Dr Nicola Harker provides 10 top tips on the assessment and management of cancer-related fatigue in primary care
Read this article to learn more about:
- the physical and psychosocial impact of fatigue on people with cancer
- the causes of fatigue and how to investigate
- what can be done to manage fatigue.
Cancer-related fatigue (CRF) is a disabling and distressing symptom, and is highly prevalent across a wide range of cancer types.1 It can manifest at any time from before the diagnosis of cancer, beyond treatment completion, to end of life.2
Tackling CRF is difficult for GPs, not least because of the brief consultation time with patients; it is hard to fully explore the fatigue in just 10 minutes. It is also challenging because CRF may be:
- an indicator of returning cancer
- a side-effect of ongoing cancer treatment
- a consequence of cancer treatment even after active treatment has ended.
Patients who were asked about their unmet needs following cancer treatment have expressed the opinion that GPs are not experts in cancer, or may be too busy to deal with long-term cancer-related problems—perhaps some GPs might share this view.3
Evidence for best practice in fatigue management is scarce and patient support services are patchy, leaving many patients unclear what to do about their fatigue symptoms.4
Some healthcare professionals might question why it is necessary to explore further, particularly for cases where it appears that fatigue is ‘just a consequence of treatment’. Is this about patients being stuck in a ‘sick role’, or being afraid to get back to normal life? Is there much I can do as a GP to help them sort out their fatigue?
This article explores what GPs need to consider when assessing such patients, and what specifically can be done. It may be worth sharing this information with practice nurses, so that a whole-team approach can be taken to assessing and managing fatigue.
1 Know the meaning of ‘fatigue’
Fatigue is not just tiredness. It is an overwhelming lack of energy, which can affect both physical and cognitive functioning.1 Cancer-related fatigue can be defined as a persistent, subjective sense of tiredness related to cancer and cancer treatment that interferes with usual functioning, and which is not relieved by rest or sleep.5,6
Fatigue has a significant impact on quality of life, and where fatigue leads to inactivity, it becomes part of a downward spiral: physical deconditioning, delayed return to work or inability to cope at work, and loss of social roles. Fatigue may also compound low mood or depression/anxiety.1
2 Recognise the symptoms
A patient with CRF may present with:7
- low mood
- loss of interest or enjoyment
The patient may not volunteer information readily, but their fatigue may be causing financial problems, difficulties returning to work, or relationship issues. Recognising that any of these presentations may be due to CRF is important, and asking specifically about fatigue is an essential part of a cancer review.
3 Take a detailed history
A detailed history should be taken for patients with fatigue. Be sure to cover:2
- the presence, intensity, and pervasiveness of the fatigue
- its course over time
- the factors that exacerbate or relieve it.
- the patient’s personality
- if the current fatigue is uncharacteristic of the patient’s reaction to illness other than cancer
- their disease and treatment history.
Specifically ask about symptoms that are suggestive of recurrence: for example, in a person with prostate cancer, check for symptoms of bone pain such as backache, or in someone with breast cancer, ask specifically about breathlessness, bone pain, headaches, or new abdominal symptoms. Showing the patient that their symptoms are being taken seriously may help to facilitate discussion and allow for a more comprehensive history, as well as being psychologically beneficial.8 The patient may be wishing to talk about disease progression, prognosis, fear of recurrence, or other issues such as traumatic experiences of treatment or body image difficulties.
Showing the patient that their symptoms are being taken seriously may help to facilitate discussion …
4 Evaluate the impact of fatigue
Try to understand how the fatigue is affecting the patient. Is it more of an issue for them, or their relatives/employer? How does fatigue impact on their life? Try to understand the context of their concerns. Are they trying to return to a stressful or demanding job? Are they a carer for an older relative or children? How is their employer reacting and do they know their employment rights? It is important to find out what the patient’s main concerns are—are they about physical or cognitive limitations, or does the patient worry that fatigue may indicate disease progression (or death)?
