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Fatigue Reduction and Management For The Primary Side-Effects Of Cancer Therapy
Ernest H Rosenbaum, MD; Barbara F. Piper, RN, OCN, DNSc.; Marilyn Dodd RN, PhD; Kathleen Dzubur, MS; Michael Glover, Pat Kramer, RN, MSN, AOCN; RoseAnn Kurshner, RN, BSN, MEd; Francine Manuel, RPT

Fatigue: What a Patient Needs to Know
Facts on Fatigue

Problems of Fatigue
What Causes Fatigue

What Physicians Need to Know
Fatigue Associated with Medical Therapy: Causes and Solutions
Tips For Reducing Fatigue

Conclusion:The Fatigue Reduction Program for Improved Quality of Life
Fatigue Diagram

Fatigue: What a Patient Needs to Know
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Fatigue is the most common symptom associated with cancer and cancer treatment. For many patients, fatigue can have a profound negative effect on quality of lives. It can impact one's sense of well being, ability to perform daily activities, relationships with family and friends, ability to cope with the illness as well as withstand the treatment. The cause of cancer related fatigue is not fully known or understood. A variety of factors are believed to contribute to fatigue. Problems like cancer, cancer treatment, low blood counts, sleep disruption, stress, poor nutrition, inactivity and medications may all contribute to fatigue.

Fatigue is a very subjective experience, which means that only the individual experiencing it really knows how it feels. There are no standard definitions for cancer-related fatigue, although it has been characterized as overwhelming, whole-body tiredness that is unrelated to activity or exertion. It is not easily relieved by sleep or rest. Patients experience a decrease in energy and an increased need for rest. Other words used to describe fatigue are: weary; worn out; listlessness; no pep; no energy; drained; a strong desire to stop and rest; a strong desire to lie down or sleep.

The fatigue experienced as a side effect of cancer or cancer treatment is different from the universal sensation of fatigue that everybody experiences. Fatigue can affect the way you think as well as how you feel. You may need more sleep. You may have trouble paying attention when reading, watching television, even talking with family members. You may find that you are not able to do all of the activities you did before your cancer treatment.

Facts on Fatigue
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In a recent survey of 379 patients reviewed by Gregory A. Curt, MD of the National Cancer Institute and a member of the Fatigue Coalition state "The physical, emotional, and economic stress of fatigue on cancer patients has a serious impact on the ability to get back to the business of living."

Overview From the Fatigue Coalition

70-90% of patients on therapy suffer from fatigue. 50% have fatigue that affects their routines on a daily basis.
Many patients feel that it is a frightening and frustrating experience to lose control and thus rely on others for support.
66% of cancer patients state problems related to fatigue are more common than those associated with pain.
Fatigue is the strongest side effect from cancer therapy at 70% followed by 22% nausea and 10% depression.
45% experienced fatigue 1 week after chemotherapy and 33% had fatigue 2 weeks after chemotherapy.
89% said fatigue and the resulting stress changed their daily living habits.
71% missed one or more days of work each month with 31% missing an entire week of work.
Patients strongly feel that fatigue impacts their ability to earn a living: 28% had to discontinue work.
59% of patients experience difficulties in socializing with friends and family due to fatigue.
As therapies become more aggressive, there is an increase in the symptoms of fatigue which can affect their future doses of therapy.
Debilitating fatigue is frequently undertreated by physicians.

Problems of Fatigue
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Fatigue is not a simple problem but has many factors and dimensions including anemia, emotional stress, physical weakness, muscle deconditioning, and the frustrations of cancer, fears of the future and of therapy. Fatigue may be compounded by the exhaustion brought on by the very drugs and radiation treatments meant to cure cancer.

Fatigue may be short-term (acute), lasting less than one month or it may be more long-term (chronic), lasting anywhere from one month to six months or longer. Acute or chronic fatigue can have a profound negative impact on the quality of life.

