Malady Wise

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Cancer-Related Fatigue

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