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

March 1, 1997

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.

NEW YORK--Fatigue is a significant problem experienced by the vast majorityof cancer patients--and also the most under-recognized and under-treatedsymptom, Barbara F. Piper, DNsc, RN, OCN, told Oncology News Internationalin 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 MedicalCenter, Omaha, stressed that cancer-related fatigue is not a 'trivial'symptom without serious sequelae.

Psychological studies have found that cancer patients experiencing fatigueare significantly more functionally impaired, depressed, distressed, andhopeless than patients without fatigue, and are more likely to have thoughtsof suicide.

Moreover, she pointed out, three retrospective clinical studies in patientswith malignant melanoma, lung cancer, and breast cancer suggest that highfatigue levels at diagnosis may be predictive of poor treatment responseand poor long-term outcome.

"Cancer-related fatigue is multicausal and multidimensional,"Dr. Piper said, adding to the difficulty in assessing and treating theproblem. She has developed the Piper Fatigue Scale, which condenses thedimensions 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 intensityof their patients' fatigue as a rational basis for treatment.

Dr. Piper pointed out that functional impairment--difficulties in performingvirtually all daily activities (dressing, showering, walking, housekeeping,talking, concentrating, decision making, working)--is a common and distressingphysical 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 moresevere fatigue than those with recurrent disease, she said, possibly becausenewly diagnosed patients have not yet learned the skills for coping withthe 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 medicalhistory and physical exam as the sixth vital sign. "Often," shesaid, "the cancer patient will not volunteer fatigue symptoms, feelingthat 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 orappears fatigued. Tell your patient that fatigue is important and thatyou are interested in assessing and validating it."

Medical causes of fatigue must be treated before other dimensions offatigue can be assessed and addressed. Dr. Piper pointed out that the frequencyand intensity of fatigue may be affected by a number of medical conditions(Table 1).

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

"Treatment of these conditions such as with blood transfusions,erythropoietin, or nutritional supplements may improve hemoglobin levelsand tissue oxygenation status, thereby reducing fatigue and improving functionalability," 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 manifestationof clinical depression. Actually, however, cancer-related fatigue and clinicaldepression are two discrete syndromes,

William Breitbart, MD, said in a telephone interview. He is associateattending psychiatrist and chief of the Psychiatry Service at MemorialSloan-Kettering Cancer Center.

In a large-scale NIH-supported study, Dr. Breitbart has used seven differentscales to grade fatigue, physical distress, psychological distress, andperformance status in patients with AIDS who had severe fatigue.

He told Oncology News International that about half of his patientswho experienced severe fatigue had no measurable clinical depression. Evenin those patients who had both fatigue and clinical depression, he said,many severe fatigue items could not be accounted for by depression itemsin the scales.

Helping Patients Cope

The two investigators both emphasized that psychiatric and/or psychosocialcounseling as well as support groups can be very useful for helping thecancer patient cope with emotional stress, anxiety, conflict, depression,and social tension in the family and work environment. Dr. Piper addedthat self-help strategies (see Table 2) can do much to reduce cancer-relatedfatigue.

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

"Currently, physicians and HMOs are looking at the efficacy ofcancer therapy not only by objective response criteria but also by qualityof life indicators," Dr. Piper said. "Fatigue is certainly onesuch indicator, and should be included at least in the physical symptomlistings of quality of life instruments."