5 Consider the possible causes
The aetiology of CRF is complex and multidimensional, encompassing a vast array of possible contributing factors.5 Consider the following causes:2,9,10
- endocrine changes (e.g. in pancreatic cancer) or obstructed breathing (e.g. in lung cancer)
- depression, anxiety, or just unresolved emotions (sadness, frustration, irritability)
- sleep difficulties
- nutrition issues
- an unrelated medical problem (e.g. thyroid, diabetes, autoimmune disorders).
Consider contacting the patient’s oncology team for advice if CRF due to treatment is suspected, particularly if there is ongoing treatment such as hormone treatment for breast or prostate cancer.
Treatments such as cranial radiotherapy or total body irradiation can cause endocrine consequences even several years later, for example, pituitary or thyroid problems; if you suspect this, your patient will need specialist endocrinology advice.11
6 Investigate where appropriate
The role of investigations is to identify specific treatable causes of CRF, and contributing factors. Most fatigue is multifactorial, and investigations must be targeted to those appropriate for the patient’s cancer type.
Record the patient’s weight and consider conducting other investigations as appropriate (see Table 1).
7 Review medications
Try to identify any medications that the patient is taking (including ones that are over-the-counter) that may be aggravating the fatigue; these include opioid analgesics, sedative-hypnotic agents, benzodiazepines, and anxiolytics. There may be frequent use of codeine-based medications, or medications for insomnia—it is worth noting that although insomnia may contribute to fatigue, it is not clear from the evidence that using pharmacological treatments to improve sleep actually reduces fatigue.13
8 Managing fatigue
Where there is an established underlying cause, appropriate treatment should be instigated, for example, dietetic advice, treatment of anaemia, or referral back to oncology for treatment of disease recurrence. Fatigue is usually multifactorial, so fatigue management plans need to be tailored to the individual and are usually multidimensional.2
Where there is an established underlying cause, appropriate treatment should be instigated …
It should be noted that trials for pharmaceutical interventions for CRF have had limited success. There is no evidence of benefit from methylphenidate for mild to moderate fatigue, although there is some evidence of possible benefit with severe fatigue in advanced disease; however, the benefits of medication should be weighed against potential side-effects (anxiety, anorexia, nausea, and insomnia). There is no evidence of benefit from dexamphetamine, but further trials are looking at whether modafinil may be beneficial in severe fatigue. Modafanil shows no benefit in mild to moderate fatigue.13
A 2012 Cochrane review examined the evidence for physical exercise in the management of CRF in adults.14 Aerobic exercise was found to significantly reduce CRF during and after cancer treatment (the strongest evidence was for solid tumours). The physical activities studied were aerobic walking and aerobic cycling. Although no optimal exercise regimen has been identified, the review recommends that cancer survivors should gradually build up to 30 minutes of moderate-intensity physical activity five times per week. In patients with CRF this might require building up activity very gradually, and it is noted that any amount of exercise is beneficial compared with no exercise.14
There may be local walking groups, for example, Walking for Health. Consider asking the patient to keep a diary of their physical exercise, as they may be ‘overdoing it’ and then ‘paying for it’ later.
In addition to physical exercise, psychosocial therapeutic interventions have strong evidence to support their use. Discussing the patient’s fears, checking their expectations for recovery, and helping them with realistic goal-setting are useful interventions. Providing access to counselling or clinical behavioural therapy where available, or to cancer support groups, may also be beneficial.5
Encouraging the patient to focus on small, achievable goals, with realistic expectations (i.e. recovery may be slow and there may be setbacks), can allow the patient and their family to see positive improvements and keep motivated. Be honest with the patient—there are no quick fixes, but recovery is possible.
9 Explore the patient’s social network and support
Is the patient struggling with work because of financial concerns? Have they stopped seeing their friends? Ask the patient if there is anything they could try that would help them feel less isolated, or more supported, or could rekindle interests (such as gentle gardening, or art/music).
