Cancer-related fatigue
Introduction
Cancer-related fatigue (CRF) is a subjective sensation that is disproportional to the widely recognised feeling of being tired. There is no consensus as to what CRF is and its use in a clinical setting is often colloquial rather than specific.1 However, it is accepted as a separate entity from the tiredness experienced by the general population. It is characterised by being pervasive and not relieved by rest.2 CRF can occur at the time of diagnosis and becomes increasingly prevalent with advancing disease.3, 4 It is a side-effect of surgery, chemotherapy and radiotherapy.5, 6, 7 CRF can also affect disease-free survivors.8
Section snippets
What is cancer-related fatigue?
There is some confusion in the literature regarding the terminology of fatigue. Unfortunately, the same term can be used to describe both an objective physical or mental decrement in performance and a subjective mental state. Both types of fatigue are usually found to a greater or lesser extent in the same individual. However, there is no direct correspondence between the two phenomena. It is quite possible to feel extremely subjectively fatigued but to perform relatively normally on objective
How can cancer-related fatigue be measured?
As a subjective state the most appropriate way to measure fatigue is to use self-report measures. At the simplest level fatigue can be measured by using a single item or a single visual analogue scale, either alone or as part of a broader quality of life assessment tool.11, 12, 13 A single-item, 11-point, numerical rating scale has been advocated as a screening tool for CRF by the National Comprehensive Cancer Network (NCCN).14 The NCCN guidelines recommend that patients with a score of 0–3
How common is cancer-related fatigue?
As the previous discussion has suggested, the prevalence of fatigue is likely to vary depending upon the assessment instrument used and the ‘threshold’ above which patients are considered to have ‘significant’ fatigue. At the most basic level, prevalence can be gauged by asking patients how fatigued they have felt in the previous month. In a multi-centre survey of heterogenous cancer patients, 58% reported that fatigue had affected them ‘somewhat’, ‘quite a bit’ or ‘very much’ in the past month.
What are the causes of cancer-related fatigue?
The underlying mechanism or ‘final common pathway’ of cancer-related fatigue remains unclear. Indeed it is unlikely that any single mechanism will ever be identified, as the symptom is almost certainly multi-factorial in origin. Although many studies have reported on the correlates of fatigue and have speculated on the cause of this symptom, there have been very few studies that have tested specific hypotheses about the underlying mechanism.
Prue and colleagues reported that most studies of CRF
How can cancer-related fatigue be treated?
Three broad approaches to tackling CRF have been investigated and these form the basis for most fatigue management programmes.
Professional guidelines
The NCCN first published evidence-based guidelines on the management of CRF in 2000. The guidelines are freely available online and are updated annually.14 The guidelines provide advice on the management of fatigue in patients on treatment, off treatment and in advanced disease. Most of the recommendations in the guidelines are graded at level 2A (uniform NCCN consensus but lower level of evidence, including clinical experience). It is recommended that patients with moderate to severe fatigue
Conclusions
Fatigue is a common and distressing symptom affecting patients with cancer from the time of diagnosis, throughout treatment and into advanced disease. It can also affect disease-free survivors sometimes for years after treatment has finished. Further work is required to understand the pathophysiology of CRF and to develop new treatment approaches. Existing management strategies require further evaluation, ideally using large scale, multi-centre RCTs.
Conflict of interest statement
Dr. Stone received a £15k educational grant from Ortho-biotech (UK) in 2001 to undertake a study of red-cell functioning in patients with cancer.
References (109)
- et al.
Fatigue: a concept analysis
Int J Nurs Stud
(1996) - et al.
Fatigue, serum cytokine levels, and blood cell counts during radiotherapy of patients with breast cancer
Int J Radiat Oncol Biol Phys
(2001) - et al.
I get tired for no reason: a single item screening for cancer-related fatigue
J Pain Symptom Manage
(2001) - et al.
Development of a Fatigue Scale
J Psychosom Res
(1993) - et al.
The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue
J Psychosom Res
(1995) - et al.
Development and validation of the cancer fatigue scale: a brief, three-dimensional, self-rating scale for assessment of fatigue in cancer patients
J Pain Symptom Manage
(2000) - et al.
