Evaluation on Symptoms and Self-Treatment due to Radiotherapy
and Chemotherapy Based on Different Cancer Stage
Yesiana Dwi Wahyu Werdani
Faculty of Nursing, Widya Mandala Catholic University Surabaya,Surabaya,Indonesia
Keywords: Radiotherapy, Chemotherapy, Cancer Stage, Self-treatment.
Abstract: Radiotherapy and chemotherapy is modality therapy in cancer patients to minimize metastatic, but it causes
disruption of the overall organ system and decrease in various body functions. It can interfere the daily
needs fulfilled, and the patient become discouraged and worsened their condition. This study was to identify
the symptoms and self-treatment due to radiotherapy and chemotherapy based on the different cancer stage.
This was mixed method design and sequential explanatory approach. Samples were 30 cancer patients taken
by purposive sampling at Indonesian Cancer Foundation East Java Branch. The instrument was a
questionnaire. Result showed the most symptoms complained by all patients in various stages was fatigue.
Pain, hair loss and constipation were dominated in cancer stage 4, nausea-vomiting and insomnia were
dominated in cancer stage 3. All patients did the self-treatment. The majority self-treatment of fatigue was
yoga exercise. Pain and nausea-vomiting were treated by combination of medication and relaxation.
Insomnia was treated by mild massage. Constipation was treated by consuming the high fiber foods.
Nobody treat the hair loss complaints. Radiotherapy and chemotherapy affect the disturbance of the
stimulation hormones and metabolism that cause several of physical symptoms. Self-treatment by the
patient could reduce the symptoms effectively.
1 BACKGROUND
Cancer is tumor cells which has the ability to
replicate rapidly and invade the normal body tissues.
(Bunz, 2008). Cancer can metastatic to all of organs
depending on the stage of cancer. Prevention of
metastatic can be done through radiotherapy and
chemotherapy. It is expected to has a longer
survival. In prior studies of women with breast
cancer post-chemotherapy found that the survival
rates of patients increased reaching 5 years (92.1%)
and 10 years (81.9%)(Rossi et al., 2015). The
effectiveness of radiotherapy and chemotherapy in
prolonging survival was followed by various effects
on physical conditions. It will lead to disruption of
the patient's daily activities and if it lasts longer can
worsen the quality of life of the patient. In the prior
studies mentioned the various physical effects post-
chemotherapy and radiotherapy separately. No
research identify these effect and the beneficial
treatment by patient to reduce it based on the cancer
stage.
In 2013 based on the basic health research stated
that the prevalence of cancer in Indonesia reached
1.4 per mil with the highest areas of Yogyakarta (4.1
‰), Central Java (2.1 ‰), Bali (2 ‰), Bengkulu and
DKI Jakarta respectively (1.9 ‰), while in East Java
reaches 1.6 ‰(HRDI, 2013).
Research on 100 cancer patients found that the
majority effects of chemotherapy is a weakness 95%
and fatigue 90%(Shahbaz Aslam et al., 2014).
Another research reported that 15 patients performed
radiotherapy, majority complained were totally
exhausted, pain like skin burning and itching(Schnur
et al., 2009). Radiotherapy and chemotherapy trigger
the occurrence of oxidative stress not only in the
target tissue, but also on healthy tissue. It causes the
toxicity and organ dysfunction(Gilliam and St. Clair,
2011). Exposure to oxidative stress on radiotherapy
and chemotherapy to the muscles can cause
weakness and progressively increase the occurrence
of fatigue(Powers and Jackson, 2008). Oxidative
stress can lead to apoptosis, metabolic disorders,
neuroinflammation, metabolic disturbances and
neuronal failure(Areti et al., 2014). Target cell
damage due to radiation on the tissues can cause
DNA damage(Baskar et al., 2014).
150
Werdani, Y.
Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage.
