
treatment. We did not find any other studies that have used this
scale. Its usefulness despite extensive psychometric data must
therefore be questioned.
The Wu Cancer Fatigue Scale [47]: The original scale had 16
items but a secondary validation study found redundant items
and the scale was revised to include only nine items [48]. The
instrument has undergone limited psychometric evaluation and
has not been used in any subsequent studies. The relative lack
of data means that it cannot be recommended for further use.

discussion
This review has demonstrated the range and number of scales
available to specifically measure CRF. A number of other tools

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Where internal consistencyCronbachs alpha unless otherwise stated; convergent validityPearsons correlation value unless otherwise stated.
MCID, minimum clinically important difference; POMS F, Profile of Mood States Fatigue subscale; A, active treatment population; P, palliative
care population; S, disease-free survivors. Scale abbreviations: FQ, Fatigue Questionnaire; FSI, Fatigue Severity Inventory; VASF, Visual Analogue
Scale for Fatigue; MAF, Multidimensional Assessment of Fatigue; MFI-20, Multidimensional Fatigue Inventory; MFSI-30, Multidimensional Fatigue
Symptom Inventory short form; PFS, Piper Fatigue Scale (revised); Schwartz CFS, Schwartz Cancer Fatigue Scale; Wu CFS, Wu Cancer
Fatigue Scale.
a
This involved cross-referencing studies in Medline and Web of Science and identifying studies in cancer where the scale has been used subsequently.

review

Annals of Oncology

Volume 20 | No. 1 | January 2009

completion time may be why their usage has been more

limited. Moreover, the advantages of measuring additional
dimensions of fatigue are not clear [19]. As yet, there is no
clinical value in distinguishing between patients with
predominantly physical, cognitive or motivational fatigue.
Until the clinical importance of these proposed dimensions has
been clarified there is little incentive to use these scales outside
of a research study. Indeed, some authors suggest that this
construct is redundant as CRF can be regarded as
a unidimensional phenomenom [19]. It is perhaps relevant that
a number of multidimensional scales have been developed that
have not been subsequently extensively used. Some of these
scales have up to 30 items and so could potentially more than
double the administration time of all the unidimensional scales.
The majority of the scales (seven out of nine) have data on
<1000 patients for any individual scale. In addition, three of
these seven scales have only been used in breast cancer patients
and so their use is even more limited. The two exceptions are
the FQ and the MFI-20. These two scales have each been used
to measure CRF in >2000 patients. However, this evaluates still
considerably fewer patients than the FACT F or EORTC QLQ
C30. The FQ, by virtue of consisting of only 11 items, offers
a two-dimensional (physical and mental) assessment of fatigue
without an increase in the time required for administration. It
was not, however, originally designed for use in cancer patients,
whereas the MFI-20 was specifically created to measure fatigue
in this population. Ultimately, the trade-off between
undertaking a comprehensive multidimensional assessment of
fatigue and the consequent problems of missing data and
questionnaire burden will be a decision for individual
researchers.

conclusions
For most purposes, a unidimensional fatigue instrument is the
appropriate measure. Of the many unidimensional scales
available the best validated and most widely used are the
EORTC QLQ C30 fatigue subscale and the FACT F. The
EORTC subscale has the virtue of brevity and is usually used as
part of the EORTC QLQ C30 quality-of-life assessment
instrument. However, its extreme brevity and limited number
of response categories may make it less sensitive to changes in
fatigue and less able to detect differences in fatigue between
groups. For this reason, the authors prefer the FACT F. This
instrument is relatively brief, has robust psychometric
properties and can also be easily combined with a validated
quality-of-life assessment instrument (such as the FACT G). In
those circumstances where a multidimensional fatigue
instrument is required, the authors recommend the use of the
FQ. Although not originally developed for use in cancer
patients, this scale has robust psychometric properties and has
been extensively used in other populations. It is brief, easy to
use and its dimensions have face validity.

funding
OM was supported by a Wellcome Trust Value in People (VIP)
award.

