CHAPTER ONE: INTRODUCTION1.1 IntroductionCancer is the name for a group of more than 100 diseases, is defined as diseases in which cancer cells divide, grow without control and can spread to surrounding tissues and when is not treated, cancers can cause severe illness and death (ACS, 2017).WHO has largely define environmental factors of cancer as those in which extrinsic factors are responsible, while genetic defect associated with cancer is defined as those with an extremely high probability of developing one or more particular cancers, regardless of environmental factors (Warnock, 2018).The National Comprehensive Cancer Network defines fatigue as a symptom characterized by tiredness related to cancer disease or to its treatment that most of time interferes with general activities, fatigue is subjective and persistent (Hilarius et al., 2011).Fatigue is one of the most common symptoms experienced by patients when receiving treatment with chemotherapy and/or radiation therapy. The Percentages of patients who experience CRF vary across studies from 25% to 100% depending on given treatment and the type and stage of cancer (NCCN, 2013). For patient diagnosed of cancer and patients who are receiving cancer treatment, physical activities seems to improve positively fatigue and appears to promote greater physical improvement following cancer treatment and this indirectly benefits the patient by increasing adaptability of both muscle and cardiac capacity functional capacity (Canário1, 2016).1.2 BackgroundThe cancer disease is estimated to increase up to 18.1 million new cases and 9.6 million deaths in 2018 worldwide. One in 6 women and one in 5 men develop cancer disease during the lifetime, one in 11 women and one in 8 men die from cancer disease. The prevalence in 5 years is estimated to be 43.8 millions (WHO, 2018).About half of the new cases and more than half of the cancer deaths, combined men and women, worldwide in 2018 are estimated to occur in Asia, in part because the region has nearly 60% of the global population. The Europe accounts for 23.4% of the global cancer cases and 20.3% of the cancer deaths, even though it contains only 9.0% of the global population. The American has 13.3% of the global population and account for 21.0% of incidence and 14.4% of mortality worldwide. Contrary to other world regions, the proportions of cancer deaths in Africa and in Asia (57.3% and 7.3%, respectively) are higher than the proportions of incident cases (48.4% and 5.8%, respectively),because these regions have a higher frequency of certain cancer types associated with poorer prognosis and higher mortality rates, in addition to limited access to timely diagnosis and treatment in many countries (WHO, 2018).International Agency for Research on Cancer (IARC) reports that, 8 million peoples are affected by cancer in Africa and contribute to 5.3 million of the cancer deaths (65 %). The report indicates that 15.6 million (48%) of the 5-year prevalent cancer cases occurred in developing countries. In Africa, the incidence of cancer has been estimated to 847.000 new cancer cases and the number of died patients from cancer was estimated to be 591.000. In women, the three most common types of cancers are breast, cervical and liver cancer. In men, the three most frequent type of cancer are prostate, liver cancers and Kaposi sarcoma. Cancer causes fears, suffering, and millions of deaths across the world and cancer disease is a great concern to the society (Ly, 2016).Fatigue has been described by cancer patients as significant problem that mostly coupled with difficulty in performing routine general activities than any other side effects associated with cancer treatment such nausea, vomiting or feeling in pain (Kassab, 2017). Cancer treatment is prone to cause CRF and to worsen the existing fatigue, chemotherapy was associated with severe CRF in patients with different types of cancer and because effective fatigue interventions are lacking, cancer patients often accept fatigue as the price to be paid for achieving a cure (Wang and Jeanie F. Woodruff, BS, 2015).Pathophysiology of fatigue related to chemotherapy is still ambiguous, and a variety of mechanisms may contribute to its development (Fu et al., 2019).These mechanisms refer to the effects of cancer and its treatment on neuropsychological impairment, muscle metabolism disregulation, mediators of inflammation and stress, hormonal changes related to effects on the hypothalamic pituitary axis, immune activation, and mainly premature menopause in women, or androgen deprivation in men (Fu et al., 2019).The WHO Global Report on NCDs addresses several risk factors for cancer, including tobacco use, alcohol consumption, lack of physical activity, and unhealthy diet, genetic factors predispositions and oncogenic infections (Vineis, Paolo, wild, 