What Causes Fatigue
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Age, sex and genetics, socio-economic and environmental factors, as well as prior experiences with weakness and fatigue have been implicated with fatigue, as have sleep disturbances and depression. But with cancer, many other factors involved in both the disease and its treatment may also contribute. These may include:

1) Changes in energy production or the lack of available nutrients. The tumor itself may make the body function in an overactive or hyper-metabolic state. Tumor cells compete for nutrients, often at the expense of normal cells' growth and metabolism. Weight loss, reduced appetite and fatigue are often the result.

2) Disease complications and/or treatment side effects such as anemia, nausea, infection and fever can create additional energy needs that your usual food intake cannot supply alone. Nutritional supplements and therapy may be needed.

3) Diagnostic tests, anesthesia, surgery, radiation therapy, chemotherapy, biotherapy, and drugs used to control symptoms and side effects (such as nausea, vomiting, pain and insomnia).

For example, drugs such as vincristine, vinblastine, navelbine, taxol and taxotere may cause fatigue because of their toxic effects on nerves (neurotoxicity). With cisplatin, low magnesium levels, along with neurotoxicity, may cause fatigue.

Fatigue that increases over time (cumulative fatigue) occurs in radiotherapy patients regardless of the part of the body being treated. This usually improves within one month, but may last up to three months or more, after treatment stops.

Fatigue may become so severe during immunotherapy or biotherapy. The biotherapy drugs (interferon, and/or Interleukin) that treatment dosages may need to be reduced. As cancer cells die in response to therapy, they release certain toxic metabolic substances (cytokines) that may contribute to fatigue. response to therapy, they release certain toxic substances that may contribute to fatigue. More attention has recently been paid to the possible role of cytokines in the development of fatigue.

4) Cytokines are natural cell products or proteins, such as the interferons and interleukins, that are normally released by white blood cells, lymphocytes and macrophages in response to infection. These cytokines carry messages that regulate other elements of the immune and neuroendocrine systems to control cancer growth. In high amounts, these cytokines can be toxic and lead to persistent fatigue.

What Physicians Need to Know
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Managing fatigue begins with talking to your doctor. Physicians frequently don't ask about fatigue. Patients often have the misconception that fatigue is just something that they must endure and they don't ask for a treatment plan to help with the fatigue. Recent awareness about the negative effects of fatigue on quality of life has led to new efforts and programs to help relieve symptoms of fatigue.

Medical Evaluation
1. A careful history to define the extent of fatigue.
2. A physical examination to look for abnormal physical or neurological findings.
3. Blood tests to assess hemoglobin levels and chemistries such as potassium, sodium and magnesium.
4. Check for metabolic abnormalities; measure thyroid and adrenal functions and serum chemistry profiles including albumen, liver and renal functions and calcium.

Fatigue Associated with Medical Therapy: Causes and Solutions
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The best way to combat fatigue is to treat the underlying cause. Unfortunately, it is not always easy to know what the exact cause is. Many factors may be involved and require treatment, particularly if the fatigue has become chronic. All possible causes must be thoroughly assessed. If fatigue is related to anemia or hypoxia (low blood oxygen), for example, blood transfusions, supplemental oxygen, and medications- epoetin alfa, designed to increase red blood cell production, may be prescribed. Other causes can be managed on an individual basis. This management may include physical therapy and strength training, changes in nutrition, and emotional support and psychological counseling.

The Causes and Solutions of Fatigue

1. Fatigue Post Therapy: as a result of therapy or surgery, fatigue may persist for a prolonged period of time even after the cancer therapy is completed
Surgery and anesthesia can lead to post-operative fatigue.
Fatigue is more related to treatment than to the cancer--and it may persist after therapy.
There can be a hyper-metabolic state from tumor growth (tumors may draw nutrients from the body).
Cellular disintegration from therapy (release of cytokines-interferons, tumor necrosis factor) may cause fatigue.
Other factors include electrolyte imbalance such as potassium, sodium and magnesium deficiency.