DOI: 10.5220/0008321901500156
In Proceedings of the 9th International Nursing Conference (INC 2018), pages 150-156
ISBN: 978-989-758-336-0
Copyright
c
2018 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
Therefore the physical symptoms due to
chemotherapy and radiotherapy is very important to
be recognized by patients earlier and empower
patients to reduce symptoms independently is
essential to improve the patient's adaptation process.
This study was to identify the physical symptoms
and self-treatment due to radiotherapy and
chemotherapy based on the cancer stage.
2 METHODS
This was mixed method design and sequential
explanatory approach. Sample was cancer patients
with radiotherapy and chemotherapy program at
Indonesian Cancer Foundation East Java Branch
which amounted to 30 people, taken by purposive
sampling technique.
The questionnaire as an instrument was made by
researchers based on theories about the effects of
chemotherapy and radiotherapy. It consists of
closed-ended questions that describe a wide range of
physical complaints in post-chemotherapy and
radiotherapy. The instrument has been tested the
validity and reliability test, the result of the
correlation coefficient was 0.872 and cronbach’s
alpha result was 0.923. It means that the instrument
is valid and reliable.
All participants were given an explanation of the
purposes, benefits and risks of this study, and who
agreed to sign a voluntary and non-compulsory
informed consent sheet.
After the participants filling out the
questionnaire, it continued with interviewed about
the self-treatment to reduce the symptoms. After the
data collected, it was compare among the symptoms
and self-treatment based on cancer stage and
calculate the percentage.
3 RESULTS
Below is the general and particular data of
participants about physical symptom and self-
treatment.
Table 1 shown the majority participants were
female (73.3%) with average of age 41 50 years
old (40%). The most type of cancer was breast
cancer (30%), based on cancer stage was III (40%)
and majority time of diagnosed with cancer was 1 -
< 2 years (40%).
Figure. 1: The symptoms due to radiotherapy and
chemotherapy based on cancer stage
Graph as shown in fig. 1 that found six
symtopms due to radiotherapy and chemotherapy,
but fatigue was found in all of stage of cancer. In
stage 1 no symtomp about hair loss and constipation.
In stage 2 4 all symtomps was found. Pain, hair
loss and constipation symptoms were dominated in
cancer stage 4, whereas nausea/ vomiting and
insomnia were dominated in cancer stage 3.
0% 50% 100%
Fatigue
Pain
Nause/Vomiting
Insomnia
Hair Loss
Constipation
Stage 1 Stage 2 Stage 3 Stage 4
Table 1. General Data of Participants at Indonesian
Cancer Foundation East Java Branch, 2017.
General
Data
Categories
Frequency
(Person)
Percentage
(%)
Age
25 30 years
3
10
31 40 years
4
13.3
41 50 years
12
40
51 60 years
9
30
> 60 years
2
6.7
Sex
Female
22
73.3
Male
8
26.7
Type of
cancer
Breast
9
30
Cervix
6
20
Nasopharing
8
26.7
Colon
2
6.7
Ovary
2
6.7
Lung
1
3.3
Lymphoma
Hodgkin
1
3.3
Rectum
1
3.3
Cancer
stage
I
4
13.3
II
6
20
III
12
40
IV
8
26.7
Time of
diagnosed
with
cancer
< 1 years
11
36.7
1 - < 2 years
12
40
2 - < 3 years
2
6.7
> 3 years
5
16.6
Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage
151
Table 2 shown that in fatigue symptom identified
two details characteristics. The first was weak and
lack of energy, it was dominated in cancer stage 1
and the second fatigue disturbing of daily activity
fulfilling was dominated in cancer stage 4. In Pain
symptom participant felt hand, feet and back cramps
was dominated in cancer stage 3 and abdominal &
back lancinating was dominated in cancer stage 4.
Participants felt nausea when smell of food and
sometimes followed by vomiting was dominated in
cancer stage 1 and 2. Nausea feel anytime
Table 3 shown that participants got trouble
getting started sleeping & woke up early were
dominated by cancer stage 3, and woke up at night
and could not sleep anymore were dominated in
cancer stage 4. In hair loss symptom the most
moderate hair loss was dominated in cancer stage 3
and severe hair loss (alopecia) was dominated in
cancer stage 4. In constipation symptom all of stage
of cancer felt straining during defecation and hard
lump of faeces except cancer stage 1.
