FORT LAUDERDALE, FlaDespite the prevalence of fatigue in cancer
patients and survivors, a number of obstacles have stood in the way
of its successful treatment, said Barbara F. Piper, DNSc, RN,
associate professor, University of Nebraska Medical Center College of
Nursing. Patients have been reluctant to bring the symptom to their
doctors attention out of a concern that they may look like
complainers or that attending to the symptom will somehow
interfere with their cancer treatment.
Physicians also have been stymied in their attempts to treat fatigue.
The physiological basis of fatigue is poorly understood, and many
proposed interventions have not been systematically studied.
Its very difficult for us as providers to bring up
something that were not quite sure we can treat, Dr.
To address these issues, the National Comprehensive Cancer Network
(NCCN) convened a panel of experts to create practice guidelines for
cancer-related fatigue. The chair of the NCCN Fatigue Guidelines
Panel, Victoria Mock, DNSc, director, Oncology Nursing Research,
Johns Hopkins Comprehensive Cancer Center, and Dr. Piper presented
the guidelines at the Fifth Annual NCCN conference.
In his introduction, Rodger Winn, MD, chair of the NCCN Adult
Guidelines Steering Committee, described the study of cancer-related
fatigue as a whole new field and discipline of medicine.
Prevalence of Fatigue
Fatigue affects 70% to 100% of patients who are receiving cytotoxic
chemotherapy, radiation therapy, or biologic response modifiers, Dr.
Mock said. The guidelines describe cancer-related fatigue as an
unusual, persistent, subjective sense of tiredness related to cancer
or cancer treatment that interferes with usual functioning.
Fatigue went unrecognized for many years until practitioners got
better control over the more acute symptoms of nausea, vomiting, and
pain. With those symptoms well-managed by medication, patients now
describe fatigue as the most distressing symptom
associated with cancer and its treatment, according to several
studies, Dr. Mock said.
Fatigue affects survivors as well as patients in active treatment,
Dr. Piper noted. Its just beginning to be recognized as
lasting longer than the treatment period, she said.
The NCCN treatment pathway advises clinicians to screen for fatigue
on the initial visit and periodically thereafter, asking patients to
rate their fatigue on a 0 to 10 scale or describe their fatigue as
mild, moderate, or severe.
When the fatigue is rated 4 and over, or as moderate or severe, the
provider should do a more focused history and physical, Dr. Piper
said. This assessment will determine whether the fatigue has
progressed and whether there have been associated or alleviating
factors. Of particular significance is whether fatigue is interfering
with daily activities.
Fatigue may very well be the result of other symptoms. Fatigue
commonly clusters with sleep disturbance, anemia, emotional distress
(ie, depression), and pain, Dr. Piper said, and may be related
to hypothyroidism. If these primary factors are present, by all
means treat the underlying cause of the fatigue.
The primary evaluation also calls for an assessment of the
patients comorbid-ities, nutritional status, and medications.
The provider should also determine whether the patient has an
exercise program. Patients who complain of fatigue may have been
counseled to get more rest rather than to exercise more. If
theyre not exercising, this can lead to the disuse syndrome
that we all know from our cardiac rehab days, Dr. Piper said.
Exercise, improved sleep habits, and better nutrition were among the
non-pharmacologic interventions recommended. Of these
recommendations, exercise has the strongest evidence base, Dr. Mock
said. Exercise increases functional capacity, leading to a
reduced effort and decreased fatigue, she said.
Walking, riding a stationary bicycle, and other forms of exercise
were represented in the eight studies conducted with cancer patients
and survivors that she cited. These studies are limited in
number because exercise has been a novel idea for cancer patients,
and the work has progressed slowly, she said.
She added that all of the exercise studies demonstrated significantly
lower fatigue and mood disturbance in patients who exercised during
treatment, and also decreased sleep disturbance when that was
included as an outcome.
Some patients, especially those with extensive disease, should be
referred to physical therapy, Dr. Mock said. Any exercise program
should be individualized to the patients needs and physical condition.
Restorative therapy, such as gardening, walking outdoors, or taking
part in volunteer activities unrelated to illness, was also among the
nonpharmacologic interventions recommended.
The panel eagerly awaits the completion of several ongoing clinical
trials that are examining the effects of nonpharma-cologic
interventions, Dr. Mock said. She added that these trials may lead to
the development of more specific guidelines for exercise and other interventions.
Cause-specific therapies are also listed as interventions in the
guidelines. Iron, blood transfusions, and erythropoietin (epoetin
alfa, Epogen, Procrit) are appropriate interventions for anemic
patients. Hypothyroidism should also be treated. Similarly, fatigue
associated with depression may be resolved with antidepressants.
Although low-dose corticosteroids and psychostimulants have
reportedly helped some patients with fatigue, the panel was not
really comfortable with the level of evidence for pharmacologic
therapy for cancer patients . . . and [it] hesitated to recommend
these until more research has been done in this area, Dr. Mock commented.
In addition to recommending appropriate pharmacologic or
nonpharma-cologic interventions, physicians can suggest coping
strategies for fatigue. Energy conservation is important. Give
them permission to postpone all nonessential activities, Dr.
Piper said. Counsel patients to focus on one activity at a time
when they have the energy to do so.
Music, television, reading, and socializing are all forms of
distraction that may help. Intervention studies have also shown that
stress management, including support groups, may be beneficial.