2. Stress
The initial support a person receives following a cancer diagnosis often dissipates with time as each support person returns to their own way of life and problems. It is often difficult to function post therapy when there is less support. People assume and treat you like life is normal, but anxiety about your health and your future may still persist.
Unfortunately, with increased needs, patients often lack the continued needed support from family and friends and must therefore rely on themself for strength and stability. Continued mental support with meditation, relaxing exerted self-hypnoses, bio-feedback helps to decrease stress and improve coping skills.
Anxiety also can contribute to sleeplessness, increased energy demands, and fatigue.
Use antidepressant drugs for symptoms of depression.
Women who become menopausal secondary to therapy may have additional stress because of hot flashes, sleeplessness, impact on sexuality, and self-image.

3. Nutrition
Nutritional dysfunction may be related to fatigue. If possible, have a registered dietitian (RD) do a nutritional analysis. A nutritionist (RD) can help plan meals and give guidance about proper nutrition. Because efforts to improve appetite, reduce weight loss, and control symptoms and side effects of nausea, vomiting and diarrhea may help reduce fatigue, a healthy diet can yield more energy.

4. Lack of Exercise
Exercise can help maintain muscle strength and flexibility. On an emotional level, it helps to reduce depression by increasing endorphins. Changes in the patterns of activity and rest can play a significant role in the prevention of fatigue. Unnecessary inactivity, prolonged bed rest, and immobility contribute to the loss of muscle strength and endurance. Muscle that is not exercised loses its ability to use oxygen, so more effort and more oxygen is required for the same amount of work when performed by conditioned muscles. This is one of the reasons that aerobic endurance exercise, such as walking three or four times a week for 20 to 30 minutes, is often prescribed for patients and family members. Stretching exercises are also helpful and can be done even when a person is not very mobile. The exercise time daily can be accumulated time from various activities (gardening, chores etc) to equal 20-30 total minutes per day.

5. Reduced Activities of Daily Living
Attention to self-care and daily living skills, such as brushing your teeth, shaving, combing your hair, getting dressed, etc., serves three purposes: it increases your ability to perform these activities, provides overall muscle toning and increases your range of motion. Performing as many self-care tasks as possible will also help you develop independence and self-esteem. Feeling dependent on others can be defeating, and a certain satisfaction can be gained from setting objectives in life and accomplishing them. Recovering from an illness or injury is certainly one of these accomplishments. Consider the degree of physical effort required for self-care tasks in terms of graduated levels based on how much mobility and energy each activity requires. Feeding yourself requires the least amount of effort. When you are stronger, you will be able to graduate to the activities of hygiene and grooming; still later, you'll be able to bathe and dress yourself. Your overall goal is to return to your former activities as fully as possible. Keep a Self-Care Progress Chart or make a list of all the activities you perform daily in caring for yourself, and then add each new accomplishment to the list along with the date on which you achieve it. Many assistive devices or gadgets are available to help you retrain yourself, making certain tasks easier to accomplish. You must conserve energy, using it appropriately to achieve both short-term and long-term goals. In addition, you should consider safety in the home. When you are tired and weak, it is all too easy to have an accident that could slow your recovery or even reverse your physical status dramatically.

6. Pain Problems
Fatigue is often related to pain and is worse when there is inadequate pain control. The drugs used for pain control may have sedative proliferative effects and contribute to fatigue.

Depression has multiple causes and plays a major role in fatigue. Use of antidepressant drugs can be of help as well as psychological counseling. Support groups can be extremely helpful.

8. Sleep Problems
Lack of restful or adequate sleep at night can cause increased fatigue and napping during the day. (Sleep disturbances such as insomnia, multiple awakenings and early waking are common symptoms of depression.) It is important to correlate sleep patterns with eating habits, pain control and depression with fatigue.