Table 4 shown that in fatigue symptoms,
participants relieve it by resting was dominated in
cancer stage 4, but yoga exercise was dominated in
cancer stage 1. In pain symptom the majority of
cancer stage 3 relieve by analgesic drug consume,
but treatment by combination of analgesic drug &
relaxation (deep breathing and distraction) were
dominated by cancer stage 4. Majority participants
in cancer stage 4 relieve nausea/ vomiting by
antiemetic drug, but in cancer stage 1 and 2 relieve
by combination of antiemetic drug & relaxation
(deep breathing).
Table 5 shown that mild massage on head, back,
hand and feet were dominated in cancer stage 1 and
2 to relieve insomnia, whereas cancer stage 4 relieve
insomnia by sleeping pills. In symptom of hair loss
the majority of participants in cancer stage 2 do no
treatment, and using hair tonic to stimulate the hair
growing were used by cancer stage 3. In symptoms
of constipation participants in cancer stage 2 3 was
relieved by high fiber foods consuming such as
vegetables, fruits and drink amount of water.
4 DISCUSSION
4.1 Symptoms and its Characteristics
The most symptoms after chemotherapy and
radiotherapy was fatigue, it occurred in all patients
with various stages of cancer. The details
characteristic identified were weakness, lack of
energy and fatigue disturbing of daily activity. The
participants have limitations in the activity and cause
the high levels of dependence on others. One of
research on 100 cancer patients reported that
weakness (95%) and fatigue (90%) after
chemotherapy (Shahbaz Aslam et al., 2014). Fatigue
(cancer related fatigue) is a subjective complaint
against the onset of physical fatigue. Post
radiotherapy or chemotherapy majority of
respondents got severe fatigue(Kummer et al.,
2013),(Bock et al., 2014),(Werdani, 2017).
Chemotherapy, surgery, and radiotherapy can lead to
increased plasma cytokines, especially TNF-α, IL-
Stage of
Cancer
Fatigue
Pain
Nausea
Weakness
& lack of
energy
(%)
Fatigue disturbing
of daily activity
(%)
Hand, feet &
back cramps
(%)
Abdominal &
back
lancinating
(%)
When smell of food
sometimes followed by
vomiting (%)
Any time sometimes
followed by vomiting
Stage 1
100
0
75
25
100
0
Stage 2
66,7
33,3
75
25
100
0
Stage 3
25
75
60
40
10
90
Stage 4
0
100
28,6
71,4
14,3
85,7
Stage of
Cancer
Fatigue
Pain
Nausea/ Vomiting
Resting
(%)
Yoga
Exercise
(%)
Analgesic
drug (%)
Combination of
analgesic drug &
relaxation (%)
Antiemetic
drug (%)
Combination of
antiemetic drug &
relaxation (%)
Stage 1
25
75
50
50
0
100
Stage 2
50
50
33.3
66.4
0
100
Stage 3
33,3
66,7
30
70
30
70
Stage 4
62,5
37,5
25
75
42,9
57,1
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
152
1β, and IL-6. TNF-α has been shown to cause
changes in neurotransmission of the central nervous
system leading to behavioral changes such as
lethargy and anorexia(Ryan et al., 2007).
Pain symptom was identified by two
characteristics, hand feet and back cramps and
abdominal & back lancinating. This complaint is felt
by the participants every day and more severe during
the activity. Pathophysiology of cancer pain involves
somatic, visceral and neuropathy. Somatic pain is
usually superficial and arises from the skin, soft
tissue and musculoskeletal tissue. Visceral pain is
dull originating from internal organs. Neuropathic
pain arises from the structure of the somatosensory
system such as receptors, peripheral nerves,
autonomic nerves and central nervous
system(Mishra et al., 2009). Another research
reported that 13% of breast cancer patients
complained of moderate to severe pain (rating> 4) at
early of radiotherapy and 23% reported moderate to
severe pain after radiotherapy(Parks et al., 2017).
