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Fatigue (PDQ®)

  • Last Modified: 03/07/2014

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Overview

Fatigue is the most common side effect of cancer treatment with chemotherapy, radiation therapy, or selected biologic response modifiers.[1] Cancer treatment–related fatigue generally improves after therapy is completed, but some level of fatigue may persist for months or years following treatment. Research indicates that for at least a subset of patients, fatigue may be a significant issue long into survivorship.[2,3] Fatigue is also seen as a presenting symptom in cancers that produce problems such as anemia, endocrine changes, and respiratory obstruction and is common in people with advanced cancer who are not undergoing active cancer treatment. Cancer treatment–related fatigue is reported in 14% to 96% of patients undergoing cancer treatment [4-10] and in 19% to 82% of patients posttreatment.[1,2]

Several studies have documented significantly worse fatigue in cancer survivors compared with noncancer populations, as described in one review article.[1] For example, a Norwegian cross-sectional study [11] compared the prevalence of fatigue in long-term survivors of testicular cancer (n = 1,431) at an average of 11 years posttreatment with the prevalence of fatigue in age-matched men in the general Norwegian population (n = 1,080). The prevalence of chronic cancer-related fatigue (CRF) was 17.1% (95% confidence interval [CI], 15.2–19.1%) among testicular cancer survivors, compared with 9.7% (95% CI, 8.0–11.5%) in the general population. Chronic CRF was also associated with multiple psychosocial problems, somatic complaints, and poor quality of life.[11]

Fatigue, like pain, is viewed as a self-perceived state. Patients may describe fatigue as feeling:[12]

  • Tired.
  • Weak.
  • Exhausted.
  • Lazy.
  • Weary.
  • Worn-out.
  • Heavy.
  • Slow.
  • Like they do not have any energy or any get-up-and-go.

Health professionals have included fatigue within concepts such as:

  • Asthenia.
  • Lassitude.
  • Malaise.
  • Prostration.
  • Exercise intolerance.
  • Lack of energy.
  • Weakness.

Research on fatigue in people with cancer has included primarily self-reports of fatigue, with fewer but increasing data exploring biologic or physiologic correlates. Such correlates have included measures of muscle weakness, maximal oxygen uptake, cytokines, and cortisol.

Fatigue experienced as a side effect of cancer treatment is differentiated from fatigue experienced by healthy people in their daily lives. Healthy fatigue is frequently described as acute fatigue that is eventually relieved by sleep and rest; cancer treatment–related fatigue is categorized as chronic fatigue because it is present over a long period of time, interferes with functioning, and is not completely relieved by sleep and rest.[13] Also, the level of CRF is often disproportionate to the level of activity or energy exerted.[13] Although the label chronic fatigue is accurate, using this label does not mean that people with cancer who experience fatigue have chronic fatigue syndrome. Using the phrase chronic fatigue can be confusing to both patients and health professionals. Terms such as cancer fatigue, cancer-related fatigue, and cancer treatment–related fatigue have all been used in the clinical literature, research literature, and educational materials for patients and the public.

Fatigue has a negative impact on all areas of function, including the following:[14-17]

  • Mood.
  • Physical function.
  • Work performance.
  • Social interaction.
  • Family care.[18]
  • Cognitive performance.
  • School work.
  • Community activities.
  • Sense of self.

The pattern of fatigue associated with cancer treatment varies according to type and schedule of treatment. For example, people treated with cyclic chemotherapy regimens generally exhibit peak fatigue in the days following treatment, then report lower levels of fatigue until the next treatment; however, those undergoing external-beam radiation therapy report gradually increasing fatigue over the course of therapy of the largest treatment field. Few studies of people undergoing cancer treatment have addressed the issue of fatigue as a result of the emotional distress associated with undergoing a diagnostic evaluation for cancer and the effects of medical and surgical procedures used for that evaluation and for initial treatment. Because most adults enter the cancer care system following at least one surgical procedure and because surgery and emotional distress are both associated with fatigue, it is likely that most people beginning nonsurgical treatment are experiencing fatigue at the beginning of treatment.[19,20]

Recommendations for fatigue management focus on identifying factors that may be contributing to fatigue. Because the only definitive causal mechanism demonstrated through research to date is chemotherapy-induced anemia, most clinical recommendations for managing fatigue caused by something other than chemotherapy-induced anemia rely on careful development of clinical hypotheses, as outlined in the National Comprehensive Cancer Network guidelines on fatigue.[21] The only level 1 intervention for CRF at this time is exercise. (Refer to the Exercise section of this summary for more information.) Much more research is needed to better define fatigue and its trajectory, understand its physiology, and determine the best ways to prevent and treat it.

