Cancer Fatigue: It's More Than Just Being Tired
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Cancer Fatigue: It's More Than Just Being Tired

Cancer fatigue can be debilitating and affect all aspects of a person's life. But there are ways to cope with and even treat it.

Extreme fatigue—the seemingly bone-crushing exhaustion that makes it difficult to brush your teeth, cook a hamburger, or climb the stairs—is one of the most common complaints of people with cancer. Unlike acute fatigue, in which tiredness comes on quickly, lasts a short time, and is relieved by rest, cancer fatigue is a prolonged, debilitating fatigue that is persistent or recurring.

The Statistics

Studies show that fatigue exists in 78% to 96% of people with cancer, particularly in people actively undergoing treatment. One study of 687 post-treatment survivors of various forms of cancer, in which patients reported that fatigue was one of the three most negative items affecting quality of life, found that this condition can linger for months or even years after the initial treatment.

A 1998 national survey of 379 chemotherapy patients revealed that cancer fatigue had a profound impact on their relationships with family, friends, bosses, and work colleagues. Activities of daily living, work performance, and overall sense of well-being were also seriously compromised. In some cases, financial resources became limited because of an impaired ability to function at work (the survey found that 28% of the respondents were forced to stop working altogether, and 75% of those who were able to work needed to make adjustments in their work schedules or habits).

Cancer fatigue can also take an emotional toll, as the chaos of getting diagnosed, exploring treatment options, and undergoing medical procedures can begin to feel physically, mentally, and emotionally exhausting. Clearly, cancer-related fatigue exacerbates the already difficult experience of learning to cope with a life-altering illness.

What Causes It

Although the exact physiologic, biochemical, and psychological causes of cancer fatigue are poorly understood, the National Cancer Institute lists a number of contributing factors:

  • Cancer therapies

    Fatigue commonly occurs when a patient undergoes surgery, chemotherapy, radiation treatment, and biologic response modifier therapy, such as Interferon. Treatment with Interferon causes fatigue as part of a group of side effects known as "flu-like" syndrome, which also includes fever, chills, muscle pain, headache, and a general sense of not feeling well. Tumor necrosis factor (TNF), a toxic substance produced by a tumor, may cause a decrease in protein stores in the muscles, thereby causing the body to work harder to carry out normal functions. Physical responses to the treatment itself, such as nausea and vomiting, also appear to contribute to fatigue.

  • Anemia

    Anemia, related to the disease process itself or to therapy, can cause fatigue.

  • Poor nutrition

    Reduced appetite, reduced food intake, nausea, and vomiting can all occur and contribute to fatigue.

  • Psychologic and cognitive factors

    Anxiety, depression, stress, mental fogginess, and decreased attention span can compound the physical causes of fatigue.

  • Medications

    Medications other than chemotherapy drugs, including opioid painkillers, beta-blockers, and neuroleptics, can cause sedation and increase fatigue.

  • Breathing impairment

    Difficulty breathing, which is particularly present in people with advanced disease and/or lung cancer, also contributes to fatigue.

    • Loss of muscle mass
    • Systemic inflammatory response
    • Disrupted sleep and circadian rhythms
    • Hormonal changes (premature menopause related to surgery or chemotherapy)

Assessment of Cancer Fatigue

Formed in 1996, The Fatigue Coalition is a multidisciplinary group comprising medical practitioners, researchers, and patient advocates from some of the top cancer hospitals. The coalition has worked diligently to assure that doctors address the issue of cancer fatigue, whether their patients bring it up during regularly scheduled visits or not.

A number of instruments are available to help clinicians assess cancer-related fatigue, including the Piper Fatigue Self-Report Scale, the Schwartz Cancer Fatigue Scale, and Lee's Visual Analogue Scale for Fatigue. A comprehensive assessment, which includes a physical examination and psychiatric evaluation to screen for depression and/or anxiety, looks at a number of factors, such as:

  • Fatigue pattern: onset, duration, intensity, and alleviating and aggravating factors
  • Treatment history: treatment-related symptoms or side affects, and current medications
  • Sleep and/or rest patterns
  • Nutrition status
  • Psychosocial profile: financial resources, ability to work, and availability of supportive family, friends, or caretakers

The International Classification of Disease (ICD), 10th revision, lists a number of criteria that can be used to determine the presence of cancer-related fatigue, including a patient's complaints of generalized weakness and limb heaviness, perceived need to struggle to overcome inactivity, sleep problems, and diminished concentration, attention, and memory.

