Cognitive Behavioral Therapy for Cancer-related Fatigue in Patients With Cancer Receiving Palliative Systemic Treatment (TIRELESS)

Making Cognitive Behavioral Therapy for Cancer-related Fatigue Fit for Implementation in Patients With Cancer Receiving Palliative Systemic Treatment

Cancer-related fatigue is highly prevalent in patients receiving treatment for gliomas or palliative systemic treatment for cancer and is experienced as one of the most burdensome symptoms affecting patients' daily functioning and quality of life. From the KWF-sponsored TIRED trial, we concluded that cognitive behavioral therapy (CBT) is effective in reducing fatigue in cancer patients with severe fatigue during palliative systemic treatment and in glioma patients. However, in its current form, integration in routine medical care is difficult and scalability is a problem, as the intervention is time-intensive, requires face-to-face consults with a psychologists, and the availability of trained psychologists is limited.

The investigators expect that inter-CBT will integrate well into clinical practice and prove non-inferior in achieving a reduction in fatigue compared to face-to-face CBT as investigated in the TIRED and GRIP study. It is further expected that the interviews will provide useful information to implement this intervention.

The main aims to answer are:

• To determine the non-inferiority of CBT primarily led by nurese, compared with benchmark studies in which CBT was provided by psychologists, in its effect on reduction in cancer-related fatigue
• To adapt CBT delivery to the needs of patients treated with palliative intent and glioma (interdisciplinary web-based CBT for cancer-related fatigue.
• To investigate its feasibility by evaluating the practical workability, acceptability, and burden for patients and health care providers.

Participants will follow the 12 weeks CBT intervention online, mainly guided by their nurse. Participants will start with a face-to-face session with the psychologists, partly together with their nurse, to start with setting their treatment goals. Then, they will work on the modules that are applicable to them. During the CBT intervention there will be a face-to-face session with their nurse to discuss the progress of their goals. Finally, all participants will complete the therapy by realizing their treatment goals. The outcomes with respect to fatigue severity and participants' goals will be discussed by the nurse with the participant in the final, face-to-face sessions. The face-to-face sessions will take 30 to max. 45 minutes, except for the first session, which will take one hour of which the nurse will be present during 15 minutes.

Researchers will compare the outcomes of the study to a benchmark study where CBT was provided by psychologists in its effect on reduction in cancer-related fatigue.

Study Overview

• Status: Recruiting
• Conditions: Cancer; Palliative Treatment
• Intervention / Treatment: Behavioral: Cognitive behavioral therapy

• Study Type: Interventional
• Enrollment (Estimated): 56
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Hans Knoop, Prof.; Phone Number: 020 5666932; Email: hans.knoop@amsterdamumc.nl

Study Locations

• Netherlands
  • North Holland
    • Amsterdam, North Holland, Netherlands, 1105AZ
      • Recruiting
      • Medical Psychology
      • Contact: Christine Henneman-Hoogeland, na; Phone Number: 020 - 566 4661; Email: c.hennemanhoogeland@amsterdamumc.nl

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Solid (non-brain) tumor patients

Inclusion Criteria:

• Receive systemic treatment with palliative intent for a solid (non-brain) tumor
• Are ≥18 years old
• Are proficient in Dutch
• Report severe fatigue (Checklist Individual Strength, fatigue severity subscale [CIS-fatigue] score ≥35)
• A life expectancy of ≥6 months according to their oncologist
• Access to a device with internet

Exclusion Criteria:

• Symptomatic brain metastases
• Dual immunotherapy
• Have a poor performance status (Karnofsky <70)
• Are currently receiving treatment for a mental disorder.
• Treatable somatic cause that could explain the presence of severe fatigue (other than the underlying disease and the cancer treatment itself)
• Severe cognitive deficits

Glioma patients

Inclusion Criteria:

• Histologically confirmed diffuse glioma WHO grade 2, 3, or 4
• No oncological treatment for at least two months prior to inclusion
• Are ≥18 years old
• Are proficient in Dutch
• Report severe fatigue (Checklist Individual Strength, fatigue severity subscale [CIS-fatigue] score ≥35)
• A life expectancy of ≥3 months according to their oncologist
• Access to a device with internet

Exclusion Criteria:

• Signs of radiological or clinical tumor progression at the time of inclusion
• Corticosteroid use
• Have a poor performance status (Karnofsky <70)
• Are currently receiving treatment for a mental disorder
• Treatable somatic cause that could explain the presence of severe fatigue (other than the underlying disease and the cancer treatment itself).
• Severe cognitive deficits