Persistent pain also felt in breast cancer patients
after 5-7 years post-chemotherapy(Mejdahl et al.,
2013).
Details characteristic of nausea/vomiting were
smelling food and at any time and it sometimes
followed vomiting, it cause reduce nutritional intake
and body weight. Participants only able to spend half
the portion of the meal. Vomiting is a reflex
triggered by a toxic substance, such as a
chemotherapy agent, which causes damage to the
gastric mucosa and the small intestine, thus
stimulating the vagal afferent interacting with the
central nervous system, and generating an emetic
response(Hesketh, 2008). Neurotransmitters that
affect the emetic response are serotonin, dopamine,
acetylcholine, and γ-aminobutyric acid (GABA),
histamine, endorphins, and cannabinoids(Navari,
2009). Cancer patients in another research stated that
the effects of chemotherapy led to nausea of 77%,
vomiting 75%(Shahbaz Aslam et al., 2014).
Insomnia characterized by trouble getting started
sleeping & woke up early and woke up at night and
could not sleep anymore. It causes respondents often
feel tired throughout the day. Radiation and
chemotherapy are both reported to produce sleep
disturbances(Liu and Ancoli-Israel, 2008). In cancer
patients, circadian rhythm disturbance is caused by
endocrine changes (such as cortisol, melatonin,
prolactin), metabolic processes (such as temperature
and circulation levels of proteins), and the immune
system (such as leukocyte and neutrophil levels)(Liu
and Ancoli-Israel, 2008). Sleep disturbances and
increased daytime drowsiness occur in adult and
child of various types of cancer including acute
lymphocytic leukemia, central nervous system
tumor, Hodgkin's lymphoma, soft tissue sarcoma,
and bone tumor(Mulrooney et al., 2004).
The symptoms of hair loss is suffered in stage 4
of cancer with degrees of hair loss vary, but it does
not make the patient feel ashamed. Research
conducted on Caucasian cancer patient reported that
post-chemotherapy cause hair loss and alopecia on a
moderate scale
(Kluger et al., 2012).
Constipation is suffered in stage 4 of cancer.
Majority of patients told that difficulty defecation
with the fastest frequency of defecation is 1 week
once times with stiff consistency of the feces.
Table 4. Description of details self-treatment to reduce the symptoms.
Stage of
Cancer
Fatigue
Pain
Nausea/ Vomiting
Resting
(%)
Yoga
Exercise
(%)
Analgesic
drug (%)
Combination of
analgesic drug &
relaxation (%)
Antiemetic
drug (%)
Combination of
antiemetic drug &
relaxation (%)
Stage 1
25
75
50
50
0
100
Stage 2
50
50
33.3
66.4
0
100
Stage 3
33,3
66,7
30
70
30
70
Stage 4
62,5
37,5
25
75
42,9
57,1
Table 5. Description of details self treatment to reduce the symptoms.
Stage of
Cancer
Insomnia
Hair Loss
Constipation
Mild massage
(%)
Sleeping pills
(%)
No Treatment
(%)
Using hair tonic
(%)
High fiber food
consuming (%)
Stage 1
100
0
0
0
0
Stage 2
100
0
100
0
100
Stage 3
66,7
33,3
42,9
57,1
100
Stage 4
40
60
50
50
100
Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage
153
Constipation often occurs 50-87% in patients with
advanced cancer(Abernethy, Wheeler and Zafar,
2009). Constipation is the third most common
symptom in patients receiving cytotoxic
chemotherapy with an overall prevalence of 16%,
with 5% being severe and 11% moderate(Anthony,
2010). Chemotherapy and radiation drugs affect the
contractile physic activity that contribute to colonic
motor activity and peristaltic reflexes (Kuizenga et
al., 2015).