The ICD-10 criteria state that a diagnosis of cancer-related fatigue can be made if: (1) "significant fatigue, diminished energy, or an increased need to rest (disproportionate to any recent change in activity level) are present" and (2) the presence of these symptoms must cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning."

Coping With Cancer Fatigue

According to the Center for Fatigue in Medical Illness, a joint project of the department of Pain Medicine and Palliative Care and the Cancer Center at Beth Israel Medical Center, Continuum Health Partners, Inc. in New York City, the treatment of cancer fatigue includes identifying and managing the underlying cause and using a variety of interventions that may include medication, patient/family education, exercise, sleep hygiene, stress management, and nutrition.

  • Treating anemia: Anemia, a major factor in cancer-related fatigue, can be treated by blood transfusion therapy, as well as by the administration of erythropoietin alfa, a synthetic hormone that stimulates the bone marrow to increase its production of red blood cells.
  • Optimizing pain control: Untreated, chronic pain may contribute to the feeling of fatigue.
  • Treating depression: There is a strong correlation between depression and fatigue.
  • Medications: Some oncology clinicians have found that low doses of psychostimulant drugs, such as Dexedrine, Ritalin and Cylert, are useful for cancer patients experiencing decreased energy, apathy, poor concentration, and weakness. Although, there are few published trials proving the effectiveness of these drugs for this purpose. These medications, which appear to decrease fatigue, increase appetite, and promote a sense of well-being, also counteract the sedating effects of painkillers such as morphine. Corticosteroids, such as dexamethasone or prednisone, may also be given, but long-term steroid therapy is usually reserved for patients with advanced disease.

    Methylphenidate is a stimulant that is related to amphetamines. It has a short half-live, and its onset of action is rapid. Modafinil is structurally different from methylphenidate. It is used for treatment of narcolepsy, and it has been usually well tolerated by cancer patients. Use of Pemoline has been limited due to liver toxicity.

  • Exercise: Numerous studies have suggested that aerobic exercise, including light-to-moderate intensity walking programs, can be useful in minimizing or improving the symptoms of cancer-related fatigue, especially during the time that patients are undergoing chemotherapy or radiation treatments. Exercise programs must be tailored to the individual according to age, gender, and physical and medical condition, and frequent rest periods are recommended. A daily diary can identify specific activities that increase fatigue, or particular times of the day when fatigue is more pronounced, allowing the patient to utilize energy conservation measures, such as alternating strenuous pursuits with more sedentary ones.
  • Diet: A healthful diet containing plenty of fruits, vegetables, and iron-rich foods can help maintain energy levels. Adequate fluid intake is important in preventing dehydration and hypotension, which tends to intensify feelings of fatigue.
  • Stress management: Other basic self-help skills include the use of stress management techniques (relaxation, deep breathing, meditation), which can be useful in reducing anxiety, enhancing coping skills and increasing energy levels. It's also important to learn to ask for help when you need it and to educate yourself about the nature and treatment of fatigue symptoms.
    • Counseling for anxiety/depression
    • Acupuncture: There is some preliminary evidence to suggest that acupuncture might be beneficial in treating cancer-related fatigue.

Fighting the cancer battle takes enormous energy, courage, and determination. By demanding skillful and compassionate management of cancer fatigue, you can begin to empower yourself and take back control of your life.

RESOURCES:

CancerFatigue.org
http://www.cancerfatigue.org

National Cancer Institute
http://www.cancer.gov

Cancer Care, Inc.
http://www.cancercare.org/

CANADIAN RESOURCES:

BC Cancer Agency
http://www.bccancer.bc.ca/default.htm

Canadian Cancer Society
http://www.cancer.ca

References

Bruera E, Driver L, Barnes EA, et al. Patient-controlled methylphenidate for the management of fatigue in patients with advanced cancer: a preliminary report. J Clin Oncol. 2003; 21:4439.

Sarhill N, Walsh D, Nelson KA, et al. Methylphenidate for fatigue in advanced cancer: a prospective open-label pilot study. Am J Hosp Palliat Care. 2001;18:187.

Sobrero A, Puglisi F, Guglielmi A, et al. Fatigue: a main component of anemia symptomatology. Semin Oncol. 2001; 28:15.

Curt GA, Breitbart W, et al. Impact of cancer-related fatigue on the lives of patients: New findings from the Fatigue Coalition. Oncologist. 2000;5:353.

Scott HR, McMillan DC, et al. The systemic inflammatory response, weight loss, performance status, and survival in patients with inoperable non-small cell lung cancer. Br J Cancer. 2002;87:264.



Last reviewed January 2007 by Marcin Chwistek, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.


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