Cancer-Related Fatigue Has Multiple Causes, and Many Are Treatable

COLUMBUS, Ohio—“Fatigue in the cancer patient has multiple causes and must be treated with a variety of strategies,” said Lois Almadrones, MSN, clinical research associate at Memorial Sloan-Kettering Cancer Center.

Caregivers are often reluctant to inquire about a patient’s fatigue and its effect on quality of life because they feel there is little that can be done to correct it, she said at a conference on cancer survivorship sponsored by the Ohio State University James Cancer Hospital and Solove Research Institute. Her presentation was sponsored by Ortho Biotech.

Chronic fatigue is an overwhelming sustained sense of exhaustion that is not relieved totally with rest, adequate nutrition, or a vacation. “By definition, chronic fatigue lasts more than 1 month,” Ms. Almadrones said.

One component of fatigue is a decreased capacity for mental work, she said. For this reason, health care providers should be sensitive to their patients’ ability to listen and retain information. Written material that can be sent home is useful for patient education.

Fatigue in cancer stems from the physical changes prompted by the cancer, treatment side effects, and psychosocial factors. Physical factors include the metabolic demands of rapidly dividing cancer cells; the biochemical or hormonal changes caused by breast, prostate, and gynecologic cancers; and anemia.

Treatment-related fatigue affects up to 100% of cancer patients. Surgery can cause fatigue through tissue damage, blood loss, and the side effects of anesthesia and analgesics. If food has been withheld, perhaps due to a colonoscopy followed by immediate colon surgery, then hunger-related fatigue will follow.

The fatigue of chemotherapy is caused by tumor destruction and disposal and damage to normal tissue in the bone marrow and GI tract. Damage to the GI tract can cause nausea and vomiting, diarrhea, and mouth sores, which, in turn, can result in a reluctance to eat. In this manner, appetite and nourishment-related symptoms can cause fatigue.

Radiation also causes fatigue due to tumor destruction and damage to normal tissue. Following the treatment schedule for radiation, which may require weekly or daily visits, is also draining.

Fatigue may be a treatment side effect of biologic response modifiers, like interferon. Indeed, fatigue can be the dose-limiting factor for these agents.

Psychosocial Factors

The psychosocial factors leading to fatigue include anxiety and depression. People with cancer understandably often have anxiety. They are likely to worry about death, cancer recurrence, job security, and finances. Anxiety—and the lack of sleep caused by anxiety—can lead to fatigue.

Since depression can be responsible for fatigue, the caregiver needs to distinguish between cancer treatment-related fatigue and depression. Generally, if the pattern of fatigue is related to the timing of cancer treatment, then the treatment is probably the cause. “However if the intensity, pattern. and duration of sadness meet the standard definition of depression, then the caregiver should refer the patient to a mental health professional,” she said.

Although undergoing cancer treatment is difficult, caregivers can help their patients by focusing on what is positive. “We need to give our patients hope to get out of the abyss of depression,” she said.

Juggling work, family, and other responsibilities is exhausting enough. For many people, “cancer becomes added on to an already stressful life,” Ms. Almadrones said. Despite the rigors of treatment, people may feel pressure to return to their jobs. Women who are responsible for the cooking and cleaning at home may be reluctant to give up those tasks. They know it is reassuring to their families if they can continue in that role.

“As professionals, we need to give cancer patients permission to ask for help, delegate, and take it easy,” she said.

Changes in sleep patterns, caused by either cancer symptoms or treatment responses, can also contribute to fatigue. Pain, nausea and vomiting, and diarrhea will affect sleep. Patients who are drinking lots of water for chemotherapy will need to urinate more frequently and this disturbs sleep. Changes in work and exercise schedules will also affect sleep.

Health care providers can help patients with fatigue by assessing the problem and offering suggestions that help patients cope. To measure fatigue, Ms. Alma-drones recommended using a linear analog scale assessment. She asks her patients to use the scale to indicate their response to these three questions:

How would you rate your energy level during the past week?

How would you rate your energy level to do your daily activities over the past week?

How would you rate your overall quality of life during the past week?

Although fatigue is a subjective experience, the use of the scale provides an objective measure with which to chart change from one visit to the next. When discussing fatigue, the health care provider should also address the needs of the patient’s partner or caregiver.

Correctable causes of fatigue, including pain, dehydration, anemia, and electrolyte imbalances, should be assessed and treated. “Anemia should be treated, even in the last days of life,” she said. “If we can keep patients’ hemoglobin up, they will have more energy, a higher activity level, and a better quality of life.” To do this, she recommended transfusions or use of epoetin alfa (Procrit), a genetically engineered form of erythropoietin, which stimulates red blood cell production.

“Helping patients maintain adequate nutrition is also important,” Ms. Almadrones said. The caregiver should help manage nausea and diarrhea, both of which will interfere with eating well. An easy-to-eat diet of energy drinks, boiled eggs, and softer foods should be recommended to patients who are having difficulty eating. “Remind patients to take smaller meals more frequently, drink adequate fluid, and rest before and after meals,” she suggested. A consultation with a dietitian may also be helpful.

If a patient complains about sleep disruption, the caregiver should try to determine the cause and manage the problem. If patients have urinary frequency due to the amount of fluids they are drinking for chemotherapy, they should be encouraged to get all their fluids in well before bedtime. “Encourage patients to practice good sleep habits, and support the use of guided imagery, massage, music therapy, or aromatherapy to encourage relaxation,” she said.

Promoting the proper balance between exercise and rest can also help fight fatigue, Ms. Almadrones noted. In some cases, patients feel more energetic and sleep better if they exercise appropriately during the day. If necessary, she said, consult with a physical therapist.

Fatigue may cause both patients and their partners to feel they must avoid all sexual activity. Health care providers can ease this anxiety by encouraging sexual activity that is balanced and paced to the patient’s needs. “Intimacy is within the ability of the cancer patient,” Ms. Almadrones said, although it need not be sexual intercourse. “Encourage couples to avoid all-or-nothing thinking regarding sex and give them permission to do something in-between, including touching, massage, and togetherness,” she said.

The health care provider can also encourage patients to take note of when they have the most energy and least energy throughout the week, while at work, and when undergoing treatment with chemotherapy and radiation. A daily log can allows patients to schedule demanding tasks to coincide with the periods when they feel best.

Finally, she said, “many patients will return to negative coping habits (smoking, drinking alcohol, using drugs) when faced with cancer, and the health care provider should be aware of this and offer counseling if appropriate.”