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Fatigue May Be Most Under-recognized, Undertreated Cancer-related Symptom

Fatigue May Be Most Under-recognized, Undertreated Cancer-related Symptom

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 of suicide.

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 'trivia.'"

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 (Table 1).

TABLE 1: Medical Conditions That Are a Potential Cause of Cancer-Related Fatigue

  • Anemia of cancer (reflecting bleeding, abnormal hematopoiesis, and/or metastatic bone disease)
  • Adverse effects of chemotherapy or radiation therapy (anemia, nausea, vomiting, diarrhea, neurologic pain, muscular weakness)
  • Malnutrition or malabsorption
  • Abnormal metabolite utilization or accumulation
  • Endocrine deficits (inadequate production of testosterone or thyroid hormone)
  • Depressed levels of red cell growth factor (erythropoietin)
  • Excessive levels of blood cell growth- inhibitory cytokines (eg, TNF-alpha, IL-1)

"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, she said.

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 fatigue.

TABLE 2: Self-Help Strategies for Cancer Patients Who Suffer From Fatigue

  • Pace daily activities
  • Delegate household tasks
  • Alter activity-rest patterns
  • Set up an activity-walking program
  • Use distractions such as listening to music, watching television, and reading

"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."

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