2014).Study done in India on Recommendations for High-Priority Research on Cancer-Related Fatigue in adult patients shows that fatigue is the most common side effect of chemotherapy and radiotherapy, it has been shown that 65–100% of patients undergoing radiotherapy and up to 82–96% of those receiving chemotherapy suffer from fatigue during their treatment course (Barsevick et al., 2013).Study done in South Africa reported that cancer related fatigue (CRF) remains a major concern for both the patient and health professional where approximately 70%-100% of cancer patients experience fatigue (Bhyat et al., 2014).CRF effect on the ability to perform activities of daily living is both profound and pervasive. Among patients with cancer and a history of chemotherapy treatment, most of patients with fatigue (91%) felt that it prevented a normal life and 88% felt that their fatigue had affected their physical activities. Patients with cancer related fatigue have reported significant impairment in their ability to perform a variety of activities of daily living, including preparing food, cleaning the house, light lifting, and social activities with friends and family (Hofmanet al., 2017).According to the NCCN and the Oncology Nursing Society, CRF management strategies focus on patient, family education and counseling, physical activity and other behavioral interventions, psycho stimulants, and treatment of contributing factors, such as pain, emotional distress, sleep disturbance, anemia (Wang and Jeanie F. Woodruff, BS, 2015).As worldwide we move forward in the war against cancer, we need to move forward equally in the war against fatigue related to chemotherapy, the study done in south Africa reported that 80% of the participants experienced fatigue during their course of cancer treatment, irrespective of the diagnosis (Bhyat et al., 2014).Study done in South Africa reported that cancer related fatigue (CRF) remains a major concern for both the patient and health professional. Approximately 70%-100% of cancer patients experience fatigue (Bhyat et al., 2014).In Rwanda, cancer pattern is a new phenomenon and need much attention, where physical activity when performed at regular basis would help to improve the quality of life of patients receiving cancer treatment. 1.3 Problem statementThe clinical experience probed the curiosity to study on fatigue following cancer patients during and after chemotherapy and its associated levels of physical activity.The National Comprehensive Cancer Network (NCCN) defines cancer-related fatigue (CRF) as “a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning (Hilarius, Kloeg, van der Wall, Komen, Gundy, & Aaronson, 2011).Study done on CRF and treatment related fatigue shows that Cancer treatment is known to be the source of CRF and to worsen the existing fatigue experienced by the patient and the same study showed that when the effective fatigue interventions are lacking, patients often accept fatigue as the price to be paid for achieving a cure (Wang and Jeanie F. Woodruff, BS, 2015).The National Comprehensive Cancer Network revealed that patients with cancer receiving chemotherapy identify fatigue as an important problem which affects their daily activities for more of the time than either nausea/vomiting or cancer pain (Wang and Jeanie F. Woodruff, BS, 2015). Study done by The University of Texas Anderson Cancer Center, showed that Cancer related fatigue (CRF) is a prevalent and disabling symptom experienced by both cancer patients and cancer survivors (Bruera, Yennurajalingam and Cancer, 2017).CRF negatively impacts a patient’s general physical activity and diminishes quality of life. CRF last longer than usual fatigue and is more severe and unrelenting. CRF can be so overwhelming that a patient may request a chemo holiday or may even elect to discontinue therapy altogether. In either case, curative treatment may be compromised (Wang and Jeanie F. Woodruff, BS, 2015).Assessing, screening, evaluation, and treatment for CRF in clinical settings remain suboptimal and may cause clinicians’ failure to offer interventions, patients’ lack of knowledge of appropriate treatments for fatigue, a desire on patients’ part to treat fatigue without medications, and a tendency to be stoic about fatigue to avoid being labeled as a “complainer” or risk having the dose of anticancer treatment reduced (Wang et al., 2015).The same study reported that Cancer related fatigue has been under reported, under diagnosed and undertreated (Wang et al., 2015).Health care professionals have been challenged in their efforts to help patients manage this distressful symptom and to maintain the quality of patients’ life (Dickinson et al.,2008) Studies have shown positive benefits of physical activity during and following treatment but it remain uncertainties related to the optimal type and duration of physical activity(KUMMER et al.,2013)In Rwanda there is scarcity of information on fatigue and physical activity among adult cancer patients receiving chemotherapy.1.4 The aim of the studyTo evaluate fatigue and physical activity level among adults cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence.1.5 Research objectives• To determine the level of fatigue among adult cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence.• To determine the level of physical activity among adult cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence.• To describe the association between fatigue and physical activity among adult cancer patients undergoing chemotherapy at Butaro Cancer Center of Excellence.1.6 Research questions• What is the level of fatigue among adult cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence?• What is the level of physical activity among adult of cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence?• What is the association between fatigue and physical activity among adult cancer patients receiving chemotherapy at Butaro Cancer Center of Excellence?1.7. Significance of the studyFatigue is the commonest side effect of chemotherapy and radiotherapy: it has been shown that 65–100% of patients undergoing radiotherapy and up to 82–96% of those receiving chemotherapy suffers from fatigue during their course of treatment and interfere with physical activity (Barsevicket al., 2013).However, they are gaps in those studies on fatigue and physical activity. One of those is that there is limited such study conducted in Rwanda and it is to fill this gap this research project is undertaken.1.8 This study has four major areas of significance:1.8.1. Nursing research:This study identify the experience of CRF among patients receiving chemotherapy by providing information to nurses and patients practices related to CRF among cancer patient receiving chemotherapy, new opportunity will be identified in order to provide a basis for further research contributing to the improvement of CRF among patients receiving chemotherapy ,1.8.2. Nursing practice:This study increases nurses and patients awareness about their own practices in relation to CRF and patients physical activity.Results of this study informed national healthcare policy makers and hospital administration in particular, to recognize gaps in assessment and management of CRF and they can develop strategies and guidelines to prevent or minimize CRF among patients receiving chemotherapy effect. Nursing education: The results of the study are an additional source of information to the available literatures on this subject as well as a foundation for future research.Nursing management: Nurses are aware of the status quo as far as cancer patients’ level of fatigue and physical activity is.1.8.3. Operational definition of key termsFor the purpose of this study, the following terms are defined as follows:Cancer: Cancer is the general name for a group of more than 100 diseases, is defined as diseases in which abnormal cells divide without control and can invade nearby tissues and Untreated cancers can cause serious illness and death (ACS, 2017).Cancer related fatigue:National Comprehensive Cancer Network (NCCN) defined CRF as “a persistent, stressful, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning (Fu et al., 2019).Chemotherapy is the use of strong drugs to treat cancer.Chemotherapy is the treatment of cancer by using chemicals that kill cancer cells. These anti cancer drugs destroy cancer cells by stopping their growth and reproduction. The drugs may rarely be intended to have a local effect, but in most cases, the intention is to destroy cancer cells wherever they may exist in the body (Tierney, 2015).Physical activity Physical activity is defined as any bodily movement produced by skeletal muscle that requires energy expenditure. Physical activity can be undertaken in many different ways: walking, cycling, sports and active forms of recreation such as dance, yoga, tai chi.Can also be undertaken as part of work (lifting, carrying or other related tasks (WHO, 2018).1.9. Structure/Organization of the studyOur research work was subdivided into six main parts. The first part which include Title page, declaration, acknowledgement, summary, table of contents, a list of symbols and abbreviations, a list of tables and a list of figures, the second part includes introduction, third party literature review, forth party methodology, fifth party results and interpretation, and six party discussion and recommendations.1.10. Conclusion of Chapter1:As there is scarcity of literature about of CRF and physical activity in Rwanda, that is why the researcher is committed to conduct this study in order to contribute to knowledge generation in Nursing.