4.2 Self-treatment to Reduce the
Symptoms
The majority of patients who suffered fatigue cope
with resting (reduced daily activities and use the
time to lie down, while some light activity such as
reading, making handwork is done by sitting). But
there is a small percentage of patients who overcome
fatigue by doing yoga exercise, because they have
understood the steps of yoga through social media
and training from local cancer organization where
they come from. In prior studies reported that the
activity of yoga for 12 weeks can reduce fatigue
significantly(Bower, Garet and Sternlieb, 2011).
In pain symptoms, the majority of patients
overcome by taking analgesic drug from the
physician and combined with the deep breathing
relaxation and distraction technique. It has learned
from health care workers in the hospital. But
sometimes the pain is still felt in moderate to mild
scale. Meditation, progressive relaxation, rhythmic
respiration, therapeutic touch, transcutaneous
electrical nerve stimulation (TENS), hypnosis, music
therapy, acupressure are among the non-invasive
methods of reducing pain in cancer patients(Woolf,
2011). Non-opioid analgesic drugs are the first step
to reduce cancer pain, but if the pain is not well
controlled then strong opioids such as morphine can
be given(PDQ Supportive and Palliative Care
Editorial Board, 2002).
In Nausea/ vomiting symptoms, the majority of
patients cope with a combination of antiemetic drug
and deep breathing relaxation techniques. In the
prior studies reported that providing a relaxation
intervention with music for 25 minutes is effective
Figure 2: The Patterns of Symptoms and Self Treatment due to Radiotherapy and Chemotherapy Based on Different
Cancer Stage
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
154
in reducing the intensity of nausea and vomiting in
cancer patients(Arakawa, 1997).
In insomnia symptom are overcome by the
majority of respondents with deep relaxation
techniques such as meditation and mild massage on
the head/ hands/ feet/ back performed by family
caregiver. Medical massage therapy interventions on
cancer patients showed significant differences in
sleep quality scores before and after intervention in
the treatment group(Kashani and Kashani, 2014).
Massage therapy can increase different levels of
relaxation in a person's body and can improve sleep
habits(Reza et al., 2010).
In hair loss symptom, the majority of patients
doing nothing of treatment, but there is a small
percentage of patients who use hair tonic to cool the
head and stimulate hair growth. Scalp cooling
especially in the frontal, superior and occipital areas
of the head can reduce hair loss during
chemotherapy(Ghaffari M et al., 2015).
In constipation symptoms overcome by
increasing the high fiber foods consuming such as
fruits, vegetables, and many waters, it help them
alleviate perceived complaints. Dietary fiber intake
increases the frequency of defecation and improves
fecal consistency, which is especially useful for
patients who are constipated (Yang et al., 2012).
Figure 2 shown that side effect of cancer therapy
(radiotherapy and chemotherapy) cause the
complicated symptoms and its details. Many self-
treatment done by patients to reduce the symptoms.
5 CONCLUSIONS
Radiotherapy and chemotherapy in cancer patients
can lead to the physical symptoms that disrupt the
balance of individual physiological basic needs
fulfilled. Every stage of cancer has different details
characteristic of symptoms. The Patients did the
self-treatment to reduce the symptoms and every
stage of cancer has different ways to overcome it.
REFERENCES
Abernethy, A. P., Wheeler, J. L. and Zafar, S. Y. (2009)
‘Detailing of gastrointestinal symptoms in cancer
patients with advanced disease: new methodologies,
new insights, and a proposed approach’, Current
Opinion in Supportive and Palliative Care, 3(1), pp.
4149. doi: 10.1097/SPC.0b013e32832531ce.
Anthony, L. B. (2010) ‘Diarrhea, Constipation, and
Obstruction in Cancer Management’, in The MASCC
Textbook of Cancer Supportive Care and
Survivorship. Boston, MA: Springer US, pp. 249260.
doi: 10.1007/978-1-4419-1225-1_26.
Arakawa, S. (1997) ‘Relaxation to reduce nausea,
vomiting, and anxiety induced by chemotherapy in
Japanese patients.’, Cancer nursing, 20(5), pp. 3429.