doi:10.1093/annonc/mdn537 | 23

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have been validated for the measurement of fatigue in

nonmalignant conditions and in the general population
but evaluation of these scales was beyond the scope of this
review.
While this review has used systematic methodology, there
are some potential limitations. The titles and abstracts were
only screened by one authorthis was because of limited time
and resources. However, both authors agreed on the final
included studies. This includes three scales which were
identified but excluded from full analysis because only one
published paper was available. These authors were not
contacted for further unpublished data as a meta-analysis was
not possible with this type of review. As a result, obtaining these
additional data would not have materially altered the
conclusions of the review (which concerned peer-reviewed
published data only).
Our estimate of the number of studies that the various scales
have been used in is on the basis of a comprehensive crossreferencing in both Medline and the ISI citation index with
full text article retrieval if necessary. The purpose of
including these approximate figures is to give the reader an
order of magnitude assessment about how often these scales
have been used in previous studies. However, this method is
not foolproof (e.g. authors may have failed to reference the
scale correctly) and so this is stated to be approximate numbers
only.
The unidimensional scales (which measure the
physical impact of fatigue) are the most widely used. They
also have some of the most robust psychometric data to
support their use. Their limitation is the scope of
measurementsubjective fatigue is more than the sensation of
physical impairment. Although measuring physical fatigue
symptoms may include the social and functional impact of
physical fatigue. This extends beyond one aspect of fatigue that
could imply that these scales cover more than one dimension of
CRF.
However, any theoretical limitation is compensated for by
their ease of use and brevity (the scales contain between three
and 13 items). The most widely used of these scales are the
FACT F and the EORTC QLQ C30 fatigue subscale which have
data from over 10 000 patients between them and have been
widely used in intervention studies to treat CRF [49]. The
FACT F has the advantage of having a validated clinically
significant score changeit also covers the social impact of
CRF but takes longer to administer than the three-item EORTC
QLQ C30 fatigue subscale. The former should be used in
a research setting and the latter could be used to monitor
clinical effects. The Profile of Mood States Fatigue has also been
extensively used but was not originally validated in cancer
patients and has no clear advantage over the other two scales. It
has been used to help validate six out of the 14 scales included.
The widespread use in a healthy population could provide
a useful baseline measure of fatigue in the general population
[50] for comparison with a cancer patient group.
The multidimensional scales are much more limited in their
usage. While they offer the theoretical advantage of covering
more aspects of fatigue, such as the cognitive or affective
symptoms, this is often at the expense of an increase in the
number of items. The more complex administration and

review
references

24 | Minton & Stone

in international clinical trials in oncology. J Natl Cancer Inst 1993; 85(5):

