Life-altering fatigue will affect 80% of people getting chemotherapy or radiation therapy, plus most people who have metastatic cancer, and even many survivors long after treatment is done.
Yet fatigue in cancer patients has been under-reported, under-diagnosed, and under-treated, according to an expert panel convened by the National Comprehensive Cancer Network (NCCN) a decade ago to recommend cancer-related fatigue treatment guidelines.
Some good news: A recent Dutch study published in the Journal of Clinical Oncology found that advanced cancer patients can get significant relief from serious fatigue, when their fatigue and other symptoms are regularly monitored and treated according to guidelines.
Some less good news: A small U.S. study published in Support Care Cancer found that even at an excellent cancer center, most metastatic cancer patients did not get any of the recommended treatments for even severe fatigue.
In one of the first randomized controlled studies of cancer-related fatigue, described in the Jan. 2nd Journal of Clinical Oncology, Dutch researchers randomly assigned 152 advanced cancer patients with significant fatigue (mean age 58, with 57% female and 65% on palliative chemotherapy) to receive either usual treatment, or usual treatment plus nurse appointments at 1, 2, and 3 months for evaluation of nine symptoms—including pain, nausea or vomiting, lack of appetite, and fatigue.
In the nurse-monitored group, patients having symptoms of average or higher intensity received treatment according to evidence-based, palliative care guidelines. Standard-care patients had their usual clinic visits with symptom treatment according to clinicians’ preferences rather than specific guidelines.
After several months, patients getting the nurse visits and protocol-guided symptom treatment showed modest but statistically significantly improvement in fatigue and related symptoms (e.g. anxiety and daily activity levels). Improvement was seen with control of symptoms such as pain, vomiting, diarrhea, lack of appetite, rather than fatigue itself.
Systematic monitoring of symptoms seemed to be the key in this and other studies, the researchers reported.
Initial U.S. Study Found that MDs Don’t Follow Fatigue-Care Guidelines
In another study published in the January 2013 journal Supportive Care in Cancer, Mayo Clinic researchers found that only 15% of colorectal cancer patients with moderate to severe fatigue recalled received advice or treatment which would have followed evidence-based guidelines for cancer-related fatigue.
Researchers surveyed 160 patients having stage IV breast, lung, prostate or colorectal cancer who reported moderate to severe fatigue. NCCN “cancer-related fatigue” guidelines list four treatment categories if fatigue continues despite control of associated conditions (e.g. pain, nausea, vomiting, diarrhea, anemia). The telephone interviewer asked patients if they recalled receiving any counseling, instructions, or treatment from their oncology care team for:
- general fatigue-reducing strategies, e.g. saving energy for vital tasks;
- increased activity techniques, e.g. starting an exercise program, seeing a physical therapist;
- psychosocial strategies such as relaxation and sleep techniques, or cognitive therapy;
- medication (either stimulants or sleep-inducers).
Even the 40% of study participants reporting severe fatigue rarely received fatigue-related counseling, instructions, or prescriptions were rarely provided.
Among all stage IV cancer participants, about 37% received prescriptions (almost all for sleep-inducing drugs), but activity-enhancement and psychosocial approaches having the strongest scientific evidence for effectiveness were the least likely to be prescribed.
Different cancers, different treatment
Significantly more patients with breast cancer (47.5%) recalled mention or receipt of psychosocial interventions, compared to 25% of patients with prostate cancer; 17.5% having lung cancer; and just 15% of colorectal cancer patients.
Although this study only covered patients in one site, the authors wrote, it was done at a “resource-rich” cancer specialty center rather than a community setting where 85% of patients receive cancer treatment.
That, they wrote, indicates that cancer-related fatigue, like cancer pain, is seriously under-treated throughout the U.S.
Take-Away for Patients:
(1) Cancer-related fatigue is real, and if untreated, can interfere with treatment, recovery, quality of life–especially in the frail and elderly;
(2) Treating related symptoms (nausea, pain, anxiety, sleep disturbance) can greatly ease fatigue; and
(3) Like those symptoms, significant fatigue can often be improved through careful monitoring and guideline-based treatment.
- “Fatigue-Busting Programs Work Even in Advanced Cancer,” Medscape. Jan 04, 2013;
- “Systematic Monitoring and Treatment of Physical Symptoms to Alleviate Fatigue in Patients With Advanced Cancer: A Randomized Controlled Trial,” Journal of Clinical Oncology published online Jan. 2, 2013 ;
- “Appropriateness of the treatment of fatigue in patients with stage IV cancer,” Support Care Cancer (2013) 21:229-233 ;
- NCCN Guidelines for Cancer-Related Fatigue