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.

References
  1. Prue G, Rankin J, Allen J, et al.: Cancer-related fatigue: A critical appraisal. Eur J Cancer 42 (7): 846-63, 2006.  [PUBMED Abstract]

  2. Bower JE, Ganz PA, Desmond KA, et al.: Fatigue in long-term breast carcinoma survivors: a longitudinal investigation. Cancer 106 (4): 751-8, 2006.  [PUBMED Abstract]

  3. Baker F, Denniston M, Smith T, et al.: Adult cancer survivors: how are they faring? Cancer 104 (11 Suppl): 2565-76, 2005.  [PUBMED Abstract]

  4. Fosså SD, Dahl AA, Loge JH: Fatigue, anxiety, and depression in long-term survivors of testicular cancer. J Clin Oncol 21 (7): 1249-54, 2003.  [PUBMED Abstract]

  5. Miaskowski C, Portenoy RK: Update on the assessment and management of cancer-related fatigue. Principles and Practice of Supportive Oncology Updates 1 (2): 1-10, 1998. 

  6. Irvine DM, Vincent L, Bubela N, et al.: A critical appraisal of the research literature investigating fatigue in the individual with cancer. Cancer Nurs 14 (4): 188-99, 1991.  [PUBMED Abstract]

  7. Vogelzang NJ, Breitbart W, Cella D, et al.: Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey. The Fatigue Coalition. Semin Hematol 34 (3 Suppl 2): 4-12, 1997.  [PUBMED Abstract]

  8. Detmar SB, Aaronson NK, Wever LD, et al.: How are you feeling? Who wants to know? Patients' and oncologists' preferences for discussing health-related quality-of-life issues. J Clin Oncol 18 (18): 3295-301, 2000.  [PUBMED Abstract]

  9. Costantini M, Mencaglia E, Giulio PD, et al.: Cancer patients as 'experts' in defining quality of life domains. A multicentre survey by the Italian Group for the Evaluation of Outcomes in Oncology (IGEO). Qual Life Res 9 (2): 151-9, 2000.  [PUBMED Abstract]

  10. Cella D, Lai JS, Chang CH, et al.: Fatigue in cancer patients compared with fatigue in the general United States population. Cancer 94 (2): 528-38, 2002.  [PUBMED Abstract]

  11. Orre IJ, Fosså SD, Murison R, et al.: Chronic cancer-related fatigue in long-term survivors of testicular cancer. J Psychosom Res 64 (4): 363-71, 2008.  [PUBMED Abstract]

  12. Barsevick AM, Whitmer K, Walker L: In their own words: using the common sense model to analyze patient descriptions of cancer-related fatigue. Oncol Nurs Forum 28 (9): 1363-9, 2001.  [PUBMED Abstract]

  13. Berger AM, Abernethy AP, Atkinson A, et al.: Cancer-related fatigue. J Natl Compr Canc Netw 8 (8): 904-31, 2010.  [PUBMED Abstract]

  14. Pickard-Holley S: Fatigue in cancer patients. A descriptive study. Cancer Nurs 14 (1): 13-9, 1991.  [PUBMED Abstract]

  15. Glaus A: Assessment of fatigue in cancer and non-cancer patients and in healthy individuals. Support Care Cancer 1 (6): 305-15, 1993.  [PUBMED Abstract]

  16. Given B, Given CW, McCorkle R, et al.: Pain and fatigue management: results of a nursing randomized clinical trial. Oncol Nurs Forum 29 (6): 949-56, 2002.  [PUBMED Abstract]

  17. Curt GA: The impact of fatigue on patients with cancer: overview of FATIGUE 1 and 2. Oncologist 5 (Suppl 2): 9-12, 2000.  [PUBMED Abstract]

  18. Passik SD, Kirsh KL: A pilot examination of the impact of cancer patients' fatigue on their spousal caregivers. Palliat Support Care 3 (4): 273-9, 2005.  [PUBMED Abstract]

  19. Ancoli-Israel S, Liu L, Marler MR, et al.: Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Support Care Cancer 14 (3): 201-9, 2006.  [PUBMED Abstract]

  20. Jacobsen PB, Hann DM, Azzarello LM, et al.: Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates. J Pain Symptom Manage 18 (4): 233-42, 1999.  [PUBMED Abstract]

  21. National Comprehensive Cancer Network.: NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 1.2014. Fort Washington, Pa: National Comprehensive Cancer Network, 2014. Available online. Last accessed March 7, 2014.