COLUMBUS, OhioFatigue in the cancer patient has multiple
causes and must be treated with a variety of strategies, said
Lois Almadrones, MSN, clinical research associate at Memorial
Sloan-Kettering Cancer Center.
Caregivers are often reluctant to inquire about a patients
fatigue and its effect on quality of life because they feel there is
little that can be done to correct it, she said at a conference on
cancer survivorship sponsored by the Ohio State University James
Cancer Hospital and Solove Research Institute. Her presentation was
sponsored by Ortho Biotech.
Chronic fatigue is an overwhelming sustained sense of exhaustion that
is not relieved totally with rest, adequate nutrition, or a vacation.
By definition, chronic fatigue lasts more than 1 month,
Ms. Almadrones said.
One component of fatigue is a decreased capacity for mental work, she
said. For this reason, health care providers should be sensitive to
their patients ability to listen and retain information.
Written material that can be sent home is useful for patient education.
Fatigue in cancer stems from the physical changes prompted by the
cancer, treatment side effects, and psychosocial factors. Physical
factors include the metabolic demands of rapidly dividing cancer
cells; the biochemical or hormonal changes caused by breast,
prostate, and gynecologic cancers; and anemia.
Treatment-related fatigue affects up to 100% of cancer patients.
Surgery can cause fatigue through tissue damage, blood loss, and the
side effects of anesthesia and analgesics. If food has been withheld,
perhaps due to a colonoscopy followed by immediate colon surgery,
then hunger-related fatigue will follow.
The fatigue of chemotherapy is caused by tumor destruction and
disposal and damage to normal tissue in the bone marrow and GI tract.
Damage to the GI tract can cause nausea and vomiting, diarrhea, and
mouth sores, which, in turn, can result in a reluctance to eat. In
this manner, appetite and nourishment-related symptoms can cause fatigue.
Radiation also causes fatigue due to tumor destruction and damage to
normal tissue. Following the treatment schedule for radiation, which
may require weekly or daily visits, is also draining.
Fatigue may be a treatment side effect of biologic response
modifiers, like interferon. Indeed, fatigue can be the dose-limiting
factor for these agents.
The psychosocial factors leading to fatigue include anxiety and
depression. People with cancer understandably often have anxiety.
They are likely to worry about death, cancer recurrence, job
security, and finances. Anxietyand the lack of sleep caused by
anxietycan lead to fatigue.
Since depression can be responsible for fatigue, the caregiver needs
to distinguish between cancer treatment-related fatigue and
depression. Generally, if the pattern of fatigue is related to the
timing of cancer treatment, then the treatment is probably the cause.
However if the intensity, pattern. and duration of sadness meet
the standard definition of depression, then the caregiver should
refer the patient to a mental health professional, she said.
Although undergoing cancer treatment is difficult, caregivers can
help their patients by focusing on what is positive. We need to
give our patients hope to get out of the abyss of depression,
Juggling work, family, and other responsibilities is exhausting
enough. For many people, cancer becomes added on to an already
stressful life, Ms. Almadrones said. Despite the rigors of
treatment, people may feel pressure to return to their jobs. Women
who are responsible for the cooking and cleaning at home may be
reluctant to give up those tasks. They know it is reassuring to their
families if they can continue in that role.
As professionals, we need to give cancer patients permission to
ask for help, delegate, and take it easy, she said.
Changes in sleep patterns, caused by either cancer symptoms or
treatment responses, can also contribute to fatigue. Pain, nausea and
vomiting, and diarrhea will affect sleep. Patients who are drinking
lots of water for chemotherapy will need to urinate more frequently
and this disturbs sleep. Changes in work and exercise schedules will
also affect sleep.
Health care providers can help patients with fatigue by assessing the
problem and offering suggestions that help patients cope. To measure
fatigue, Ms. Alma-drones recommended using a linear analog scale
assessment. She asks her patients to use the scale to indicate their
response to these three questions:
How would you rate your energy level during the past week?
How would you rate your energy level to do your daily activities over
the past week?
How would you rate your overall quality of life during the past week?
Although fatigue is a subjective experience, the use of the scale
provides an objective measure with which to chart change from one
visit to the next. When discussing fatigue, the health care provider
should also address the needs of the patients partner or
Correctable causes of fatigue, including pain, dehydration, anemia,
and electrolyte imbalances, should be assessed and treated.
Anemia should be treated, even in the last days of life,
she said. If we can keep patients hemoglobin up, they
will have more energy, a higher activity level, and a better quality
of life. To do this, she recommended transfusions or use of
epoetin alfa (Procrit), a genetically engineered form of
erythropoietin, which stimulates red blood cell production.
Helping patients maintain adequate nutrition is also
important, Ms. Almadrones said. The caregiver should help
manage nausea and diarrhea, both of which will interfere with eating
well. An easy-to-eat diet of energy drinks, boiled eggs, and softer
foods should be recommended to patients who are having difficulty
eating. Remind patients to take smaller meals more frequently,
drink adequate fluid, and rest before and after meals, she
suggested. A consultation with a dietitian may also be helpful.
If a patient complains about sleep disruption, the caregiver should
try to determine the cause and manage the problem. If patients have
urinary frequency due to the amount of fluids they are drinking for
chemotherapy, they should be encouraged to get all their fluids in
well before bedtime. Encourage patients to practice good sleep
habits, and support the use of guided imagery, massage, music
therapy, or aromatherapy to encourage relaxation, she said.
Promoting the proper balance between exercise and rest can also help
fight fatigue, Ms. Almadrones noted. In some cases, patients feel
more energetic and sleep better if they exercise appropriately during
the day. If necessary, she said, consult with a physical therapist.
Fatigue may cause both patients and their partners to feel they must
avoid all sexual activity. Health care providers can ease this
anxiety by encouraging sexual activity that is balanced and paced to
the patients needs. Intimacy is within the ability of the
cancer patient, Ms. Almadrones said, although it need not be
sexual intercourse. Encourage couples to avoid all-or-nothing
thinking regarding sex and give them permission to do something
in-between, including touching, massage, and togetherness, she said.
The health care provider can also encourage patients to take note of
when they have the most energy and least energy throughout the week,
while at work, and when undergoing treatment with chemotherapy and
radiation. A daily log can allows patients to schedule demanding
tasks to coincide with the periods when they feel best.
Finally, she said, many patients will return to negative coping
habits (smoking, drinking alcohol, using drugs) when faced with
cancer, and the health care provider should be aware of this and
offer counseling if appropriate.