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Fatigue in the Advanced Cancer Patient

Fatigue in the Advanced Cancer Patient. Doctor, why am I so tired?. Fatigue & Cancer. Definitions Causes Pathophysiology Assessment Treatment issues. Fatigue & Asthenia. Greek (Asthenos) “absence or loss of strength” Combination of physical & mental fatigue May precede diagnosis

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Fatigue in the Advanced Cancer Patient

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  1. Fatigue in the Advanced Cancer Patient Doctor, why am I so tired?

  2. Fatigue & Cancer • Definitions • Causes • Pathophysiology • Assessment • Treatment issues

  3. Fatigue & Asthenia • Greek (Asthenos) • “absence or loss of strength” • Combination of physical & mental fatigue • May precede diagnosis • Often ass’d with cachexia • Worsened by chemo/RT/surg • Rarely assessed or treated

  4. Pain Fatigue/Asthenia Constipation Dyspnea Nausea Delirium Depression/suffering 80 - 90% 75 - 90% 70% 60% 50 - 60% 30 - 90% 40 - 60% Symptom Prevalence

  5. Asthenia • 3 elements • Fatigue • easily tired;  ability to maintain adequate performance • Weakness • subjective sensation; difficulty initiating activity (not neuro/muscular disease) • Mental fatigue • impaired concentration, memory loss & emotional lability

  6. Cachexia/malnutrition Dehydration Infection Hematologic causes Metabolic disorders Chronic hypoxia Neurologic dysf’n Psychogenic causes Endocrine disorders Insomnia Chronic overexertion Pharmacologic Cardio/pulm disorders Liver failure Renal failure Chemo/RT Etiology

  7. Causes • Electrolyte disorders • Ca++, K+, Mg++, Na+ • Endocrine disorders •  thyroid,  cortisol, diabetes • Hematologic •  Hgb,  WBC

  8. Causes • Infections • TB, viral (e.g. hepatitis), fungal • Neurologic disorders • auto dysf’n, myasthenia, parkinsonism • Pharmacologic • chemotx, sedatives, EtOH, narcotics

  9. Mechanisms • 3 factors • Direct: produced by tumor • Induced: secondary to tumor effect • Accompanying: associated with malignancy, contribute to asthenia

  10. CNS Mechanisms • Hypothetical, little actual research • RAS active in fatigue experience • cortical stimulation & sensory activity • Chronic stimulation (pain) may yield fatigue • Physical fatigue may protect RAS • Asthenia d/t breakdown of RAS by stimuli from • environment & cortex; humoral factors

  11. Mechanisms in Muscle • Cachexia = loss of muscle and fat • Pts with N caloric intake may show: • lactate production • atrophy of type II fibres • cathepsin-D • impaired mm function • Caused by ‘asthenins’/cytokines

  12. Assessment • Why? • Subjective sensation; self-assess best • Characterize, monitor, research purposes • Many tools developed • Gold standard (nonexistent): • simple, easily understood • valid, reliable, multidimensional

  13. Assessment Tools • Unidimensional • Performance status (Karnofsky, ECOG) • Rhoten Fatigue Scale • Multidimensional • F’nal Assessment of Cancer Tx (FACT) • Edm F’nal Assessment Tool (EFAT) • Multid’nal Fatigue Inventory (MFI-20)

  14. Management • Pharmacologic measures • Corticosteroids (Decadron) •  appetite, energy, short-term • Amphetamines (Ritalin) •  sedation,  activity, opioid ass’n • Megesterol acetate (Megace) •  appetite,? asthenia, expensive

  15. Management • Promising Rx treatments • Thalidomide •  AIDS wasting, anti-TNF • Melatonin • Cannabinoids • Clenbuterol • -3 fatty acids

  16. Management • Non-pharmacologic measures • Moderate exercise • Adapting ADL • Rest, energy conservation • Psychotherapy • Self-help; activity diary • Family/caregiver involvement

  17. Conclusions • Common condition • Multiple causes • Mechanisms unclear • Assessment important • Multidimensional treatment • More research needed

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