Cancer-Related Fatigue

慈濟醫院血液腫瘤科 高瑞和醫師

Cancer-related fatigue is a persistent, subjective senseof tiredness related to cancer or cancer treatment thatinterferes with usual functioning.

DEFINITION OF CANCER-RELATED FATIGUE

中文：疲憊，疲累

Cancer-Related Fatigue

• Acute fatigue: physiologic response, recoverable

Chronic fatigue: pathologic condition, unable to recover even after rest

• Affect body and mind: physical, emotional, mental

• 身心憔悴

• Temporal relationship with interventionChemotherapy peaks within daysRadiation therapy peaks after weeks

• May persist for prolonged period• Almost universal with biologic response modifiers

Cancer-Related Fatigue

Causes of Cancer-Related Fatigue

Physiologic Underlying neoplasm Antineoplastic treatment Concomitant systemic disease Sleep disorders Immobility and lack of exercise Chronic pain

Psychological Anxiety, depression

Cancer-related pathophysiology that cause fatigue

Symptoms related to energy imbalance

Pain and pain treatment

AnemiaCachexiaInfectionParaneoplastic syndromeMetabolic disorder

Stress and moodFatigue induced by

cancer therapy

Signs of Cancer-Related Fatigue

• Feeling tired, weary or exhausted even after sleeping • Lacking energy to do your regular activities • Having trouble concentrating, thinking clearly, or

remembering • Feeling negative, irritable, impatient, or unmotivated • Lacking interest in normal day-to-day activities • Spending less attention on personal appearance • Spending more time in bed or sleeping

Diagnosis of Cancer-Related Fatigue

Ask the patient• Do you feel tired or fatigued?• Does fatigue make you change your activities?

Patient self-report is the best diagnostic tool

Prevalence of Cancer-Related Fatigue

• 50% at diagnosis, 75% if bone metastasis• Patient with chemotherapy 80-96%• Patient with radiotherapy 60-93%

*Cox et al: In general population, 20% men and 30% women always feel tired.

Fatigue-1 & Fatigue-2 studies

Impact on QOL

Fatigue-1 study 1996

• 2/3 patients considered that fatigue affected their performance of normal daily activities• 61% patients claimed that fatigue influenced their life more than pain

Impact on QOL

Fatigue-2 Study 1998

• Fatigue (25%) other than nausea (13%) as the main symptom after chemotherapy• Loss of emotional control: 90%• A feeling of isolation and solitude: 74%• Dejection: 72%• Marked effect on employment and financial status: 75% had changed employment • The effects on care-giver: more working breaks (20%)

Stone et al Ann Oncol 2000

• 52% never reported fatigue to their oncologist• Only 14% had received treatment or advice on how to manage fatigue• 33% with fatigue declared they had not received adequate treatment

538 cancer patients

Extent of The Problem

Oncologist’s view: pain in more clinically relevant than fatigue (61% vs 37%)

Patient’s view: fatigue affects everyday life much more than pain (61% vs 19%)

Extent of The Problem

1. Screening2. Primary evaluation3. Interventions4. Reevaluation

SCREENING

Disease status and treatment Rule out recurrence or progression Current medications/medication changes Review of systems In-depth fatigue assessment Onset, pattern, duration Change over time Associated or alleviating factors Interference with function

Primary Evaluation Phase

Focused History:

How is Fatigue Assessed?

1. When did the fatigue first start?2. When did you first realize that it is an unusual

type of fatigue for you?3. How has it progressed over the course of your

treatment or since your diagnosis?4. What help relieve your fatigue?5. What makes your fatigue worse?6. How has the fatigue affected your daily

activities or the activities that give meaning and enjoyment to your life?

• Pain• Emotional distress: depression• Sleep disturbance• Anemia• Nutrition assessment:

weight/calori intake changefluid, electrolyte imbalance

• Activity level: changes in exercise or activity pattern,deconditioning

• Comorbidities: infection, cardiac, pulmonary, renal, hepatic, neurologic, endocrine, hypothyroidism

Assessment of Treatable Contributing Factors

Anemia and Cancer-Related Fatigue

Correlation between Hb levels ( 12g/dL vs. 12g/dL) and fatigue

QOL parameters P value

Higher QOL scores 0.003Less fatigue 0.01Fewer symptoms of anemia 0.02Better sensation of physical well being 0.003Better sensatin of function al well being 0.001

QOL: quality of life

Sobreo et al. Semin Hemato 2001, 28:15-18

Treatment of Anemia-related Fatigue

• Iron, folic acid replacement• Blood transfusion• Erythropoietin therapy: supported by strong

clinical evidence10,000 units sc tiw or40,000 units sc weekly

INTERVENTION-1

Patient/Family Education

Common Strategies for Management of FatigueINTERVENTION-2

Non-PharmacologicINTERVENTION-3

PharmacologicINTERVENTION-4

Re-evaluation

What to look for?

• Feeling like you have no energy • Increased sleeping • Lack of desire to do normal activities • Decreased attention to personal appearance • Feeling tired even after sleeping • Difficulty concentrating

Patient Self-Care

• Plan rest periods to conserve energy for important things

• Schedule necessary activities throughout the day rather than all at once

• Engage in light activity • Get enough rest and sleep • Eat a nutritious diet including plenty of liquids • Remember that fatigue caused by treatment side

effects is temporary and that energy will

What to do?

Patient Self-Care

Finale

Fatigue is common in cancer patients which should be recognized, evaluated, monitored, documented and treated promptly at all stages of the disease, both during and after treatment.

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The End