The Lesage and Portenoy article fulfills several important purposes. First, the authors remind us of the critical need to become more systematic and diligent in assessing and monitoring fatigue, a potentially debilitating symptom that is now recognized as the most common adverse effect experienced by cancer patients undergoing active treatment.[1] In the assessment of fatigue, the authors acknowledge that "the gold standard of evaluation is the patient’s self-report."
Several valid and reliable single- and multiple-item intensity
scales can be used to quickly screen patients for this important symptom.[2-5]
Given that these scales—particularly the
0-10 verbal and numeric rating scales—are easy to complete and score, there
is no reason that fatigue should go unrecognized or unmonitored. Indeed, the
assessment, monitoring, and treatment of fatigue are now expected aspects of
standard oncologic care.[1]
As a result, each practice setting must immediately work toward incorporating an intensity scale for measuring fatigue and determining response to treatment into its documentation and patient-completed history forms. Evidence-based fatigue practice guidelines also need to be incorporated into clinical practice.
Fatigue Intensity and Screening
Two studies have documented marked declines in physical functioning in cancer patients with a fatigue intensity score of 7 on a scale of 0 to 10.[6,7] In addition, a recently completed international study validated the following intensity categories for fatigue in breast and prostate cancer patients receiving active therapy using the multidimensional Piper Fatigue Scale’s total fatigue score: none (0), mild (1-3), moderate (4-6), and severe (7-10).[B.F. Piper et al, unpublished data.] Since these intensity levels constitute the best available data for evidence-based practice guidelines, they can serve as "triggers" to alert health-care professionals of the need (particularly in patients at moderate to severe levels) to conduct a more comprehensive and multidimensional assessment followed by the initiation of primary and symptomatic treatments, either alone or in combination, as clinically indicated and suggested by Lesage and Portenoy.
In addition, it is important to recognize that all patients need to be screened for fatigue at baseline, as they undergo their initial diagnostic work-up for cancer. Cancer patients may experience fatigue (as measured in comparisons with controls) even before treatment begins.[8] When fatigue precedes the initial cancer diagnosis, treatment of fatigue may need to be instituted earlier in the course of the illness (and its treatment) than might normally be expected. It has been posited that earlier therapy for fatigue may be more likely to prevent the condition from becoming chronic, although the timing and effectiveness of fatigue interventions in general need more study.
Screening should be performed repeatedly at all subsequent treatment-related and follow-up visits. Patient self-report diaries can also be used for this purpose. Chronic fatigue, a possible late effect of cancer and/or its treatment, has been documented in several cancer survivor studies. The incidence and prevalence rates for survivor fatigue range from 17%, when strict ICD-10 diagnostic criteria (International Classification of Diseases-10th revision) are applied, to as high as 80% when less stringent criteria are applied.[9] Other areas in which fatigue incidence/prevalence rates and response to treatment have not been well-studied include patients receiving palliative or terminal care and those receiving preventive care because they are at high risk for cancer or its recurrence.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
