Fatigue is one of the most common, distressing, and frustrating side effects of cancer and its treatment. While red blood cell growth factors (erythropoietin) have greatly reduced the fatigue associated with anemia, patients continue to be confronted with fatigue that interferes with normal physical and emotional function both during and following treatment.
Cancer treatment-related fatigue is associated with reduced physical strength, aerobic function, cognitive dysfunction, and depressed mood. Fatigue is generally reported to be worse among younger patients. While some chemotherapy regimens may cause more fatigue than others, there are no identified risk factors for disabling levels of fatigue.
MK is a 58-year-old woman with stage III breast cancer. She received neoadjuvant chemotherapy consisting of doxorubicin (A), cyclophosphamide (C), and paclitaxel (T), or ACT. After 6 weeks of treatment she had achieved a good tumor response (shrinking approximately 3 cm) and was a candidate for breast conservation surgery. One month following the completion of surgery she returned to continue chemotherapy and completed the dose dense ACT regimen. In order to prevent neutropenia she received granulocyte colony-stimulating factor (G-CSF, filgrastim [Neupogen]). When her hemoglobin fell below 11 g/dL she was started on an erythropoietic agent to correct her anemia.
Although from a medical perspective MK tolerated treatment well, she continued to experience worsening fatigue, complained of feeing irritable and moody, and reported problems with her memory. These side effects were sufficiently troubling that she didn't feel comfortable doing her usual activities and felt safest at home. She stopped going to the grocery store, asking her husband to help with this and other chores.
MK was assessed for depression and started on Wellbutrin XL 300 mg daily. Within 2 weeks of starting Wellbutrin XL her symptoms of depression improved. However, her fatigue persisted; during the second half of chemotherapy she became increasingly sedentary, only leaving the house for medical appointments. She would walk from her house, to the car, and then to the infusion room and be exhausted and out of breath. The more she protected herself and tried to rest the worse she felt, not only physically but emotionally. Fatigue was taking its toll on her as she became more and more debilitated from trying to reduce her fatigue by resting and doing nothing.
As MK neared the completion of chemotherapy she vocalized great concern about her ability to continue with treatment and begin radiation therapy; she was just too weak. At this point, MK was referred to the cancer rehabilitation program.
The cancer rehabilitation program required MK to commit to exercising with a therapist 3 days a week. A systematic, step-by-step approach was taken to increase her aerobic capacity and muscle strength. Each exercise session started off with a slow warmup on a recumbent bicycle and then increased in intensity to approximately 60% to 75% of her predicted maximum heart rate. She pedaled at this intensity for varying periods of timeless time when she initially stated the program, with gradual increases in duration at this constant intensity.
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