Fatigue Overlooked in
Cancer Patients
Yet it
diminishes quality of life, researchers say
MONDAY, Sept. 22 (HealthDayNews) -- Doctors rarely
discuss fatigue with their cancer patients, even though it has a major impact
on the patients' quality of life.
That's what an Italian study in the Nov. 1 issue of Cancer found.
Cancer-related fatigue (CRF) has largely gone unnoticed by doctors, who tend
to be focused on more obvious and acute cancer patient symptoms such as nausea
and vomiting.
After reviewing published literature, the Italian researchers determined
that CRF affects 50 percent to 75 percent of all cancer patients and an even
greater percentage (80 percent to 96 percent) of cancer patients undergoing
chemotherapy.
The study found the impact of CRF on quality of life is experienced by
cancer patients for a much longer time than symptoms such as nausea, depression
or pain.
Despite the impact of CRF, the mechanisms that cause or promote it are
poorly understood, the authors write. There are several theories but little
direct scientific evidence to support them.
"Clearly, more work is necessary to gain a better understanding of the pathophysiology and treatment of CRF. Nonetheless, tools
for improving quality of life in patients with fatigue are already available,"
the authors write.
They say that treating anemia in cancer patients with exercise and
medications are the most consistently effective approaches to dealing with CRF.
This patient summary on fatigue is adapted from a summary written for health
professionals by cancer experts. This and other credible information about
cancer treatment, screening, prevention, supportive care, and ongoing clinical
trials is available from the National Cancer Institute. Fatigue is one of the
most common complaints of people diagnosed with cancer. This brief summary
describes fatigue, its causes and treatment.
Fatigue occurs in 14% to 96% of people with cancer, especially those
receiving treatment for their cancer. Fatigue is complex, and has biological,
psychological, and behavioral causes. Fatigue is difficult to describe and
people with cancer may express it in different ways, such as saying they feel
tired, weak, exhausted, weary, worn-out, fatigued, heavy, or slow. Health
professionals may use terms such as asthenia, fatigue, lassitude, prostration,
exercise intolerance, lack of energy, and weakness to describe fatigue.
Fatigue can be described as a condition that causes distress and decreased
ability to function due to a lack of energy. Specific symptoms may be physical,
psychological, or emotional. To be treated effectively, fatigue related to
cancer and cancer treatment needs to be distinguished from other kinds of
fatigue.
Fatigue may be acute or chronic. Acute fatigue is normal tiredness with
occasional symptoms that begin quickly and last for a short time. Rest may
alleviate fatigue and allow a return to a normal level of functioning in a
healthy individual, but this ability is diminished in people who have cancer.
Chronic fatigue is long lasting. Chronic fatigue syndrome describes prolonged
debilitating fatigue that may persist or relapse. This illness is sometimes
diagnosed in people who do not have cancer. Although many treatment- and
disease-related factors may cause fatigue, the exact process of fatigue in
people with cancer is not known.
Fatigue can become a very important issue in the life of a person with
cancer. It may affect how the person feels about him- or herself, his or her
daily activities and relationships with others, and whether he or she continues
with cancer treatment. Patients receiving some cancer treatments may miss work,
withdraw from friends, need more sleep, and, in some cases, may not be able to
perform any physical activities because of fatigue. Finances can become difficult
if people with fatigue need to take disability leave or stop working
completely. Job loss may result in the loss of health insurance or the
inability to get medical care. Understanding fatigue and its causes is
important in determining effective treatment and in helping people with cancer
cope with fatigue. Tests that measure the level of fatigue have been developed.
The causes of fatigue in people with cancer are not known. Fatigue commonly
is an indicator of disease progression and is frequently one of the first
symptoms of cancer in both children and adults. For example, parents of a child
diagnosed with acute lymphocytic leukemia or
non-Hodgkin's lymphoma frequently seek medical care because of the child's
extreme fatigue. Tumors can cause fatigue directly or indirectly by spreading
to the bone marrow, causing anemia, and by forming toxic substances in the body
that interfere with normal cell functions. People who are having problems
breathing, another symptom of some cancers, may also experience fatigue.
