Patients Urged to Work With Professionals Against Fatigue

NEW YORK—The persistence of fatigue for up to a year after cancer treatment is a common and debilitating occurrence. Participants in a Cancer Care, Inc. teleconference were given information on the causes of cancer-related fatigue and strategies for coping with it.

Denise Reinke, an oncology nurse practitioner from Dearborn, Michigan, urged patients not to accept fatigue as inevitable, but to communicate with their doctors and other members of the treatment team in an effort to resolve this important quality-of-life issue.

"Between 78% and 99% of patients will experience fatigue in varying degrees at some point in their treatment," Ms. Reinke said.

Cancer Care, Inc.

Cancer Care is a national nonprofit organization providing help for people with cancer, their families, and professional caregivers. A staff of counselors with MSW degrees provides counseling, answers questions, gives referrals, and conducts educational programs on specific subjects of value for cancer patients and their families.

Cancer Care can be reached through its toll-free number, 1-800-813 HOPE (in New York City, 212-302-2400) or at www.cancercare.org.

She added that this fatigue is different in character and intensity from normal fatigue that results from hard physical or mental effort. "Cancer-related fatigue is overwhelming and is out of proportion to the activity that precedes it," she said. Merely bathing or getting dressed can be so exhausting that patients report needing to go back to bed rather than proceeding with daily activities.

Forgetfulness, an inability to concentrate, and difficulty with problem solving are also characteristics of this type of fatigue. These signs of mental fatigue are not relieved by rest, Ms. Reinke said.

She explained that there is no clear understanding of the mechanism behind cancer-related fatigue. It is thought that it might be caused by the disease itself, though that does not explain why treatment often exacerbates the symptom rather than relieving it.

She pointed out that different treatment modalities produce different patterns of fatigue. Patients receiving chemotherapy tend to feel the most intense fatigue for 7 to 10 days post-treatment. The result is that they frequently begin to feel better just before beginning their next treatment cycle only to be felled by another cycle of exhaustion.

With radiation therapy, on the other hand, fatigue tends not to set in initially. Rather, it has a gradual onset, reaching its peak around the third or fourth week of treatment and persisting for weeks or even months afterwards.

Contributing Factors

Aside from treatment, many other factors are viewed as contributing to fatigue in cancer patients. Dehydration, nutritional deficiencies, infection, depression, disordered sleep, and thyroid abnormalities are among potential causes. An effort should be made to identify and treat the underlying cause.

Comorbidities can also contribute to fatigue, and chief among them is anemia. Ms. Reinke explained that anemia is a common side effect of chemotherapy, which targets rapidly dividing cells, including red blood cells.

For that reason, patients who report persistent and crippling fatigue should be evaluated and, if necessary, treated for anemia. Red blood cell transfusions and epoetin alfa (Epogen, Procrit) are effective interventions, she said. Patients receiving injections of epoetin one to three times weekly report a noticeable increase in energy and improved function and quality of life.

Nonmedical Strategies

Although patients are advised to report fatigue to their doctors, there are nonmedical strategies that can be adopted to increase energy or cope with its lack. Increased physical activity was recommended as a way to battle fatigue, as counterintuitive as that might seem.

"It takes more energy to move disused muscles," Ms. Reinke explained. "Exercise keeps muscles strong, and even walking can make a patient feel more energetic."

She warned that patients should talk with their doctor or other member of the treatment team before beginning an exercise program. For those who are unable to engage in physical exercise, she recommended spending time outdoors, in a natural setting. Watching birds or listening to a fountain can help restore mental energy and improve focus. Reducing stress through various means can also be effective in combating fatigue.

Ms. Reinke suggested conserving energy by simplifying daily tasks, especially on days when fatigue is most intense. She mentioned sitting down while engaged in activities ranging from food preparation to bathing, and suggested using a plastic chair or seat while showering. It is also important to arrange work areas so that everything is within easy reach. She recommended alternating periods of activity with short periods of rest, but discouraged daytime naps longer than a half hour.

Because asking for help is difficult for many people, she suggested making a list of necessary tasks and dividing them among the most important, those that should be done, those that would be nice to do but are not essential, and those that can be postponed or eliminated all together.

A second list should be made of potential helpers, including family, friends, neighbors, and people in the community. When people ask what they can do to help, the prioritized list will serve as a menu from which to choose.

Questions from participants in the teleconference reflected concern about the long-term nature of post-treatment fatigue. Several listeners reported feeling exhausted for as long as a year after treatment had been completed. They were assured that this is not unusual, but that it should not be suffered in silence or dismissed as imaginary or a sign of laziness.

Both Ms. Reinke and Carolyn Messner, ACSW, director of education and training at Cancer Care and host of the teleconference, underlined the importance of reporting all fatigue or difficulty with memory or concentration to the doctor for evaluation.

They encouraged patients to work with their treatment team to develop strategies to overcome this common symptom. "Do not leave your doctor’s office without a plan on how to approach your fatigue, one that is specifically tailored to you," Ms. Reinke said.