365376.
25. Krupp LB, LaRocca NG, Muir Nash J, Steinberg AD. The fatigue severity scale.
Application to patients with multiple sclerosis and systemic lupus erythematosus.
Arch Neurol 1989; 46(10): 11211123.
26. Stone P, Richards M, AHern R, Hardy J. A study to investigate the
prevalence, severity and correlates of fatigue among patients with cancer in
comparison with a control group of volunteers without cancer. Ann Oncol 2000;
11(5): 561567.
27. Yellen SB, Cella DF, Webster K et al. Measuring fatigue and other anemia-related
symptoms with the Functional Assessment of Cancer Therapy (FACT)
measurement system. J Pain Symptom Manage 1997; 13(2): 6374.
28. Cella D, Eton DT, Lai JS et al. Combining anchor and distribution-based methods
to derive minimal clinically important differences on the Functional Assessment
of Cancer Therapy (FACT) anemia and fatigue scales. J Pain Symptom Manage
2002; 24(6): 547561.
29. McNair DM and Lorr M EITS Manual for the Profile of Mood States. San Diego,
CA: Educational and Testing Service 1971.
30. Norcross JC, Guadagnoli E, Prochaska JO et al. Factor structure of the Profile of
Mood States (POMS): two partial replications. J Clin Psychol 1984; 40(5):
12701277.
31. Meek PM, Nail LM, Barsevick A et al. Psychometric testing of fatigue instruments
for use with cancer patients. Nurs Res 2000; 49(4): 181190.
32. Schwartz AL, Meek PM, Nail LM et al. Measurement of fatigue. Determining
minimally important clinical differences. J Clin Epidemiol 2002; 55(3):
239244.
33. Chalder T, Berelowitz G, Pawlikowska T et al. Development of a fatigue scale.
J Psychosom Res 1993; 37(2): 147153.
34. Loge JH, Abrahamsen AF, Ekeberg O et al. Hodgkins disease survivors
more fatigued than the general population. J Clin Oncol 1999; 17(1): 253
261.
35. Hann DM, Jacobsen PB, Azzarello LM et al. Measurement of fatigue in
cancer patients: development and validation of the Fatigue Symptom Inventory.
Qual Life Res 1998; 7(4): 301310.
36. Lee K, Hicks G, Nino-Murcia G. Validity and reliability of a scale to measure
fatigue. Psychiatry Res 1991; 36: 291298.
37. Roscoe JA, Morrow GR, Hickok JT et al. Effect of paroxetine hydrochloride
(Paxil
) on fatigue and depression in breast cancer patients receiving
chemotherapy. Breast Cancer Res Treat 2005; 89(3): 243249.
38. Smets EM, Garssen B, Cull A, de Haes JC. Application of the multidimensional
fatigue inventory (MFI-20) in cancer patients receiving radiotherapy. Br J Cancer
1996; 73(2): 241245.
39. Stein KD, Martin SC, Hann DM et al. A multidimensional measure of fatigue for
use with cancer patients. Cancer Pract 1998; 6(3): 143152.
40. Stein KD, Jacobsen PB, Blanchard CM et al. Further validation of the
multidimensional fatigue symptom inventory-short form. J Pain Symptom
Manage 2004; 27(1): 1423.
41. Loge JH, Ekeberg O, Kaasa S et al. Fatigue in the general Norwegian
population: normative data and associations. J Psychosom Res 1998; 65:
5365.
42. Hann DM, Denniston MM, Baker F et al. Measurement of fatigue in cancer
patients: further validation of the Fatigue Symptom Inventory. Qual Life Res
2000; 9(7): 847854.
43. Belza B. Comparison of self-reported fatigue in rheumatoid arthritis and controls.
J Rheumatol 1995; 22(4): 639643.
44. Smets EM, Garssen B, Bonke B et al. The Multidimensional Fatigue Inventory
(MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res
1995; 39(3): 315325.
45. Piper BF, Dibble SL, Dodd MJ et al. The revised Piper Fatigue Scale:
psychometric evaluation in women with breast cancer. Oncol Nurs Forum 1998;
25(4): 677684.
46. Schwartz AL. The Schwartz Cancer Fatigue Scale: testing reliability and validity.
Oncol Nurs Forum 1998; 25(4): 711717.