It may be useful to signpost the patient to Macmillan’s financial support tool, which is designed to help patients with some financial decisions that they may face after being diagnosed with cancer. Macmillan Information Services (found within many hospital trusts) employ Citizen’s Advice Bureau advisors who can provide advice and support to patients and their families
Another helpful resource is The Macmillan Coping with fatigue (tiredness) booklet15, which can help patients find ways of handling their fatigue.
10 When to refer
Where your assessment of the CRF leads to concerns about disease recurrence or the need for further investigations (such as in possible heart failure, consequences of chemotherapy, or co-existing pathology such as auto-immune or endocrine diseases) then referral to specialist teams is indicated.
Referring the patient to psychosocial services may be appropriate if these are available locally. Some patients feel that their life completely changes when faced with cancer, and may benefit from counselling to adjust to their new life ‘with and beyond cancer’. Showing a willingness to ask about this and to have difficult but important conversations is a significant part of helping patients to recover.
- Hofman M, Ryan J, Figueroa-Moseley C et al. Cancer-related fatigue: the scale of the problem. Oncologist 2007; 12 (Suppl 1): 4–10.
- Mitchell S. Cancer-related fatigue: state of the science. PM R 2010; 2 (5): 364–383.
- Lewis R, Neal R, Hendry M et al. Patients’ and healthcare professionals’ views of cancer follow-up: systematic review. Br J Gen Pract 2009; 59 (564): e248–e259.
- Mitchell S, Berger A. Cancer-related fatigue: the evidence base for assessment and management. Cancer J 2006; 12 (5): 374–387.
- Mustian K, Morrow G, Carroll J et al. Integrative nonpharmacologic behavioral interventions for the management of cancer-related fatigue. Oncologist 2007; 12 (Suppl 1): 52–67.
- Mock V, Atkinson A, Barsevick A et al. NCCN practice guidelines for cancer-related fatigue. Oncology (Williston Park) 2000; 14: 151–161.
- Cancer Research UK. Symptoms of fatigue. Cancer Research UK, 2016. www.cancerresearchuk.org/about-cancer/coping/physically/fatigue/symptoms (accessed 9 August 2017).
- Armes J, Crowe M, Colbourne L et al. Patients’ supportive care needs beyond the end of cancer treatment: a prospective, longitudinal survey. J Clin Oncol 2009; 27 (36): 6172–6179.
- Piper B, Borneman T, Sun V et al. Cancer-related fatigue: role of oncology nurses in translating National Comprehensive Cancer Network assessment guidelines into practice. Clin J Oncol Nurs 2008; 12 (5 Suppl): 37–47.
- Cancer Research UK. Causes of fatigue. Cancer Research UK, 2016. www.cancerresearchuk.org/about-cancer/coping/physically/fatigue/causes (accessed 8 August 2017).
- Macmillan Cancer Support. Throwing light on the consequences of cancer and its treatment. Macmillan Cancer Support, 2013. Available at: www.macmillan.org.uk/documents/aboutus/research/researchandevaluationreports/throwinglightontheconsequencesofcanceranditstreatment.pdf
- Han S, Huang Y, Li Z. The prognostic role of preoperative serum albumin levels in glioblastoma patients. BMC Cancer 2015; 15: 108.
- Pachman D, Barton D, Swetz K, Loprinzi C. Troublesome symptoms in cancer survivors: fatigue insomnia, neuropathy, and pain. JClin Oncol 2012; 30 (30) 3687–3696.
- Cramp F and Byron-Daniel J. Exercise for the management of cancer related fatigue in adults. Cochrane Database Syst Rev 2012: 11: CD006145.
- Macmillan Cancer Support. Coping with fatigue. Macmillan Cancer Support, 2015. Available at: be.macmillan.org.uk/Downloads/CancerInformation/LivingWithAndAfterCancer/MAC11664CopingwithfatigueE6reprintlowrespdf20150723.pdf