cancer related fatigue

1. Cancer Related Fatigue
Dr Prabhat Ranjan
Department of Medical Oncology
SRMC

2. Definition
• CRF- A distressing, persistent, subjective sense of physical, emotional
and/or cognitive tiredness or exhaustion related to cancer or cancer
treatment that is not proportional to recent activity and that interferes with
usual functioning.

3. Prevalence
• CRF affects between 15 and 90 percent of cancer patients overall and more
than 75 percent of those with advanced cancer or bone metastases
• The wide range of these estimates likely reflects variable diagnostic criteria
used to define CRF
• Up to one-third of cancer survivors have persistent posttreatment fatigue

4. Major Contributing Factors
• Cancer therapy, including cytotoxic agents, biologic response modifiers,
molecularly targeted therapies (especially those targeting the vascular
endothelial growth factor and epidermal growth factor receptor), hormonal
therapies (eg, androgen deprivation therapy), and RT
• Progressive tumor growth
• Unrelieved pain
• Anemia

5. • Metabolic/nutritional/hormonal issues, such as poor nutrition, fluid/electrolyte
disturbances, hypothyroidism, male hypogonadism, menopause, and dehydration
• Comorbidities, including cardiac, respiratory, renal, hepatic, and endocrine
dysfunction, infection, neuromuscular disorders
• Medication side effects, especially sedation from opioid analgesics
• Deconditioning
• Depressed mood, emotional distress, and sleep disturbance

7. Screening
• All patients with malignant disease should be screened for CRF at the initial visit, at
each chemotherapy visit,at the end of primary therapy, and then annually during
follow-up survivor care, when the diagnosis of advanced disease is made
• One example is a visual analog scale (VAS, "How would you rate your fatigue on a
scale of 0 to 10?"), with 0 representing no fatigue and 10 the worst imaginable
fatigue
• Mild, moderate, and severe fatigue are represented by scores of 1 to 3, 4 to 6, and 7
to 10, respectively.

8. • Clinician must rely upon patient self-reports to assess its presence and
severity, which can then be supported by additional sources of information,
such as physical examination, laboratory data, or the descriptions of family
members.

9. Clinical Assessment
• If Mild Intensity(visual analog scale [VAS] or Brief Fatigue Inventory [BFI]
score 1 to 3)
1. Focused fatigue evaluation is not needed
2. Periodic reassessment should be undertaken
3. If fatigue worsens, a focused fatigue assessment should then be undertaken.

10. • Moderate to severe CRF (as defined by a score ≥4 on a scale of 1 to 10)
1. Focused fatigue history
2. An assessment of disease status-If it is determined that fatigue is unrelated
to disease progression or recurrence, informing patients and their family
members of this fact may substantially reduce anxiety levels.

12. 3. Assessment of potentially treatable contributory factors-for eg
anaemia,unrelieved pain etc
4. Review of all (prescription and over the counter) medications, assessment of
activity levels, and nutritional assessment.
5. Appropriate referrals to trained professionals (eg, cardiologist,
endocrinologist, mental health professional) as needed

14. Interventions
• Supported by expert opinions:
1. Work with patient and family to improve assessment of fatigue and identify
management strategies
2. Promote open communication between patient,family,and caregiving team
to facilitate discussions about the experience of fatigue and its effects on
daily life

15. 3. Consider attention restoring activities such as exposure to natural
environments and pleasant distractions such as music
4. Encourage a balanced diet with adequate intake of fluid,calories,
protein,carbohydrates,fat,vitamins and minerals

16. • Interventions with strong evidence:
1. Exercise
2. Supportive counseling
3. Measures to optimize sleep quality
4. Energy conservation and activity management
5. Yoga
6. Management of Concurrent Symptoms

17. • Interventions with some evidence:
1. Acupuncture
2. Massage
3. Corticosteroids
4. Ginseng
5. Bright light therapy
6. Mindfulness based Stress reduction
7. Healing touch, hypnosis, progressive muscle relaxation