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Benchmark study; The results will be compared to a benckmark consisting of a historical study population from the TIRED trial and the GRIP trial in which CBT was delivered by psychologists specialized in CBT.	Behavioral: Cognitive behavioral therapy; Cognitive behavioural therapy (CBT) is a therapy that can help you manage your problems by changing the way you think and behave.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fatigue severity will be measured using the subscale fatigue severity (8 items, 7-point Likert scale) of the Checklist Individual Strength (CIS-fatigue).	The CIS-fatigue has shown to be sensitive to change, has good reliability and discriminative validity. Scores range from 8 to 56. A score of ≥35 indicates severe fatigue. Change = (week 14 score - baseline score).	Screening, baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fatigue will be assessed with the symptom scale Fatigue ((3 items, 4-point Likert scale) of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, version 3.0).	The EORTC QLQ-C30 is developed for use in clinical trials in cancer patients. Total scores on each subscale are linearly converted to a 0 to 100 scale. Higher scores indicate more fatigue. Change = (week 14 score - baseline score).	Baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)
Quality of Life will be measured using the subscale global health status/QoL (2 items, 7-point Likert Scale) of the EORTC QLQ-C30.	The EORTC QLQ-C30 is one of the most commonly used HRQoL instruments in the palliative setting and is known to be a reliable and valid measure of the quality of life of patients with cancer. A high score indicates good HRQoL. Change = (week 14 score - baseline score).	Baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)
Functional impairment will be measured using the subscales emotional functioning (4 items, 4-point Likert scale) and physical functioning (5 items, 4-point Likert scale, range 0 to 100) of the EORTC QLQ-C30.	Raw scores for both subscales are convertible to a score of 0 to 100. A high score represents a high level of functioning. Change = (week 14 score - baseline score).	Baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)
Functional impairment will be assessed with the work and social adjustment scale (WSAS)	Raw scores for both subscales are convertible to a score of 0 to 100. A high score represents a high level of functioning. Change = (week 14 score - baseline score).	Baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)
Healthcare consumption	In order to estimate the healthcare costs related to fatigue we will compare the therapist time spent per patient within the TIRELESS project with the time spent per patient within the benchmark study (TIRED study). We will use an adapted version of a questionnaire on health consumption and productivity loss (TiC-P). At baseline, patients will be asked about their healthcare consumption over the past 4 months.The healthcare consumption during the four months of the intervention (study participation) will then be compared to the four months preceding the intervention. A group of 25 patients who are severely fatigued and eligible for study participation, but who do not want to participate will be asked if they are willing to complete the TiC-P at the same time points (T0, T1, T2) as the study participants. We then will compare health care consumption of these two groups.	Baseline (T0), week 14 after T0 (T1) and week 26 after T0 (T2)
Usability of the e-health platform will be assessed using the System Usability Scale (SUS)	The System Usability Scale is a 10-item questionnaire rated on a 5-point Likert scale. The total SUS score ranges from 0 to 100, with higher scores indicating better perceived usability.	T1: week 14 after T0

Collaborators and Investigators

• Sponsor: Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
• Collaborators: Dutch Cancer Society

Publications and helpful links

General Publications

• Poort H, Verhagen CA, Peters ME, Goedendorp MM, Donders AR, Hopman MT, Nijhuis-van der Sanden MW, Berends T, Bleijenberg G, Knoop H. Study protocol of the TIRED study: a randomised controlled trial comparing either graded exercise therapy for severe fatigue or cognitive behaviour therapy with usual care in patients with incurable cancer. BMC Cancer. 2017 Jan 28;17(1):81. doi: 10.1186/s12885-017-3076-0.
• Gorter M, Rottgering JG, Belgers V, Blom MEC, Thomassen B, De Witt Hamer PC, Niers JM, Kouwenhoven MCM, Bienfait HP, Gathier CS, Compter A, Geurts M, Snijders TJ, van de Ven PM, Douw L, Knoop H, Klein M. Bayesian adaptive randomized trial of blended cognitive behavioral therapy for severe fatigue in stable diffuse glioma. Neuro Oncol. 2026 Mar 1;28(3):693-703. doi: 10.1093/neuonc/noaf256.

Helpful Links

• TIRED trial, historical benchmark study

Study record dates

Study Major Dates

• Study Start (Actual): June 3, 2024
• Primary Completion (Estimated): June 1, 2027
• Study Completion (Estimated): February 1, 2028

Study Registration Dates

• First Submitted: February 23, 2024
• First Submitted That Met QC Criteria: July 15, 2024
• First Posted (Actual): July 22, 2024

Study Record Updates

• Last Update Posted (Actual): June 15, 2026
• Last Update Submitted That Met QC Criteria: June 11, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neoplasms; Behavior Therapy; Psychotherapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy
• Other Study ID Numbers: NL85495.018.23

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No