NEW YORK--Fatigue is a significant problem experienced by the vast majority
of cancer patients--and also the most under-recognized and under-treated
symptom, Barbara F. Piper, DNsc, RN, OCN, told Oncology News International
in a telephone interview.
In a separate interview, William Breitbart, MD, of Memorial Sloan-Kettering,
explained that fatigue may be mistaken for depression and treated inappropriately.
Dr. Piper, associate professor of nursing, University of Nebraska Medical
Center, Omaha, stressed that cancer-related fatigue is not a 'trivial'
symptom without serious sequelae.
Psychological studies have found that cancer patients experiencing fatigue
are significantly more functionally impaired, depressed, distressed, and
hopeless than patients without fatigue, and are more likely to have thoughts
Moreover, she pointed out, three retrospective clinical studies in patients
with malignant melanoma, lung cancer, and breast cancer suggest that high
fatigue levels at diagnosis may be predictive of poor treatment response
and poor long-term outcome.
"Cancer-related fatigue is multicausal and multidimensional,"
Dr. Piper said, adding to the difficulty in assessing and treating the
problem. She has developed the Piper Fatigue Scale, which condenses the
dimensions of fatigue into four sub-scales: affective meaning, sensory,
cognitive/mood, and behavioral/severity.
This scale is being used at several major cancer centers to help physicians,
nurses, and psychosocial health care personnel assess the causes and intensity
of their patients' fatigue as a rational basis for treatment.
Dr. Piper pointed out that functional impairment--difficulties in performing
virtually all daily activities (dressing, showering, walking, housekeeping,
talking, concentrating, decision making, working)--is a common and distressing
physical manifestation of cancer-related fatigue.
Functional impairment can lead to manifestations of emotional distress,
ranging from anxiety and feelings of hopelessness to behavioral changes,
depression, and even self-destructive ideation, she said.
Patients with newly diagnosed early-stage breast cancer often have more
severe fatigue than those with recurrent disease, she said, possibly because
newly diagnosed patients have not yet learned the skills for coping with
the emotional stress of a cancer diagnosis, with treatment-associated fatigue,
and with the prospect of potential disease recurrence.
The Sixth Vital Sign?
Dr. Piper proposed that fatigue should be incorporated into every medical
history and physical exam as the sixth vital sign. "Often," she
said, "the cancer patient will not volunteer fatigue symptoms, feeling
that the physician or health care provider should not be bothered with
She urged physicians and nurses to bring the question out into the open,
"regardless of whether or not your patient complains of fatigue or
appears fatigued. Tell your patient that fatigue is important and that
you are interested in assessing and validating it."
Medical causes of fatigue must be treated before other dimensions of
fatigue can be assessed and addressed. Dr. Piper pointed out that the frequency
and intensity of fatigue may be affected by a number of medical conditions
"Treatment of these conditions such as with blood transfusions,
erythropoietin, or nutritional supplements may improve hemoglobin levels
and tissue oxygenation status, thereby reducing fatigue and improving functional
ability," Dr. Piper said.
Management of other treatment-related medical symptoms (eg, nausea,
vomiting, diarrhea, neurologic pain) may also impact positively on fatigue,
Many physicians consider cancer related fatigue to be a manifestation
of clinical depression. Actually, however, cancer-related fatigue and clinical
depression are two discrete syndromes,
William Breitbart, MD, said in a telephone interview. He is associate
attending psychiatrist and chief of the Psychiatry Service at Memorial
Sloan-Kettering Cancer Center.
In a large-scale NIH-supported study, Dr. Breitbart has used seven different
scales to grade fatigue, physical distress, psychological distress, and
performance status in patients with AIDS who had severe fatigue.
He told Oncology News International that about half of his patients
who experienced severe fatigue had no measurable clinical depression. Even
in those patients who had both fatigue and clinical depression, he said,
many severe fatigue items could not be accounted for by depression items
in the scales.
Helping Patients Cope
The two investigators both emphasized that psychiatric and/or psychosocial
counseling as well as support groups can be very useful for helping the
cancer patient cope with emotional stress, anxiety, conflict, depression,
and social tension in the family and work environment. Dr. Piper added
that self-help strategies (see Table 2) can do much to reduce cancer-related
"Currently, physicians and HMOs are looking at the efficacy of
cancer therapy not only by objective response criteria but also by quality
of life indicators," Dr. Piper said. "Fatigue is certainly one
such indicator, and should be included at least in the physical symptom
listings of quality of life instruments."