title: Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period.
abstract: BACKGROUND
  Anxiety, depression, insomnia, fatigue, and pain are frequently reported by cancer patients. These symptoms are highly interrelated. However, few prospective studies have documented the sequence with which symptoms occur during cancer care.
  
  
  OBJECTIVE
  This longitudinal study explored the temporal relationships between anxiety, depression, insomnia, fatigue, and pain over an 18-month period in a large population-based sample of nonmetastatic cancer patients (N = 828), using structural equation modeling.
  
  
  METHODS
  The patients completed a battery of self-report scales at baseline and 2, 6, 10, 14, and 18 months later.
  
  
  RESULTS
  The relationships between the same symptom at two consecutive assessments showed the highest coefficients (β = 0.29 to 0.78; all ps ≤ 0.05). Cross-loading parameters (β = 0.06 to 0.19; ps ≤ 0.05) revealed that fatigue frequently predicted subsequent depression, insomnia, and pain, whereas anxiety predicted insomnia.
  
  
  CONCLUSIONS
  Fatigue and anxiety appear to constitute important risk factors of other cancer-related symptoms and should be managed appropriately early during the cancer care trajectory.
authors.affiliation: School of Psychology, Université Laval, Québec, QC, Canada.
authors.forename: Claudia
authors.initials: C
authors.lastname: Trudel-Fitzgerald
authors.forename: Josée
authors.initials: J
authors.lastname: Savard
authors.forename: Hans
authors.initials: H
authors.lastname: Ivers
mesh_terms: D000328:Adult; D000368:Aged; D001007:Anxiety / Q000150:complications / Q000175:diagnosis*; D003863:Depression / Q000150:complications / Q000175:diagnosis*; D018450:Disease Progression; D005221:Fatigue / Q000150:complications / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications / Q000175:diagnosis*; D010146:Pain / Q000150:complications / Q000175:diagnosis*; D011446:Prospective Studies; D011788:Quality of Life; D012307:Risk Factors; D057566:Self Report; D012720:Severity of Illness Index; D007319:Sleep Initiation and Maintenance Disorders / Q000150:complications / Q000175:diagnosis*; D011795:Surveys and Questionnaires; D013997:Time Factors