Fatigue can occur for many reasons. The extreme stress
that people with cancer experience over a long period of time can cause them to
use more energy, leading to fatigue. However, there may be other reasons
that cancer patients suffer from fatigue. The central nervous system (the brain
and spinal cord) may be affected by the cancer or the cancer therapy
(especially biological therapy) and cause fatigue. Medication to treat pain,
depression, vomiting, seizures, and other problems related to cancer may also
cause fatigue. Tumor necrosis factor (TNF) is a substance that can be produced
by a tumor, or may be given to a patient as a treatment for some types of
cancer. TNF may cause a decrease in protein stores in muscles causing the body
to work harder to perform normal functions, and therefore causing fatigue.
It is not always possible to determine the factors that cause fatigue in
patients with cancer. Possible factors include cancer treatment, anemia,
medications, weight loss and loss of appetite, changes in metabolism, decreased
levels of hormones, emotional distress, difficulty sleeping, inactivity,
difficulty breathing, loss of strength and muscle coordination, pain,
infection, and having other medical conditions in addition to cancer.
Fatigue is a common symptom following radiation therapy or chemotherapy. It
may be caused by anemia, or the collection of toxic substances produced by
cells. In the case of radiation, it may be caused by the increased energy
needed to repair damaged skin tissue.
Several factors have been linked with fatigue caused by chemotherapy. Some
people may respond to the diagnosis and treatment of cancer with mood changes
and disrupted sleep patterns. Nausea, vomiting, chronic pain, and weight loss
can also cause fatigue.
Fatigue has long been associated with radiation therapy although the
connection between them is not well understood. Fatigue usually lessens after
the therapy is completed, although not all patients return to their normal
level of energy. Patients who are older, have advanced disease, or receive
combination therapy (for example, chemotherapy plus radiation therapy) are at a
higher risk for developing long-term fatigue.
Biological therapy frequently causes fatigue. In this setting, fatigue is
one of a group of side effects known as "flu-like" syndrome. This
syndrome also includes fever, chills, muscle pain, headache, and a sense of
generally not feeling well. Some patients may also experience problems with their
ability to think clearly. The type of biological therapy used may determine the
type and pattern of fatigue experienced.
Many people with cancer undergo surgery for diagnosis or treatment. Fatigue
is a problem following surgery, but fatigue from surgery improves with time. It
can be made worse, however, when combined with the fatigue caused by other
cancer treatments.
Anemia may be a major factor in cancer-related fatigue and quality of life
in people with cancer. Anemia may be caused by the cancer, cancer treatment, or
may be related to other medical causes.
Fatigue often occurs when the body needs more energy than the amount being
supplied from the patient's diet. In people with cancer, 3 major factors may be
involved: a change in the body's ability to process food normally, an increased
need by the body for energy (due to tumor growth, infection, fever, or problems
with breathing), and a decrease in the amount of food eaten (due to lack of
appetite, nausea, vomiting, diarrhea, or bowel obstruction).
The moods, beliefs, attitudes, and reactions to stress of people with cancer
can contribute to the development of fatigue. Approximately 40% to 60% of the
cases of fatigue among all patients (cancer patients as well as other patients)
are not caused by disease or other physical reasons. Anxiety and depression are
the most common psychological disorders that cause fatigue.
Depression may be a disabling illness that affects approximately 15% to 25%
of people who have cancer. When patients experience depression (loss of
interest, difficulty concentrating, mental and physical tiredness, and feelings
of hopelessness), the fatigue from physical causes can become worse and last
longer than usual, even after the physical causes are gone. Anxiety and fear
associated with a cancer diagnosis, as well as its impact on a person's
physical, mental, social, and financial well-being are sources of emotional
stress. Distress from being diagnosed with cancer may be all that is needed to
trigger fatigue. (Refer to the PDQ summaries on Depression and on Anxiety for
more information.)
Decreased attention span and difficulty understanding and thinking are often
associated with fatigue. Attention problems are common during and after cancer
treatment. Attention may be restored by activities that encourage rest. Sleep
is also necessary for relieving attention problems but it is not always enough.
Disrupted sleep, poor sleep habits, less sleep at night, sleeping a lot
during the day, or no activity during the day may contribute to cancer-related
fatigue. Patients who are less active during the daytime and awaken frequently
during the night report higher levels of cancer-related fatigue.
