Treatment of Cancer Related Fatigue

What is cancer-related fatigue?

Cancer-related fatigue (CRF) is one of the most common and distressing symptom faced by cancer patients. 

Fatigue is a symptom that is perceived by the patients and is not visible or assessable by the physician or caregiver. The CRF is different from the normal fatigue because it is not relieved with rest. A cancer patient may describe it as a feeling of being tired, weak, restless, weary, heavy, worn out, drained, exhausted, washed-out, slow, or inability to perform routine activities which they could perform with ease before encountering cancer. 

For some people, CRF is more bothersome than other cancer-related symptoms like pain, nausea, vomiting, or depression. Following are some pointers that direct to CRF:

• A feeling of being tired that doesn’t get better with rest or sleep and keeps coming back or becomes severe with time.
• A feeling of tiredness after or during a usual activity
• A feeling of being tired without any activity 
• An increase in sleep duration or problem in initiating sleep

How is the level of cancer-related fatigue (CRF) measured?

Fatigue is perceived by a patient, and thus the patient can only tell about the level of fatigue experienced by him/her. 

In general, the level of fatigue is assessed by asking the patient to rate the level of fatigue that he/she experiences on a visual analog scale (VAS) of 0 to 10. Where “0” represents no fatigue and “10” represents the worst imaginable fatigue. When the VAS score is 1–3, 4–6, and 7–10, level of fatigue is termed as mild, moderate, and severe, respectively. 

Various other tools/questionnaires have been developed and validated to more accurately assess the level of cancer-related fatigue. Examples of such tools include Brief Fatigue Inventory (BFI), Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF), Functional Assessment of Cancer Therapy instrument (FACT-F), and European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQC30), fatigue subscale. These tools may be appropriate in some instances and are generally employed in clinical trials to assess the change in the level of fatigue over time.
 

What is the treatment for cancer-related fatigue?

Based on the clinical assessment of the patient, the physician will suggest the most appropriate measures to reduce the cancer related fatigue. 

Following are some examples of such measures that can help in reducing the CRF:

Increase physical activity

It may seem contrasting but light exercise or aerobics can help in reducing cancer related fatigue. Various research studies have revealed that cancer patients who exercise regularly experience less fatigue and depression. Light exercise helps the lungs cancer and heart to work better and reduce fatigue. Also, exercise makes you sleep better thereby reducing depression. Thus, increased physical activity is recommended for all cancer patients. 

Maintain proper nutrition

To prevent fatigue it is important to maintain proper nutrition. You should get enough calories along with essential nutrients like carbohydrates, protein, fats, vitamins, minerals, and others. This can be achieved with the help of a balanced diet. Take plenty of fluids to keep yourself hydrated and to drain-off wastes from your body via urine. Consume easily digestible food and avoid consuming junk food. You may consult a nutrition counselor for deciding upon your diet chart and eating schedule.  

Relaxation techniques/Behavioural therapy

Being relaxed is helpful in reducing fatigue. You may choose to practice a brief morning/evening walk, meditation, yoga, spending time in a garden, bird watching, painting, or prayer whatever you like and what makes you feel relaxed. You can opt for getting a behavioral or alternative therapy like acupuncture or naturopathy for relaxing.  

Utilize your energy wisely

It is very important to save energy and utilize the same for the most important activities. You can achieve this by keeping a tack of energy level during a day and performing routine activities accordingly. Exercise and stretching can be done when you have the most energy. You should know your limits and should not strain too much while exercising. Also, don't feel shy in accepting help from others. It will be good for you if others can take care of some activities that you cannot perform like driving, cooking, scheduling, etc.

Distract yourself

Try to distract yourself from the feeling of fatigue by indulging yourself in things you enjoy. You can listen to your favorite songs; read a joyful novel; watch a movie of your choice; hang on with friends, or do other relaxing tasks that do not require too much labor. 