Available at:
http://www.ncbi.nlm.nih.gov/pubmed/9394056
(Accessed: 12 December 2017).
Areti, A. et al. (2014) ‘Oxidative stress and nerve damage:
Role in chemotherapy induced peripheral neuropathy’,
Redox Biology, 2, pp. 289295. doi:
10.1016/j.redox.2014.01.006.
Baskar, R. et al. (2014) ‘Biological response of cancer
cells to radiation treatment’, Frontiers in Molecular
Biosciences, 1. doi: 10.3389/fmolb.2014.00024.
Bock, P. R. et al. (2014) ‘Targeting inflammation in
cancer-related-fatigue: a rationale for mistletoe
therapy as supportive care in colorectal cancer
patients.’, Inflammation & allergy drug targets, 13(2),
pp. 10511. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/24766319
(Accessed: 12 December 2017).
Bower, J. E., Garet, D. and Sternlieb, B. (2011) ‘Yoga for
persistent fatigue in breast cancer survivors: results of
a pilot study.’, Evidence-based complementary and
alternative medicine : eCAM. Hindawi, 2011, p.
623168. doi: 10.1155/2011/623168.
Bunz, F. (2008) Principles of Cancer Genetics. Dordrecht:
Springer Netherlands. doi: 10.1007/978-1-4020-6784-
6.
Ghaffari M, S. M. et al. (2015) ‘Site-Dependence Scalp
Cooling System to Prevent Hair Loss during
Chemotherapy’, Journal of Bioengineering &
Biomedical Science. OMICS International, 05(02), pp.
16. doi: 10.4172/2155-9538.1000158.
Gilliam, L. A. A. and St. Clair, D. K. (2011)
‘Chemotherapy-Induced Weakness and Fatigue in
Skeletal Muscle: The Role of Oxidative Stress’,
Antioxidants & Redox Signaling, 15(9), pp. 2543
2563. doi: 10.1089/ars.2011.3965.
Hesketh, P. J. (2008) ‘Chemotherapy-Induced Nausea and
Vomiting’, New England Journal of Medicine.
Massachusetts Medical Society , 358(23), pp. 2482
2494. doi: 10.1056/NEJMra0706547.
HRDI (2013) ‘Basic Health Research 2013.’
Kashani, F. and Kashani, P. (2014) ‘The effect of massage
therapy on the quality of sleep in breast cancer
patients.’, Iranian journal of nursing and midwifery
research. Wolters Kluwer -- Medknow Publications,
19(2), pp. 1138. Available at:
Evaluation on Symptoms and Self-Treatment due to Radiotherapy and Chemotherapy Based on Different Cancer Stage
155
http://www.ncbi.nlm.nih.gov/pubmed/24834078
(Accessed: 12 December 2017).
Kluger, N. et al. (2012) ‘Permanent scalp alopecia related
to breast cancer chemotherapy by sequential
fluorouracil/epirubicin/cyclophosphamide (FEC) and
docetaxel: a prospective study of 20 patients’, Annals
of Oncology, 23(11), pp. 28792884. doi:
10.1093/annonc/mds095.
Kuizenga, M. H. et al. (2015) ‘Neurally mediated
propagating discrete clustered contractions
superimposed on myogenic ripples in ex vivo
segments of human ileum’, AJP: Gastrointestinal and
Liver Physiology, 308(1), pp. G1G11. doi:
10.1152/ajpgi.00230.2014.
Kummer, F. et al. (2013) ‘Relationship between cancer-
related fatigue and physical activity in inpatient cancer
rehabilitation.’, Anticancer research, 33(8), pp. 3415
22. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23898113
(Accessed: 12 December 2017).
Liu, L. and Ancoli-Israel, S. (2008) ‘Sleep Disturbances in
Cancer.’, Psychiatric annals, 38(9), pp. 627634.
Available at:
http://www.ncbi.nlm.nih.gov/pubmed/21243092
(Accessed: 12 December 2017).