9. Anemia
Anemia can occur as a result of the cancer or the cancer treatment. When there is a decrease in the number of circulating red blood cells, the oxygen carrying capacity of the blood is diminished. Patients feel tired due to the inadequate supply of oxygen to muscles and other organs. When patients received treatment to correct anemia, they reported significant improvements in energy, activity and quality of life. Treatment for anemia may include red blood cell (RBC) transfusions and/or the use of epoetin alfa, erythropoetin (EPO) injections to stimulate blood production.

Tips For Reducing Fatigue
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Patients are often misinformed about fatigue as 61% assumed the condition would disappear by itself and 45% said that there was nothing their physician could do about this condition. Twenty five percent said their physician did not explain the cause of their fatigue or possible treatments. These are some simple techniques to keep in mind:

1. Develop a realistic daily schedule. This should include rest and structured work times. Listen to your body and don't overexert yourself as this may exacerbate fatigue.

2. Use energy saving tips - aids to daily living (ADL) such as dressing while sitting on a chair or toilet seat.

3. Rehabilitation Exercises including physical and occupational therapy may be of help along with mild exercises or walking - classes designed to overcome fatigue are recommended. Family members or friends can help take you on walks to provide a helping hand when you are tiring. Mild to moderate exercise to help promote energy are a boost for quality of life even though they may feel tired. Exercise: Winningham has reported increased exertion/activity tolerance before onset of physiologically based fatigue in patients participating in an exercise program.

4. Avoid too much rest. Whereas over exercise may cause fatigue by using important energy stores, lack of exercise can also cause fatigue through physical deconditioning and deterioration.

5. Enjoy accomplishments such as a short walk or even showering.

6. Eat a healthy diet prepared with the aid of a nutritionist to improve energy. Maintain appropriate levels of protein, vitamins, minerals, or supplements to ensure adequate nutrition.

7.Control emotional fatigue with psychosocial support and relaxation techniques- like self-hypnosis. Guided imagery can be very effective. Be patient with yourself and try not to be too self-critical if you are unable to perform exercises or work. Try to keep faith and believe in yourself that with time you will feel better.

8. Take time to pamper yourself: Enjoy a bath, get a massage, listen to your favorite music, watch a sunset or visit the sea shore.

9. Keep a fatigue journal of your progress. Note when fatigue occurs, lifts or lingers. This can help you to make a realistic daily schedule and may need to lower or drop work load or change your lifestyle.

10.Talk with your doctor about prescribing drugs to relieve fatigue such as Psycho-stimulants: Methylphenidate (Ritalin), Pemoline and dextroamphetamine (Dexadrine). These may be of help although there are no completed studies for cancer-related fatigue. Please note that constant monitoring is necessary when taking these drugs as adverse side effects including anorexia, insomnia, anxiety, delirium and tachycardia may result. Antidepressants such as elavil nortriptyline and desipramine or bupropion may help as antidepressants and may help increase energy. Steroids have also been of some help.

11. If anemia is a problem, Epoetin-alfa or a similar drug approved for cancer treatment of related fatigue may be helpful

Conclusion:The Fatigue Reduction Program for Improved Quality of Life
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It is essential to combat fatigue because it affects how we live, how well we tolerate cancer therapy, and our overall quality of life. Fatigue can rob us of our ability to live a fuller life to our best level.

Susan L. Scheer, a member of the Fatigue Coalition and a member of the National Coalition for Cancer Survivorship said that "the real message of the survey findings is that many patients with fatigue are suffering alone when treatment options are available. Clearly, based on these results, fatigue may jeopardize patients' careers and their ability to take care of themselves and their families. The treatment community and patients need to recognize this fact and actively seek and request more treatment options."

Develop your own personal fatigue treatment guidelines
Analyze your fatigue journal and devise a realistic daily schedule.
Adapt methods of energy conservation through lifestyle changes.
Work alongside your doctor or therapist to identify medications that may help.

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First appeared May 1, 1999; updated September 10, 2008