Take adequate sleep

Maintaining good sleep habit helps in relieving fatigue. You should try to sleep for at least 7 to 8 hours in the night with a fixed schedule for going to and getting out of the bed each day. If naps are required during the daytime, they should be short (<30 minutes) and minimal so that they do not affect your nighttime sleep. Too much sleep should also be avoided as this can induce fatigue. In case you face any problem in getting asleep, listen to soothing music that may help in inducing sleep. Avoid caffeine and exercise during the evening. 

Pharmacologic Intervention

In the case of poor response from above-noted measures, the physician may recommend certain laboratory tests or medications. The physician may ask for getting a blood test to diagnose anemia or other problems. In the case of anemia, blood transfusion or erythropoietin may be suggested. In case of other problems, appropriate medicine can be given based on the overall assessment and severity of cancer-related fatigue. Central nervous system stimulants, such as methylphenidate or modafinil, have shown efficacy in the management of CRF and are recommended for this purpose. Antidepressants may also be considered in the case of patients who have developed fatigue due to depression. 

Cause of Cancer Related Fatigue?

Although the exact cause of CRF is not clear, in most cases it is caused by the disease itself, and less commonly by the cancer treatment being given. 

Cancer is uncontrolled growth of certain body cells that keep on dividing without dying. Thus, cancer cells consume more resources/energy leading to a shortage of resources/energy for the normal cells. This shortage causes a feeling of fatigue. Cancer may also cause fatigue due to the formation of harmful chemicals that disrupt the normal cell function, especially of those cells involved in the respiration and blood formation/circulation.

The cancer treatment, especially the chemotherapy, radiotherapy, bone marrow transplants, and biologic therapies may cause the destruction of normal cells apart from the cancer cells. This may cause fatigue as the body require extra energy to repair the damage caused by the treatment.

Now let’s discuss the various causes of cancer related fatigue in detail:

1. A decrease in the red blood cells count (anemia) that may be caused by the disease itself (e.g. leukemia) or due to the side effect of treatment on the bone marrow. Red blood cells carry oxygen to different cells, which acts as the fuel for body cells. In the absence of adequate oxygen supply cells cannot function normally, which lead to excessive fatigue.

2. Decreased appetite, nausea, vomiting, constipation, and diarrhea are commonly observed in cancer patients. These conditions may arise due to factors related to disease or due to side effects of treatment. These conditions may prevent adequate food intake by the patient, which is essential for normal body functioning. Also, the disease/treatment might impair the absorption of nutrients from the ingested food. This deprivation of nutrients leads to the development of fatigue.

3. Cancer patients generally experience anxiety and depression. Also, the disease/treatment adversely affects the mental, social, and financial well-being of the patient leading to the build-up of unpleasant emotions. The emotional distress often affects physical activity and led to the development of fatigue.

4. Cancer patients often experience sleep disturbances. They might not sleep adequately because of emotional distress, awakening at night, daytime sleep causing a problem with night sleep, early morning awakening, inability to get asleep again, or due to disease/treatment-related pain. This lack of sleep deprives the cancer patient of adequate rest require for normal functioning and worsens the fatigue.

5. Cancer-related pain is another common symptom/side effect of cancer/treatment. The disease-related pain can cause mood disturbances, sleep problems, irritation, and depression. These psychological changes may lead to the worsening of fatigue.

6. Cancer/treatment may cause an alteration in the normal protein or hormonal levels that are linked to inflammatory processes. A disturbance in the normal level of these chemicals can cause a feeling of fatigue.

7. Many cancer patients have other medical problems or disorders that are not directly related to cancer. These disorders may cause a disturbance in normal body functioning and thus may lead to fatigue development. Examples of such comorbidities include cardiac problems, nervous system problems, low thyroid or adrenal hormones level, digestive system disorders, infection, diabetes, arthritis, high blood pressure, or others.

8. Due to above-discussed problems associated with cancer, patients usually restrain from exercise or other physical activities. They might think that it will save energy. However, different research studies have shown that light exercise or being physically active help in reducing cancer-related fatigue.