Cancer-Related Fatigue

What is cancer-related fatigue?

Fatigue is the feeling of exhaustion, being completely worn out, unable to concentrate, feeling "heavy", and more tired than you have ever felt. Cancer-related fatigue (CRF) is caused by cancer and its treatments. Patients with CRF describe feeling physically, mentally, and emotionally drained.

This fatigue impacts a person's quality of life. Many patients see this as part of their treatment and don't ask for help from their healthcare providers. Many healthcare providers suggest rest, but research has found it is not very helpful.

Fatigue is one of the most common symptoms of cancer patients. Studies show that between 26 to 90 out of 100 patients have fatigue during their treatment. The reason for this large range is that the definition of fatigue is the extent and type of tumor, and the type of treatment is different in each study. Also, fatigue may not be the same for every person.

When does CRF often get better?

Fatigue can get better and sometimes worse during the cancer diagnosis and treatment. Patients getting chemotherapy often have a peak in fatigue 4-5 days after treatment, or when blood counts are low (nadir). For patients getting radiation, fatigue tends to peak at the end of treatment and it gets better 1-3 months after therapy. Many patients report fatigue for months or years after therapy, even if their cancer is in remission.

What causes CRF?

There are medical and psychosocial reasons that can cause or increase fatigue. If you have one of these conditions, it should be treated. Some medical conditions that cause fatigue are:

• Anemia which is a low red blood cell count.
• Pain.
• Infection.
• Cardiac (heart) or pulmonary (lung) disease.
• Side effects of medication.
• Thyroid disorders.
• Nutritional deficiency.
• Renal (kidney) failure.

Psychosocial conditions that can cause fatigue are:

• Lack of family, friends, and community social support.
• Poor coping skills.
• Anxiety.
• Depression.
• Sleep problems like a lack of sleep or disrupted sleep patterns.

There are many ideas about why cancer patients have fatigue.

Cytokines are proteins that are let go by cells and are messengers for the immune system. These proteins help your immune system work by doing things like managing inflammation, immune function, and making blood cells. Researchers have found that cancer causes your body to release more of certain cytokines. The levels of these cytokines are higher in people with CRF, suggesting they could be a cause. Some cancers cause people to have higher "resting energy consumption." This means they burn more calories at rest than someone without cancer and need more energy to do daily activities. People with CRF have also been found to make less of certain hormones. There is probably not one single cause, but rather many things that contribute to CRF.

How can you reduce or prevent fatigue?

There are only two ways to reduce or prevent fatigue: treatment of anemia and exercise. It is hard to know how to reduce or prevent CRF since it is not well understood. We will discuss some other ways to manage fatigue that have been shown to be helpful.

Treating Anemia

Anemia means you have less red blood cells (RBCs) than you usually do. Some symptoms are shortness of breath or trouble breathing with exertion (physical effort) and fatigue. Most cancer treatments kill cells that grow at a fast rate. RBCs grow at a fast rate so are often affected. Anemia can cause fatigue. Treating anemia can help with fatigue.

There are many ways to treat anemia. Your provider may tell you to take over-the-counter iron pills daily or may order blood transfusions. They may also recommend B12 or folic acid supplements.

Your provider may order injections of a "growth factor", which can be used to stimulate the growth of red blood cells. By increasing how many red blood cells your body is making, this growth factor may lower your risk of becoming anemic, and may also lower the number of blood transfusions you may need.

Growth factors are given by injection. You may get the injections from the oncology nurse, or you and/or a family member may be taught how to give them at home. Once your red blood cell count is back to a normal level, the injections will be stopped.

Your provider may delay treatments until your red blood cell count has gone back to normal levels. In most studies, treating anemia led to less fatigue and a better quality of life.

Exercise

If your muscles are weak, you may need to use more energy and effort to do a task. Exercise has been studied as a preventive measure for fatigue and has been shown to work best when started before fatigue sets in. Exercise can help reduce fatigue from cancer and treatment.

 Exercise leads to a better mood, more energy, feeling more rested, and a better ability to concentrate. Light exercises, such as taking a walk, doing simple arm exercises, marching in place, non-strenuous swimming, or pedaling on a stationary bike are all forms of exercise that help. It may be helpful to ask someone to walk with you. A walk to a nice park or garden may help you relax and take your mind off your worries.

Most exercise study participants started before or during cancer therapy in an effort to prevent fatigue. It can be much harder to start a program once fatigue has set in, but it is not impossible. Start off slow and keep going if you are able.

Make your healthcare team aware of your exercise plan before starting. Your providers may suggest cancer rehab which could include physical therapy to help you get moving. Certain exercises may not be recommended, especially for those with bone metastases, low blood counts, or other health conditions. Do whatever form of exercise you enjoy. The important thing is that you do some activity. You will feel much better once you get started.

Saving Your Energy

Rest is often suggested to treat CRF but it often does not help. One way rest can help is through energy conservation (saving your energy) and activity planning. This means planning and saving your energy for when you want or need it most. For example, if your son is playing in a soccer game this afternoon that you really want to go to, take it easy in the morning and conserve energy for the afternoon. Remember that you may not have the energy to stay for an entire game, so if you want to be there until the end, go a little late.

Another way to conserve energy is to ask for help. Ask a friend to clean the house for you, prepare a meal for your family, drive the school carpool, or just sit and talk. These may seem like simple tasks, but they can be very helpful if you have CRF.

Sleep problems and not getting enough sleep can add to or cause fatigue. Keep a normal sleep schedule and talk to your provider about options if you are having trouble sleeping at night. Avoid caffeine later in the day so you will be more likely to sleep at night. Avoid naps or limit them to 20-30 minutes and not too late in the day. See our article on insomnia for more tips.

Integrative Therapies

Mind-body interventions have been studied in the treatment of fatigue. Acupuncture, healing touch, hypnosis, massage, yoga, guided imagery, and relaxation have been found to be helpful. Managing stress can also help you manage fatigue. You may join a support group with other patients or connect with a peer through peer mentoring programs.

Medications

Medications called psychostimulants have been studied to help treat fatigue. Some small trials have found an increase in energy with the use of these medications, but they were not all tested in cancer patients. These medications include methylphenidate (Ritalin), dexmethylphenidate (Focalin), and modafinil (Provigil). Modafinil is a medication used to treat narcolepsy. In cancer patients, it was found to help those with severe fatigue, but not mild or moderate levels of fatigue. There are side effects to these medications such as loss of appetite, sleep problems, dizziness, headache, and nausea. Overall, studies have shown that CRF is best treated with other types of treatments and not medications. But, if other treatments are not helping, your healthcare team may suggest medications.

Depression and anxiety can make fatigue worse. Studies show that treatment with anti-depressants was helpful in patients with clinical depression to help manage their fatigue. It is normal to feel sadness after a diagnosis of cancer, but this does not always lead to depression. In fact, studies have found that only 25 to 30 out of 100 cancer patients meet the criteria for a diagnosis of depression.

Corticosteroids, such as dexamethasone and prednisone, have been studied and may help in the short-term for some patients. There are side effects of long-term steroid use so they should only be used for a short amount of time.

Clinical Trials and Specialists

You should talk to your healthcare team if you are having fatigue and explain how it is affecting your quality of life. Your provider can suggest treatments and interventions to help with fatigue. Ask about clinical trials studying fatigue. Some centers have fatigue clinics that deal with this symptom. Find available trials using the OncoLink Clinical Trials Matching System.

Resources for More Information

Managing Fatigue: Here you will find a list of helpful tips about fatigue and cancer-related anemia. You will find information that explains what fatigue is, why it happens, how it is treated, and what you can do to prevent yourself from developing it.