Volume 20 | No. 1 | January 2009

Downloaded from annonc.oxfordjournals.org by guest on November 9, 2010

1. Stone P, Richards M, AHern R, Hardy J. Fatigue in patients with cancers of the

breast or prostate undergoing radical radiotherapy. J Pain Symptom Manage
2001; 22(6): 10071015.
2. Stone P, Hardy J, Broadley K et al. Fatigue in advanced cancer: a prospective
controlled cross-sectional study. Br J Cancer 1999; 79(910): 14791486.
3. Bower JE, Ganz PA, Desmond KA et al. Fatigue in long-term breast carcinoma
survivors. Cancer 2006; 106(4): 751758.
4. Minton O, Stone P. How common is fatigue in disease-free breast cancer
survivors? A systematic review of the literature. Br Cancer Res Treat 2007 doi:
10.1007/s10549-007-9831-1.
5. Cella D, Davis K, Breitbart W et al. Cancer-related fatigue: prevalence of
proposed diagnostic criteria in a United States sample of cancer survivors. J Clin
Oncol 2001; 19(14): 33853391.
6. Radbruch L, Strasser F, Elsner F et al. Fatigue in palliative care patientsan
EAPC approach. Palliat Med 2008; 22: 1332.
7. NCCN Clinical Practice Guidelines in Oncology. Cancer Related Fatigue. http://
www.nccn.org (8 January 2008, date last accessed).
8. Streiner DL, Norman GR. Health Measurement ScalesA Practical Guide to
Their Development and Use, 1st edition. Oxford: Oxford University Press 1989;
175 pp.
9. Yoshitake H. Relations between the symptoms and the feeling of fatigue.
Ergonomics 1971; 14(1): 175186.
10. Morrow G, Hickok J, Roscoe J et al. Differential effects of paroxetine on fatigue
and depression: a randomized, double-blind trial from the University of Rochester
Cancer Center Community Clinical Oncology Program. J Clin Oncol 2003;
21(24): 46354641.
11. Ahsberg E. Dimensions of fatigue in different working populations. Scand J
Psychol 2000; 41(3): 231241.
12. Ahsberg E, Furst CJ, Ahsberg E, Furst CJ. Dimensions of fatigue during
radiotherapyan application of the Swedish Occupational Fatigue Inventory
(SOFI) on cancer patients. Acta Oncol 2001; 40(1): 3743.
13. Piper BF. Piper fatigue scale available for clinical testing. Oncol Nurs Forum
1990; 17(5): 661662.
14. Okuyama T, Akechi T, Kugaya A et al. Development and validation of the
cancer fatigue scale: a brief, three-dimensional, self-rating scale for
assessment of fatigue in cancer patients. J Pain Symptom Manage 2000; 19(1):
514.
15. Glaus A. Fatigue in patients with cancer. Analysis and assessment. Recent
Results Cancer Res 1998; 145(IIX): 1172.
16. Passik SD, Kirsh KL, Donaghy K et al. Patient-related barriers to fatigue
communication: initial validation of the Fatigue Management Barriers
Questionnaire. J Pain Symptom Manage 2002; 24(5): 481493.
17. Quick M, Fonteyn M. Development and implementation of a clinical survey
for cancer-related fatigue assessment. Clin J Oncol Nurs 2005; 9(4):
435439.
18. Holley SK. Evaluating patient distress from cancer-related fatigue: an instrument
development study. Oncol Nurs Forum 2000; 27(9): 14251431.
19. Lai J-S, Crane P, Cella D. Factor analysis techniques for assessing sufficient
unidimensionality of cancer related fatigue. Qual Life Res 2006; 15(7):
11791190.
20. Knobel H, Loge JH, Brenne E et al. The validity of EORTC QLQ-C30 fatigue scale
in advanced cancer patients and cancer survivors [see comment]. Palliat Med
2003; 17(8): 664672.
21. Storey DJ, Waters RA, Hibberd CJ et al. Clinically relevant fatigue in cancer
outpatients: the Edinburgh Cancer Centre symptom study. Ann Oncol 2007;
18(11): 18611869.
22. Cella D. Functional Assessment of Cancer Therapy Website. www.facit.org (28
January 2008, date last accessed).
23. Mendoza TR, Wang XS, Cleeland CS et al. The rapid assessment of fatigue
severity in cancer patients: use of the Brief Fatigue Inventory. Cancer 1999;
85(5): 11861196.
24. Aaronson NK, Ahmedzai S, Bergman B et al. The European Organization for
Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use

Annals of Oncology

Annals of Oncology

47. Wu HS, McSweeney M, Wu H-S, McSweeney M. Assessing fatigue in persons

with cancer: an instrument development and testing study. Cancer 2004; 101(7):
16851695.
48. Wu HS, Wyrwich KW, McSweeney M et al. Assessing fatigue in persons with
cancer: further validation of the Wu Cancer Fatigue Scale. J Pain Symptom
Manage 2006; 32(3): 255265.

review
49. Minton O, Stone P, Richardson A et al. Drug therapy for the management
of cancer related fatigue. Cochrane Database of Systematic Reviews.
Reviews 2008 Issue 1. Chichester, UK: John Wiley & Sons, Ltd 2008; (1).
50. David A, Pelosi A, McDonald A et al. Tired, weak, or in need of rest:
fatigue among general practice attenders. Br Med J 1990; 301(6762):
11991202.

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