Overview

• 15 to 90% of patients have cancer-related fatigue (CRF)

• 1 in 3 people have persistent fatigue for years

• Affects QoL

• Fatigue is often the most distressing symptom of cancer treatment and is consistently under-reported

Definition

• Distressing, subjective sense of physical, emotional and/or cognitive tiredness

• CRF differs from normal fatigue which is usually temporary and relieved by rest

Factors

• Cancer therapy including CTx

• Tumour growth

• Unrelieved pain

• Anaemia

• Metabolic disturbances such as poor nutrition

• Medication side effects

• Deconditioning

• Depression mood, emotional distress, and sleep disturbance

Pathogenesis

• Direct CNS toxicity from treatment

• Anaemia and myelosuppression

• Loss of muscle mass and abnormalities in using ATP

• Neurophysiologic skeletal muscle changes

• Chronic stress response + HPA

• Immune activation and proinflammatory cytokines

• Disrupted sleep

• Hormonal changes

Criteria

Assessment

• Consider scoring tools to assess fatigue

History

• Fatigue onset, duration, pattern of fatigue

• Associated factors

• Alleviating factors

• Effect on physical and cognitive functioning and on patient’s ADL

• Comprehensive review of systems is warranted to ascertain organ systems affected

• Directed physical exam

• Directed investigations

• Smoking, alcohol, illicit drug use, work history

• Activitiy level and exercise tolerance

Diagnostic Workup

• Electrolytes (sodium, potassium, chloride, bicarbonate)

• Chemistry panel (creatinine, blood urea nitrogen, glucose, magnesium, calcium, phosphorus, total bilirubin, serum transaminases, alkaline phosphatase, lactic dehydrogenase, albumin, total protein)

• Thyroid-stimulating hormone (TSH)

• Complete blood count (CBC) with differential and platelet count

• Serum testosterone, in males if clinical history suggestive of hypogonadism

Possible contributory factors

Medications

• Often overlooked cause of fatigue

Activity level

• Deconditioning

• Formal exercise programs

• Baselines ADLs

Nutritional assessment

• Weight changes, caloric intake, fluid and electrolyte balances

Treatment

Control of contributory factors

• If any factors known to be associated with fatigue are identified then treat them accordingly

  • Anaemia, Thyroid, Sleep Disorders, Opioid sedation etc

  • Optimise physical symptoms such as pain, nausea, dyspnoea

Anaemia

• Symptomatic anaemic needs an accurate diagnosis to look for causes

  • Blood loss, haemolysis, iron folic acid, Vitamin B12

Sleep Disturbance

• For those with insomnia or other sleep disturbance, implement measures to improve

Exercise

• 150 minutes of moderate aerobic activity per week (fast walk, cycle, swim)

• 2 to 3 strength training sessions weekly (weight lifting)

• Cancer patients often advised to downregulate activity to avoid fatigue, this leads to muscular all wasting and deconditioning

• Most studies looking at exercise during and after cancer treatment show benefits in fatigue

• Also improvements in cardiorespiratory fitness, strength, fatigue, moderate reduction in sleep disturbance

Mind and body practices

• Cognitive behavioural intervention

Meditation and mindfulness-based approaches

• Good evidence mindfulness-based stress reduction may relieve fatigue in cancer survivors

Yoga

• Small but significant effect

Acupuncture

• Small amount evidence

Tai chi

• Small amount evidence

Psychostimulants

• For severe fatigue can consider

  • Modafanil 100 to 200mg mane and midi

  • Methylphenidate 5mg mane and midi

Testosterone

• Hypogonadal men

Antidepressants

• No improvement on fatigue

Glucocorticoids

• Terminal phase with a high degree of burden

Ginseng

• Therapeutic trial reasonable

• Small studies show evidence

Vitamins

• No evidence