Medications other than those used in chemotherapy may also contribute to
fatigue. Opioids used in treating cancer-related pain
often cause drowsiness, the extent of which may vary depending on the
individual. Other types of medications such as tricyclic
antidepressants and antihistamines may also produce the side effect of
drowsiness. Taking several medications may compound fatigue symptoms.
To determine the cause and best treatment for fatigue, the person's fatigue
pattern must be determined, and all of the factors causing the fatigue must be
identified. The following factors must be included:
Underlying factors that contribute to fatigue should be evaluated and
treated when possible. Contributing factors include anemia, depression,
anxiety, pain, dehydration, nutritional deficiencies, sedating medications, and
therapies that may have poorly tolerated side effects. Patients should tell
their doctors when they are experiencing fatigue and ask for information about
fatigue related to underlying causes and treatment side effects.
There are different kinds of anemia. A medical history, a physical
examination, and blood tests may be used to determine the kind and extent of
anemia that a person may have. In people with cancer there may be several
causes.
Most of the treatments for fatigue in cancer patients are for treating
symptoms and providing emotional support because the causes of fatigue that are
specifically related to cancer have not been determined. Some of these
symptom-related treatments may include adjusting the dosages of pain
medications, administering red blood cell transfusions or blood cell growth
factors, diet supplementation with iron and vitamins, and antidepressants or psychostimulants.
Although fatigue is one of the most common symptoms in cancer, few
medications are effective in treating it. A health care provider may prescribe
medication in low doses that may help patients who are depressed, unresponsive,
tired, distracted, or weak. These drugs (psychostimulants)
can give a sense of well-being, decrease fatigue, and increase appetite. They
are also helpful in reversing the sedating effects of morphine, and they work
quickly. However, these drugs can also cause sleeplessness, euphoria, and mood
changes. High doses and long-term use may cause loss of appetite, nightmares,
sleeplessness, euphoria, paranoid behavior, and possible heart problems.
Treatment for fatigue that is related to anemia may include red blood cell
transfusions. Transfusions are an effective treatment for anemia,
however possible side effects include infection, immediate transfusion
reaction, graft-versus-host disease, and changes in immunity. Treatment for
anemia related fatigue, in patients undergoing chemotherapy, may also include
drugs that stimulate the production of blood cells such as epoetin
alfa.
Exercise (including light- to moderate-intensity walking programs) helps
many people with cancer. People with cancer who exercise may have more physical
energy, improved appetite, improved ability to function, improved quality of
life, improved outlook, improved sense of well being, enhanced sense of
commitment, and improved ability to meet the challenges of cancer and cancer
treatment.
Exercise may also help patients with advanced cancer, even those in hospice
care. More benefit may result when family members are involved with the patient
in the physical therapy program.
Any changes in daily routine require the body to use more energy. People
with cancer should set priorities and keep a reasonable schedule. Health
professionals can help patients by providing information about support services
to help with daily activities and responsibilities. An activity and rest
program can be developed with a health care professional to make the most of a
patient's energy. Practicing sleep habits such as not lying down at times other
than for sleep, taking short naps no longer than one hour, and limiting
distracting noise (tv,
radio) during sleep may improve sleep and allow more activity during the day.
Treating chronic fatigue in cancer patients means accepting the condition
and learning how to cope with it. People with cancer may find that fatigue
becomes a chronic disability. Although fatigue is frequently an expected,
temporary side effect of treatment, other factors may cause it to continue.
Since fatigue is the most common symptom in people receiving outpatient chemotherapy,
patients should learn ways to manage the fatigue. Patients should be taught the
following:
This section is for patients who have had no cancer treatment for at least 6
months. The causes of fatigue are different for patients who are receiving
therapy compared to those who have completed therapy. Also, the treatment for
fatigue may be different for patients who are no longer receiving treatment for
cancer.
Fatigue in people who have completed treatment for cancer and who are
considered to be disease-free is a different condition than the fatigue
experienced by patients receiving therapy. Fatigue may significantly affect the
quality of life of cancer survivors. Studies show that some patients continue
to have moderate to severe fatigue for up to 18 years after bone marrow
transplantation. Long-term therapies such as tamoxifen
can also cause fatigue. Fatigue can cause poor school performance years later
in children who were treated for brain tumors and cured. Long-term follow-up
care is important for patients after cancer therapy. Physical causes should be
ruled out when trying to determine the cause of fatigue in cancer survivors.