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Managing Fatigue in Patients with Advanced Cancer

March 2018, Vol 8, No 3

The prevalence of fatigue is very high across the cancer continuum, with approximately 60% of patients with advanced cancer experiencing this condition. Even for patients with curable cancer, fatigue can persist well after treatment has ended.

“Fatigue is multidimensional, and it’s experienced and reported differently by each individual, but its central features are loss of efficiency, mental fogginess, inertia, and nonrestorative sleep,” said Sandra A. Mitchell, PhD, AOCN, Research Scientist and Program Director, Outcomes Research Branch at the National Cancer Institute. Dr Mitchell discussed the topic at the 2017 Palliative and Supportive Care in Oncology Symposium.

Dr Mitchell noted that fatigue may occur as an isolated symptom or as 1 component within a cluster that includes pain, depression, and sleep disturbances. “It can be challenging to distinguish fatigue from depression, cognitive dysfunction, or asthenia, and personality and coping style may influence fatigue experiences,” she added.

The National Comprehensive Cancer Network recommends that every patient be screened for the presence of fatigue at regular intervals. Furthermore, if present, fatigue should be assessed quantitatively on a 0-to-10 scale, Dr Mitchell said, with a severity of 4 or worse warranting expanded evaluation, including a complete medical history and physical examination.

Evidence-Based Fatigue Management

A large body of evidence-based interventions is available that can improve fatigue outcomes, Dr Mitchell suggested. Numerous trials have demonstrated robust and consistent evidence of the benefit of several interventions, and exercise, in particular, is likely to be effective.

Patients who experience fatigue should build up to 150 minutes of weekly moderate-intensity activity (eg, brisk walking, bicycling, swimming, deep-water walking/running) over at least 1 month, and then add strength training to the regimen. She suggested referral to an exercise physiologist, trainer, physiatrist, or physical therapist for specific and detailed recommendations about the type, intensity, and frequency of exercise for the individual patient.

“As functional capacity improves, the exercise program should advance,” said Dr Mitchell, adding that mobile health tools, such as activity monitors and apps, may strengthen motivation and adherence to the exercise program.

There is also strong evidence that yoga reduces fatigue, Dr Mitchell observed, particularly in cancer survivors, although the evidence is “less compelling” for yoga during active treatment. In addition, progressive muscle relaxation has been shown to improve fatigue outcomes across a range of populations, including in patients with advanced cancer, she added.

There is also consistent evidence that psychoeducational interventions improve fatigue outcomes, although the effects may be limited, according to Dr Mitchell. Psychoeducation for fatigue includes anticipatory guidance, energy conservation, coaching to enhance self-efficacy, setting goals, and emotional support.

Cognitive behavioral interventions for sleep have demonstrated beneficial effects across a wide range of patient populations. This multicomponent intervention includes relaxation, sleep consolidation, stimulus control, and reducing cognitive emotional arousal. An intervention can be effectively delivered individually, in groups, and via e-health formats.

There is robust and consistent evidence that meditation and mindfulness-based stress reduction interventions can reduce fatigue and fatigue-related daytime interference, as well as favorably affect fatigue-related biomarkers.

Systematic symptom monitoring with advanced practice nurse interventions and palliative care consultation has been shown to reduce symptom burden and improve fatigue outcomes.

Finally, cognitive behavior therapy for fatigue, depression, and pain, with and without hypnosis, improved fatigue across a wide range of patient populations in several studies, she said.

“The fatigue management plan should be individualized in accordance with patient goals, tolerance, and response to interventions,” said Dr Mitchell, noting that in individual circumstances, providers may also consider recommending massage, acupuncture, bright light therapy, or tai chi/qigong. “There is some preliminary evidence supporting these interventions, but providers need to evaluate effectiveness carefully,” she concluded.

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