Mejdahl, M. K. et al. (2013) ‘Persistent pain and sensory
disturbances after treatment for breast cancer: six year
nationwide follow-up study.’, BMJ (Clinical research
ed.), 346, p. f1865. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/23580693
(Accessed: 12 December 2017).
Mishra, S. et al. (2009) ‘Breakthrough cancer pain:
Review of prevalence, characteristics and
management’, Indian Journal of Palliative Care,
15(1), p. 14. doi: 10.4103/0973-1075.53506.
Mulrooney, D. A. et al. (2004) ‘Fatigue and sleep in
survivors of childhood cancer: A report from the
Childhood Cancer Survivor Study (CCSS)’, Journal of
Clinical Oncology, 22(14_suppl), pp. 81298129. doi:
10.1200/jco.2004.22.90140.8129.
Navari, R. M. (2009) ‘Pharmacological Management of
Chemotherapy-Induced Nausea and Vomiting’, Drugs.
Springer International Publishing, 69(5), pp. 515533.
doi: 10.2165/00003495-200969050-00002.
Parks, J. et al. (2017) ‘Predictors of Breast Pain in Breast
Cancer Patents One Year After Whole Breast
Radiation Therapy’, International Journal of
Radiation Oncology, Biology, Physics, 99, p. E41. doi:
10.1016/j.ijrobp.2017.06.689.
PDQ Supportive and Palliative Care Editorial Board
(2002) Cancer Pain (PDQ®): Health Professional
Version, PDQ Cancer Information Summaries.
Available at:
http://www.ncbi.nlm.nih.gov/pubmed/26389387
(Accessed: 12 December 2017).
Powers, S. K. and Jackson, M. J. (2008) ‘Exercise-
Induced Oxidative Stress: Cellular Mechanisms and
Impact on Muscle Force Production’, Physiological
Reviews, 88(4), pp. 12431276. doi:
10.1152/physrev.00031.2007.
Reza, H. et al. (2010) ‘The effect of acupressure on
quality of sleep in Iranian elderly nursing home
residents’, Complementary Therapies in Clinical
Practice, 16(2), pp. 8185. doi:
10.1016/j.ctcp.2009.07.003.
Rossi, L. et al. (2015) ‘Impact of Adjuvant Chemotherapy
on Breast Cancer Survival: A Real-World Population’,
PLOS ONE. Edited by T. F. Bathen, 10(7), p.
e0132853. doi: 10.1371/journal.pone.0132853.
Ryan, J. L. et al. (2007) ‘Mechanisms of cancer-related
fatigue.’, The oncologist. AlphaMed Press, 12 Suppl
1(Supplement 1), pp. 2234. doi:
10.1634/theoncologist.12-S1-22.
Schnur, J. B. et al. (2009) ‘Breast Cancer Patients’
Experience of External-Beam Radiotherapy’,
Qualitative Health Research, 19(5), pp. 668676. doi:
10.1177/1049732309334097.
Shahbaz Aslam, M. et al. (2014) ‘Side Effects of
Chemotherapy in Cancer Patients and Evaluation of
Patients Opinion about Starvation Based Differential
Chemotherapy’, Journal of Cancer Therapy Jour-nal
of Cancer Therapy, 5(5), pp. 817822. doi:
10.4236/jct.2014.58089.
Werdani, Y. D. W. (2017) ‘EFFECT OF
MINDFULLNESS MEDITATION ON STRESS
LEVEL AND COPING MECHANISM IN CANCER
PATIENTS’, Folia Medica Indonesiana, 53(1), pp.
3340. doi: 10.20473/FMI.V53I1.5488.
Woolf, C. J. (2011) ‘Central sensitization: Implications for
the diagnosis and treatment of pain’, Pain,
152(Supplement), pp. S2S15. doi:
10.1016/j.pain.2010.09.030.
Yang, J. et al. (2012) ‘Effect of dietary fiber on
constipation: a meta analysis.’, World journal of
gastroenterology. Baishideng Publishing Group Inc,
18(48), pp. 737883. doi: 10.3748/wjg.v18.i48.7378.
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
156