Extreme fatigue—the seemingly bone-crushing exhaustion that makes it difficult to brush your teeth, cook a hamburger, or climb the stairs—is one of the most common complaints of people with Cancer. Unlike acute fatigue, in which tiredness comes on quickly, lasts a short time, and is relieved by rest, Cancer fatigue is a prolonged, debilitating fatigue that is persistent or recurring.
The Statistics
Studies show that fatigue exists in 78% to 96% of people with Cancer,
particularly in people actively undergoing treatment. One study of 687
post-treatment survivors of various forms of Cancer, in which patients
reported that fatigue was one of the three most negative items affecting
quality of life, found that this condition can linger for months or even
years after the initial treatment.
A 1998 national survey of 379 chemotherapy patients revealed that cancer
fatigue had a profound impact on their relationships with family,
friends, bosses, and work colleagues. Activities of daily living, work
performance, and overall sense of well-being were also seriously
compromised. In some cases, financial resources became limited because
of an impaired ability to function at work (the survey found that 28% of
the respondents were forced to stop working altogether, and 75% of those
who were able to work needed to make adjustments in their work schedules
or habits).
Cancer fatigue can also take an emotional toll, as the chaos of getting
diagnosed, exploring treatment options, and undergoing medical
procedures can begin to feel physically, mentally, and emotionally
exhausting. Clearly, Cancer-related fatigue exacerbates the already
difficult experience of learning to cope with a life-altering illness.
What Causes It
Although the exact physiologic, biochemical, and psychological causes of Cancer fatigue are poorly understood, the National Cancer Institute lists a number of contributing factors:
- Cancer therapies
Fatigue commonly occurs when a patient undergoes surgery, chemotherapy, radiation treatment, and biologic response modifier therapy, such as Interferon. Treatment with Interferon causes fatigue as part of a group of side effects known as "flu-like" syndrome, which also includes fever, chills, muscle pain, headache, and a general sense of not feeling well. Tumor necrosis factor (TNF), a toxic substance produced by a tumor, may cause a decrease in protein stores in the muscles, thereby causing the body to work harder to carry out normal functions. Physical responses to the treatment itself, such as nausea and vomiting, also appear to contribute to fatigue.
- Anemia
Anemia, related to the disease process itself or to therapy, can cause fatigue.
- Poor nutrition
Reduced appetite, reduced food intake, nausea, and vomiting can all occur and contribute to fatigue.
- Psychological and cognitive factors
Anxiety, depression, stress, mental fogginess, and decreased attention span can compound the physical causes of fatigue.
- Medications
Medications other than chemotherapy drugs, including opioid painkillers, beta-blockers, and neuroleptics, can cause sedation and increase fatigue.
- Breathing impairment
Difficulty breathing, which is particularly present in people with advanced disease and/or Lung Cancer, also contributes to fatigue.
- Loss of muscle mass
- Systemic inflammatory response
- Disrupted sleep and circadian rhythms
- Hormonal changes (premature menopause related to surgery or chemotherapy)
Assessment of Cancer Fatigue
Formed in 1996, The Fatigue Coalition is a multidisciplinary group
comprising medical practitioners, researchers, and patient advocates
from some of the top Cancer hospitals. The coalition has worked
diligently to ensure that health care providers address the issue of
Cancer fatigue, whether their patients bring it up during regularly
scheduled visits or not.
A number of instruments are available to help clinicians assess
Cancer-related fatigue, including the Piper Fatigue Self-Report Scale,
the Schwartz Cancer Fatigue Scale, and Lee's Visual Analogue Scale for
Fatigue. A comprehensive assessment, which includes a physical
examination and psychiatric evaluation to screen for depression and/or
anxiety, looks at a number of factors, such as:
- Fatigue pattern: onset, duration, intensity, and alleviating and aggravating factors
- Treatment history: treatment-related symptoms or side-effects, and current medications
- Sleep and/or rest patterns
- Nutrition status
- Psychosocial profile: financial resources, ability to work, and availability of supportive family, friends, or caretakers
The International Classification of Disease (ICD), 10th revision,
lists a number of criteria that can be used to determine the presence of
Cancer-related fatigue, including a patient's complaints of generalized
weakness and limb heaviness, perceived need to struggle to overcome
inactivity, sleep problems, and diminished concentration, attention, and
memory.
The ICD-10 criteria state that a diagnosis of Cancer-related fatigue can
be made if:
- "Significant fatigue, diminished energy, or an increased need to rest (disproportionate to any recent change in activity level) is present."
- The presence of these symptoms must cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning."
Coping with Cancer Fatigue
According to the Center for Fatigue in Medical Illness, a joint project of the department of Pain Medicine and Palliative Care and the Cancer Center at Beth Israel Medical Center, Continuum Health Partners, Inc. in New York City, the treatment of Cancer fatigue includes identifying and managing the underlying cause and using a variety of interventions that may include medication, patient/family education, exercise, sleep hygiene, stress management, and nutrition.
- Treating anemia
Anemia, a major factor in Cancer-related fatigue, can be treated by blood transfusion therapy, as well as by the administration of erythropoietin Alfa, a synthetic hormone that stimulates the bone marrow to increase its production of red blood cells.
- Optimizing pain control
- Treating depression
- Medications
Some oncology clinicians have found that low doses of psycho stimulant drugs, such as Dexedrine, Ritalin and Cylert, are useful for Cancer patients experiencing decreased energy, apathy, poor concentration, and weakness. There are few published trials proving the effectiveness of these drugs for this purpose, however. These medications, which appear to decrease fatigue, increase appetite, and promote a sense of well-being, also counteract the sedating effects of painkillers such as morphine. Corticosteroids, such as dexamethasone or prednisone, may also be given, but long-term steroid therapy is usually reserved for patients with advanced disease.
Methylphenidate is a stimulant that is related to amphetamines. It has a short half-life, and its onset of action is rapid. Modafinil is structurally different from methylphenidate. It is used for treatment of narcolepsy, and it has been usually well tolerated by Cancer patients. Use of Pemoline has been limited due to liver toxicity.
- Exercise
- Diet
A healthful diet containing plenty of fruits, vegetables, and iron-rich foods can help maintain energy levels. Adequate fluid intake is important in preventing dehydration and hypotension, which tends to intensify feelings of fatigue.
- Stress management
Other basic self-help skills include the use of stress management techniques (relaxation, deep breathing, and meditation) which can be useful in reducing anxiety, enhancing coping skills and increasing energy levels. It's also important to learn to ask for help when you need it and to educate yourself about the nature and treatment of fatigue symptoms.
- Counseling for anxiety/depression
- Acupuncture: There is some preliminary evidence to suggest that acupuncture might be beneficial in treating Cancer-related fatigue.
Fighting the Cancer battle takes enormous energy, courage, and
determination. By demanding skillful and compassionate management of
Cancer fatigue, you can begin to empower yourself and take back control
of your life. One of the best ways to deal with cancer and it's
effects is to stay informed by reading a reputable and authoritative
magazine such as Women's Health Advisor Magazine