Fatigue and psychological distress – exploring the relationship in women treated for breast cancer
Eur J Cancer
(2004) - et al.
Combining anchor and distribution-based methods to derive minimal clinically important differences on the Functional Assessment of Cancer Therapy (FACT) anemia and fatigue scales
J Pain Symptom Manage
(2002) - et al.
Fatigue in patients with prostate cancer receiving hormone therapy
Eur J Cancer
(2000) - et al.
Fatigue in patients with cancers of the breast or prostate undergoing radical radiotherapy
J Pain Symptom Manage
(2001)
Exploring the validity of the Chalder fatigue scale in chronic fatigue syndrome
J Psychosom Res
Fatigue in the general Norwegian population: normative data and associations
J Psychosom Res
Preliminary evaluation of a clinical syndrome approach to assessing cancer-related fatigue
J Pain Symptom Manage
The prevalence and moderators of fatigue in people who have been successfully treated for cancer
J Psychosom Res
Cancer-related fatigue: a critical appraisal
Eur J Cancer
Fatigue and psychiatric morbidity among Hodgkin’s disease survivors
J Pain Symptom Manage
Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system
J Pain Symptom Manage
The relationship between fatigue and quality of life and inflammation during anthracycline-based chemotherapy in breast cancer
Biol Psychol
Fatigue during breast radiotherapy and its relationship to biological factors
Int J Radiat Oncol Biol Phys
The association between fatigue and inflammatory marker levels in cancer patients: a quantitative review
Brain Behav Immun
Diurnal cortisol rhythm and fatigue in breast cancer survivors
Psychoneuroendocrinology
Elevated basal cortisol levels and attenuated acth and cortisol responses to a behavioral challenge in women with metastatic breast cancer
Psychoneuroendocrinology
Stress sensitivity in metastatic breast cancer: analysis of hypothalamic–pituitary–adrenal axis function
Psychoneuroendocrinology
A pilot study of a supervised group exercise programme as a rehabilitation treatment for women with breast cancer receiving adjuvant treatment
Eur J Oncol Nurs
The effect of a physical exercise program in palliative care: a phase II study
J Pain Symptom Manage
Supportive intervention for fatigue in patients undergoing chemotherapy: a randomized controlled trial
J Pain Symptom Manage
Fatigue in cancer patients compared with fatigue in the general United States population
Cancer
An explanatory model of fatigue in women receiving adjuvant breast cancer chemotherapy
Nurs Res
Fatigue in advanced cancer: a prospective controlled cross-sectional study
Br J Cancer
Attentional fatigue following breast cancer surgery
Res Nurs Health
Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment
Support Care Cancer
The course of severe fatigue in disease-free breast cancer patients: a longitudinal study
Psycho-oncology
Fatigue in palliative care patients – an EAPC approach
Palliat Med
The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology
J Natl Cancer Inst
Assessment of fatigue in cancer and non-cancer patients and in healthy individuals
Support Care Cancer
Validation of the Edmonton Symptom Assessment Scale
Cancer
The Functional Assessment of Cancer Therapy-Anemia (FACT-An) Scale: a new tool for the assessment of outcomes in cancer anemia and fatigue
Semin Hematol
Fatigue in patients with cancer. Analysis and assessment. Recent results
Cancer Res
Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory
Qual Life Res
The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer
Oncol Nurs Forum
The Schwartz Cancer Fatigue Scale: testing reliability and validity
Oncol Nurs Forum
A multidimensional measure of fatigue for use with cancer patients
Cancer Pract
The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory
Cancer
Measurement of fatigue in cancer patients: further validation of the Fatigue Symptom Inventory
Qual Life Res
Evaluating patient distress from cancer-related fatigue: an instrument development study
Oncol Nurs Forum
Cognitive function, fatigue, and menopausal symptoms in women receiving adjuvant chemotherapy for breast cancer
J Clin Oncol
Epoetin alfa treatment results in clinically significant improvements in quality of life in anemic cancer patients when referenced to the general population
J Clin Oncol
Relationship between changes in hemoglobin level and quality of life during chemotherapy in anemic cancer patients receiving epoetin alfa therapy
Cancer
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