Cancer-related fatigue (also referred to as CRF) refers to tiredness or exhaustion you may face as a result of cancer or cancer treatments. This type of fatigue impacts you physically, emotionally, and mentally, and it is not necessarily tied to physical activity or exertion. It is also not necessarily alleviated by rest. Cancer-related fatigue is one of the most common complaints amongst cancer patients.

How Common is Cancer-Related Fatigue?

Cancer-related fatigue can be life altering; it will affect up to 70-80% of those who undergo chemotherapy or radiation therapy, as well as those with metastatic cancer. Many survivors also face CRF long after treatment is complete.

What Causes CRF and What Are Associated Conditions?

While cancer or cancer treatments may result in fatigue, associated conditions can cause it, too. These may include:

• Pain 
• Anemia
• Nausea, vomiting and diarrhea
• Inactivity
• Poor nutrition
• Weight loss
• Certain medications and treatment (as well as treatment combinations)
• Mental health disorders (depression and anxiety are two leading causes of fatigue)
• Trouble sleeping 

What Does CRF Feel Like?

Most patients say cancer-related fatigue feels similar to everyday fatigue. This looks different for each patient, which can be a struggle when it comes to treating and reporting, but it may present itself as: 

• Chronic tiredness
• Low energy
• Sleepiness
• Inability to carry out daily activities without getting exhausted or worn down
• Poor memory 
• Struggle to concentrate

How Do You Treat and Manage CRF?

Although cancer-related fatigue in cancer patients has been under-reported, under-diagnosed, and under-treated, physicians and researchers have been studying ways to treat CRF and establishing scales, definitions, standards of care, and treatment guidelines to address it. 

NCCN Guidelines for Fatigue

More than a decade ago, the National Comprehensive Cancer Institute (NCCN) convened an expert panel to review cancer-related fatigue and recommend treatment guidelines. Several other organizations followed suit and also established guidelines, including the Oncology Nursing Society (ONS), American Society of Clinical Oncology (ASCO), among others.

According to the American Cancer Society’s article on CRF, NCCN’s “guidelines for fatigue and survivorship remain the most frequently updated and widely circulated” when it comes to screening, evaluating, and managing fatigue for cancer patients.

The guidelines include practical ways to reduce the fatigue and suggestions for monitoring and treating associated conditions that may be contributing to it.

Read NCCN’s information about managing fatigue.

Read NCCN’s guidelines for cancer-related fatigue (for medical professionals; login required)

Hurdles to Treating CRF 

Although evidence-based guidelines are available, and cancer patients can find significant relief if they’re followed, it has been a struggle to get the guidelines implemented. Even at excellent cancer centers, most patients do not get any of the recommended treatments for fatigue. This is due to many reasons, and especially since fatigue symptoms can be subjective.

What is the Research on CRF?

There have been several studies performed to understand cancer-related fatigue and find ways to identify, manage and treat it. 

Dutch Randomized Controlled Trial of Cancer-Related Fatigue

One of the first randomized-controlled studies of cancer-related fatigue, “Systematic Monitoring and Treatment of Physical Symptoms to Alleviate Fatigue in Patients With Advanced Cancer: A Randomized Controlled Trial,” was published in the Jan. 2, 2013 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 significant 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, and lack of appetite, rather than fatigue itself. Systematic monitoring of symptoms seemed to be the key in this and other studies, the researchers reported.

2013 Mayo Study Finds CRC Patients Under-Treated for CRF

A study published in the January 2013 issue of Supportive Care in Cancer titled, “Appropriateness of the treatment of fatigued patients with stage IV cancer,” explained how Mayo Clinic researchers found only 15% of colorectal cancer patients with moderate to severe fatigue said they recalled receiving advice or treatment which would have followed evidence-based guidelines for cancer-related fatigue.

Four Treatment Categories of 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, and 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 or seeing a physical therapist)
• psychosocial strategies (e.g. relaxation and sleep techniques or cognitive therapy)
• medication (e.g. stimulants or sleep-inducers)

Even the 40% of study participants reporting severe fatigue rarely received fatigue-related counseling, instructions, or prescriptions.

CRC Patients: Least Likely to Receive Interventions

Among all stage IV cancer participants in the study, about 37% received prescriptions (almost all for sleep-inducing drugs). But activity-enhancement and psychosocial approaches, which carry the strongest scientific evidence for effectiveness, were the least likely to be prescribed.

Significantly, more patients with breast cancer (47.5%) recalled mention or receipt of psychosocial interventions compared to patients with prostate cancer (25%), lung cancer (17.5%), and colorectal cancer (15%). 

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.

Tips for Patients Facing Cancer-Related Fatigue

Cancer-related fatigue is real and if untreated, can interfere with treatment, recovery, and quality of life. This is especially true for older patients. Treating related symptoms (nausea, pain, anxiety, and sleep disturbance) can greatly ease fatigue. Like those symptoms, significant fatigue can often be improved through careful monitoring and guideline-based treatments.

If your doctor hasn’t asked about fatigue or offered symptom management, bring it up! There are guidelines available to help you.

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