Fatigue is one of the most common and distressing effects of the cancer experience and can interfere with your daily functioning and quality of life.
The American Society of Clinical Oncology (ASCO) recently adopted new recommendations for the screening, assessment, and care of cancer-related fatigue. Published in the Journal of Clinical Oncology, the guidelines emphasize the need for oncologists to recognize the symptoms and address the causes of fatigue in their patients. Experts now recommend that all patients with cancer be evaluated for fatigue after completing primary treatment and be offered specific information on how to manage it.
William Breitbart, Acting Chair of the Department of Psychiatry and Behavioral Sciences and Chief of the Psychiatry Service, was on the panel of experts that developed the guidelines. He answered our questions about fatigue and suggested strategies that may help.
What are the causes of cancer-related fatigue?
Cancer-related fatigue is often triggered by chemotherapy, radiation, and some biologic therapies used to treat the disease. Complications of cancer or cancer treatment — such as anemia, a problem with your endocrine or thyroid function, or low testosterone levels — can also induce fatigue. In addition, remaining inactive and immobile for long periods of time can cause you to become deconditioned and result in fatigue.
Tumors themselves may cause fatigue by consuming many of the body’s nutrients and secreting small proteins called cytokines that cause inflammation. The effects of fatigue may be compounded by preexisting or newly acquired health conditions such as lung, heart, or kidney problems, or by emotional issues such as anxiety or depression.
In addition, certain medications given to control some of the symptoms of cancer — such as painkillers, antidepressants, sleep aids, or drugs to control anxiety or nausea — can sometimes cause sedation and fatigue.
Do some symptoms raise the risk of developing fatigue?
Yes. Certain symptoms tend to be synergistic in terms of how they affect people with cancer. So-called “symptom clusters” include uncontrolled pain, insomnia, and intractable nausea, and left untreated they not only may become more severe but also may worsen your fatigue. You and your physician should be aware of these symptoms and try to address them at their onset.
Can fatigue be treated?
Rest alone typically does not restore energy in someone who has cancer-related fatigue. However, treating the underlying cause of fatigue will often make you feel better. It’s important to report your symptoms to your doctor so that he or she can identify and address the possible root of the problem.
For example, if you are anemic, your physician can boost your red blood cells with a blood transfusion or medication. Your doctor may recommend that you stop taking a medicine that is known to cause fatigue or replace it with something else. Relieving pain and nausea will reduce fatigue, and for some people, replenishing nutritional or vitamin deficiencies may be helpful.
Given the multiple factors contributing to cancer-related fatigue, interventions should be tailored to your specific needs.
Are complementary therapies useful in reducing fatigue?
Nonpharmacologic approaches such as aerobic exercise, yoga, and certain kinds of meditative practices including tai chi and qi gong have been shown to reduce fatigue among cancer survivors. Some research suggests that acupuncture may also be useful, and that continues to be studied at Memorial Sloan Kettering and elsewhere. It remains unclear whether herbal remedies and supplements are beneficial.
Does fatigue manifest itself differently in people with early-stage cancer versus those with advanced disease?
There are some differences. For example, we often see a pattern of fatigue in people who receive chemotherapy. They will typically feel well for a day after the treatment, and then be quite fatigued for a few days after that. They may feel less tired over the days that follow, then recover and feel pretty good until their next treatment.
However, people with advanced disease who are on prolonged treatment tend to endure a more chronic or constant state of fatigue.
It may be helpful for some patients to use a psycho-stimulant drug such as amphetamine, Ritalin, or modafinil on those days when fatigue interferes with the ability to function or work. However, if fatigue lingers, you may find it necessary to boost your energy every day as opposed to on an as-needed basis. Discuss your options with your physician to determine what will work best for you.
Is it normal for fatigue to persist after treatment has ended?
In most cases, fatigue is a consequence of the cancer and the cancer therapy. However, it’s not uncommon for cancer survivors to experience fatigue well after they have completed treatment and are disease free. For example, certain chemotherapies can cause long-term lung or heart toxicities or neuropathy that can persist beyond the end of treatment and make you feel fatigued.
Is there overlap between fatigue and depression?
Fatigue is often a prominent symptom of depression, but it can be difficult to tease out the differences between the two. Someone who is depressed often feels very sad and tearful, hopeless, worthless, or guilty, and very fatigued. Someone who is primarily fatigued may feel down and lack motivation, but does not tend to feel those symptoms of depression.
If you treat the depression, the fatigue often gets a lot better. There is a growing body of research on interventions that have been studied in people in active treatment and are now being evaluated in cancer survivors. One approach, called cognitive behavioral therapy, is a form of psychotherapy that can help you adapt to and work around your fatigue. The goal is to stay motivated in order to accomplish the one priority you deem most important instead of giving up on everything altogether.
What practical advice would you offer to someone having a hard time with fatigue?
When you do have energy, use that time wisely. Conserve your energy to maintain the essential things in your life. It may be spending time with your family, holding your children or grandchildren, or going to a restaurant, a movie, or the theater. Participate in those activities, even if you have to ask for help. Disconnecting yourself from those activities could leave you demoralized and isolated. We have a debt to ourselves, to living our lives, and to preserving the essence of who we are by holding on to the things that give our lives meaning.