Guest Commentary by Dr. Andrea Barsevick
Fatigue: Is it Normal or Pathological? And How Can We Best Treat It?
Despite years of scientific study of cancer-related fatigue (CRF), questions related to its definition, measurement, underlying mechanisms, and effective interventions remain unanswered. Yet, the high prevalence of CRF and its negative effects on quality-of-life outcomes, including work and family functioning, make it a critical problem for cancer patients and survivors. Clearly, more research is needed to reduce morbidity associated with this symptom.
To address this, on April 13 and 14, NCI’s Symptom Management and Health-related Quality of Life Steering Committee will convene a closed-attendance state-of-the-science meeting on CRF, which I will chair. During this meeting, we will summarize the science, address gaps in knowledge that require further study, and develop a focused agenda for future research.
The steering committee is a group of scientists, clinicians, and patient advocates who have been working together since 2007 to evaluate the scientific quality of proposed trials testing symptom and quality-of-life interventions. This group also convenes periodic state-of-the-science meetings to address critical questions that could improve the evaluation and prioritization of NCI-supported clinical trials.
Why is CRF such a difficult symptom to understand? Why have we been unable to develop effective therapies to prevent or treat it? Part of the answer may lie in the fact that, unlike many other symptoms, fatigue can be caused by both disease and treatment. Also, in everyday life, people without cancer experience fatigue. As a result, the line between fatigue as a normal occurrence and fatigue as a pathological symptom is blurred.
There has been progress, however, in our understanding of this subjective phenomenon. Diagnostic criteria for CRF have been proposed for further evaluation, and new measurement methods have been developed. Recently, researchers have started to examine the underlying biology of this symptom from a mechanistic perspective, which will be necessary for those who go on to develop new therapies to treat it.
Nurses have provided important leadership in these areas of research. Dr. Christine Miaskowski and her team at the University of California, San Francisco, for example, have contributed to our understanding of the biology of CRF. Dr. Barbara Piper at the University of Arizona has been a pioneer in fatigue measurement. And Dr. Debra Barton of the Mayo Clinic determined that a nutritional supplement (American ginseng) was effective in reducing CRF. In my own lab at Fox Chase, we have found that a behavioral intervention (energy conservation and activity management) also reduces CRF. These researchers and several others will be contributing to our state-of-the-science discussion to determine how we can build on our current knowledge base and deliver the greatest benefit for cancer patients.
With the progress that has been made and the significant challenges that remain, the NCI steering committee members and I decided to focus our efforts by bringing together experts in the behavioral and biological aspects of CRF and in research design and methods to develop new hypotheses and methods for the study of CRF. The recommendations that result from our meeting will be published, presented at scientific meetings, and distributed to government agencies and foundations that fund symptom research. Critical issues that arise during the proceedings may become the subject of additional publications.
Perhaps the best way to appreciate the urgent need to better understand and treat CRF is from the perspective of cancer patients and survivors who have experienced it. In discussing CRF, invariably they talk about their inability to get out of the house, work, cook meals and do dishes, get up the stairs to go to bed, or do half the things they did before. It is for these reasons that scientists need to fill the gaps in our knowledge of CRF.
Dr. Andrea Barsevick
Associate Professor and Director of Nursing Research
Fox Chase Cancer Center