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Overcoming Cancer-Related Fatigue: Diagnosis, Causes, and Treatment Strategies

Cancer-related fatigue (CRF) is a distressing and persistent sense of exhaustion impacting up to 100% of cancer patients. It interferes with daily activities and social interactions, resulting from cancer and its treatments, as well as factors like anemia, sleep disturbances, and psychological distress. Strategies to cope with CRF include energy conservation techniques, non-pharmacologic interventions such as moderate exercise, and pharmacologic options for sleep and pain management. Engaging in moderate physical activity during and after treatment can help mitigate symptoms and improve quality of life.

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Overcoming Cancer-Related Fatigue: Diagnosis, Causes, and Treatment Strategies

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  1. Insomnia and Fatigue Andrea Richtel Branas, MSE, MPT, CLT Lead Therapist Good Shepherd Penn Partners Abramson Cancer Center

  2. Cancer Related Fatigue (CRF) Distressing, persistent, subjective sense physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. NCCN Guidelines V 1.2013, Cancer-Related Fatigue

  3. Cancer Related Fatigue • Reported as the most common and distressing side effect of cancer treatment • Affects 70-100% of the cancer population • Can make it hard to: • Be with friends and family • Do daily activities • Follow treatment plan

  4. What does fatigue feel like? • No energy • Need more sleep • Sleeping is not restful • Normal activities are difficult to do • Difficulty focusing your attention

  5. What causes Fatigue? Cancer and it’s treatment

  6. What causes Fatigue • Cancer • Cancer treatments (surgery, chemo, radiation) • Anemia • Insomnia/sleep disturbance • Nutrition • Depression and anxiety • Medications • Too much activity • Lack of exercise

  7. Symptom Cluster • Fatigue is commonly clustered with symptoms of: • Pain • Sleep disturbance • Emotional distress

  8. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  9. Energy Conservation • Finding easier ways to perform tasks • Saving your energy • Avoiding fatigue, by balancing work and rest • Changing how you do activities • So you can do more without as much fatigue

  10. Energy Conservation • Pacing • Planning • Posture • Organization

  11. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  12. Non-Pharmacologic • Activity Enhancement • Exercise • Rehabilitation • Psychsocial Intervention • Nutrition

  13. “Activity Enhancement” “It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment”

  14. ACSM Guidelines • ACSM Roundtable on Exercise Guidelines for Cancer Survivors • Medicine & Science in Sports and Exercise, June 2010 • ***Avoid Inactivity*** • Exercise should be individualized • Exercise is safe both during and after most types of cancer treatment

  15. Exercise with lymphedema • Weight Lifting in Women with Breast-Cancer-Related Lymphedema • In breast cancer survivors with stable lymphedema, slowly progressive weight lifting did not significantly increase limb swelling. • Decreased incidence of flares • Decreased lymph symptoms • Increased strength Schmitz KH, et al. Weight Lifting in Women with Breast-Cancer-Related Lymphedema. N Engl J Med 2009;361:664-73.

  16. Physical Activity • American Cancer Society guidelines • Adopt a physically active lifestyle.     • Adults: • Moderate or greater activity for 30 minutes or more on five or more days of the week. • Always talk to your doctor/nurse first! • Special precautions • Low blood counts • Bone metastases Byers et al. (2002). American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention. CA: A Cancer Journal for Clinicians 52: 92-119.

  17. How do you get started with exercise? Vs. Vs.

  18. Physical Therapy • Not sure what to do • Recent surgery • Medically complex • Lymphedema • Very deconditioned

  19. Exercise Specialist • ACSM/ACS Certified Cancer Exercise Trainer • No specific muscle/joint pains • Need guidance • No lymphedema

  20. Exercise at Home • Experienced exerciser • Know how to slowly progress • Know how to come back after a holiday • Know how to monitor how hard you are working

  21. Bare minimum • Walk • Walk • Walk • Walk • Something is more than nothing! • Start Low and Progress Slow!

  22. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  23. Pharmacologic • Medications for: • Pain • Insomnia • stimulants

  24. Sleep Distrubance • Hypersomnia –sleeping too much • Insomnia – not enough sleep • 30%-75% of patients with cancer

  25. Why is sleep disrupted? • Pain • Anxiety • Night sweats • Upset stomach • Frequent urination • Difficulty breathing • Poor sleep habits • Medication www.cancer.gov

  26. Look closely at your sleep Issues • Sleep history • Impact of insomnia on daily activities • Sleep diary • Mood evaluation – check for depression & anxiety • Apnea/snoring ADL = activity of daily living Fleishman. Journal of the National Cancer Institute Monographs No. 32. 2004; Bennett, Cameron, Brown, et al. Oncology Nursing Forum. 2010.

  27. Help for Insomnia • Behavioral therapy • Stimulus control therapy • Sleep restriction therapy • Sleep hygiene education • Regular exercise • Medications Mills, Graci. Cancer Symptom Management. 2004; Savard, Simard, Ivers, et al. JCO. 2005.

  28. Medical Treatments • CLASSIC THERAPIES • Benzodiazepines (temazepam) • Imidazopyridines (zolpidem) • Pyrazolopyrimidine (zaleplon) • Pyrrolopyrazine (eszopiclone) • Behavior Therapy (sleep restriction, stimulus control) • Antidepressants (amitriptyline , trazodone, doxepin) } benzodiazepine receptor agonists BZRAs Savard, Simerd, Ivers, et al. JCO. 2005.

  29. Other Pharmacologic strategies • Psychostimulants • Corticosteroids • Antidepressants • Treatment of depression related fatigue • Herbals • Promising • Drug-drug interactions possible NCCN Practice Guidelines in Oncology v1.2011: Cancer-Related Fatigue. Downloaded from http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf.

  30. Controlling your fatigue

  31. How do you gain control? • Know your symptoms • Monitor symptoms regularly • Share your symptoms with • Care team • Family and friends • Try new treatments • But only 1 at a time

  32. Getting to know your fatigue • Rate your fatigue

  33. On your calendar • Fatigue • Mood • Activity • Medication • Stressors • Sleep

  34. Symptoms Calendar F= Fatigue P = Pain M= mood S= hours of sleep Exercise

  35. Share symptoms with care team • Discuss: • Medications • Activity • Sleep • Mood • Pain

  36. Exercise

  37. Eliminate caffeine, nicotine, & alcohol Check meds with MD Keep bedtime and wake-time same Exercise Avoid late afternoon naps Eliminate big bedtime snacks Limit night-time fluids Avoid noise Keep correct temperature Get outside Get up if not sleeping Reserve bed for sleep Sleep Hygiene Mills, Graci. Cancer Symptom Management. 2003; Savard, Simerd, Ivers, et al. JCO. 2005.

  38. Eat Well

  39. Managing Side Effects from the Psycho/Social Point of View • Side effects are no fun! • How you respond to side effects is completely up to you

  40. Managing Side Effects • Relationship to Self • Acceptance • Emotional Release • Not over-identifying with the body • Relationship to Others • Communicating Feelings • Educating Others • Getting help!

  41. Moving On What is the most loving thing you can do for yourself?

  42. Questions and Discussion

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