Coping with Fatigue related to Cancer and Chemotherapy

Coping with Pain related to Cancer and Chemotherapy

It's More Than Just Being Tired! Cancer fatigue can be debilitating and affect all aspects of a person's life. But there are ways to cope with and even treat it.

Extreme fatigue-the seemingly bone-crushing exhaustion that makes it difficult to brush your teeth, cook a hamburger or climb the stairs-is one of the most common complaints of people with cancer. Unlike acute fatigue, in which tiredness comes on quickly, lasts a short time, and is relieved by rest, cancer fatigue is a prolonged, debilitating fatigue that is persistent or recurring.

The Statistics: Studies show that fatigue exists in 78% to 96% of people with cancer, particularly in people actively undergoing treatment. One study of 687 post-treatment survivors of various forms of cancer, in which patients reported that fatigue was one of the three most negative items affecting quality of life, found that this condition can linger for months or even years after the initial treatment.

A 1998 national survey of 379 chemotherapy patients revealed that cancer fatigue had a profound impact on their relationships with family, friends, bosses, and work colleagues. Activities of daily living, work performance, and overall sense of well-being were also seriously compromised. In some cases, financial resources became limited because of an impaired ability to function at work (the survey found that 28% of the respondents were forced to stop working altogether, and 75% of those who were able to work needed to make adjustments in their work schedules or habits).

Cancer fatigue can also take an emotional toll, as the chaos of getting diagnosed, exploring treatment options, and undergoing medical procedures can begin to feel physically, mentally and emotionally exhausting. Clearly, cancer-related fatigue exacerbates the already difficult experience of learning to cope with a life-altering illness.

What Causes It: Although the exact physiologic, biochemical and psychologic causes of cancer fatigue are poorly understood, the National Cancer Institute lists a number of contributing factors:

• Cancer therapies: Fatigue commonly occurs when a patient undergoes surgery, chemotherapy, radiation treatment, and biologic response modifier therapy, such as Interferon. Treatment with Interferon causes fatigue as part of a group of side effects known as "flu-like" syndrome, which also includes fever, chills, muscle pain, headache and a general sense of not feeling well. Tumor necrosis factor (TNF), a toxic substance produced by a tumor, may cause a decrease in protein stores in the muscles, thereby causing the body to work harder to carry out normal functions. Physical responses to the treatment itself, such as nausea and vomiting, also appear to contribute to fatigue.

• Anemia - Anemia related to the disease process itself or to therapy can cause fatigue.

• Poor nutrition - Reduced appetite, reduced food intake and nausea and vomiting can all occur and contribute to fatigue.

• Psychologic and cognitive factors - Anxiety, depression, stress, mental fogginess and decreased attention span can compound the physical causes of fatigue.

• Medications - Medications other than chemotherapy drugs, including opioid painkillers, beta-blockers and neuroleptics, can cause sedation and increase fatigue.

• Breathing impairment - Difficulty breathing, which is particularly present in people with advanced disease and/or lung cancer, also contributes to fatigue.

Assessment of Cancer Fatigue: Formed in 1996, The Fatigue Coalition is a multidisciplinary group comprising medical practitioners, researchers and patient advocates from some of the top cancer hospitals. The coalition has worked diligently to assure that health care providers address the issue of cancer fatigue, whether their patients bring it up during regularly scheduled visits or not.

A number of instruments are available to help clinicians assess cancer-related fatigue including: 

• the Piper Fatigue Self-Report Scale

• the Schwartz Cancer Fatigue Scale

• Lee's Visual Analogue Scale for Fatigue. 

A comprehensive assessment, which includes a physical examination and psychiatric evaluation to screen for depression and/or anxiety, looks at a number of factors, such as:

• Fatigue pattern: onset, duration, intensity, and alleviating and aggravating factors 

• Treatment history: treatment-related symptoms or side affects, and current medications 

• Sleep and/or rest patterns 

• Nutrition status 

• Psychosocial profile, including financial resources, ability to work, and availability of supportive family, friends or caretakers.

The International Classification of Disease (ICD), 10th revision, lists a number of criteria that can be used to determine the presence of cancer-related fatigue, including a patient's complaints of generalized weakness and limb heaviness, perceived need to struggle to overcome inactivity, sleep problems, and diminished concentration, attention, and memory.

The ICD-10 criteria state that a diagnosis of cancer-related fatigue can be made if: (1) "significant fatigue, diminished energy, or an increased need to rest (disproportionate to any recent change in activity level) are present" and (2) the presence of these symptoms must cause "clinically significant distress or impairment in social, occupational or other important areas of functioning."

Coping with Cancer Fatigue 

According to the Center for Fatigue in Medical Illness, a joint project of the department of Pain Medicine and Palliative Care and the Cancer Center at Beth Israel Medical Center, Continuum Health Partners, Inc. in New York City, the treatment of cancer fatigue includes identifying and managing the underlying cause and using a variety of interventions that may include medication, patient/family education, exercise, sleep hygiene, stress management and nutrition.

• Treating anemia - Anemia, a major factor in cancer-related fatigue, can be treated by blood transfusion therapy, as well as by the administration of erythropoietin alfa, a synthetic hormone that stimulates the bone marrow to increase its production of red blood cells.

• Medications - Some oncology clinicians have found that low doses of psychostimulant drugs, such as Dexedrine, Ritalin and Cylert, are useful for cancer patients experiencing decreased energy, apathy, poor concentration and weakness, although there are few published trials proving the effectiveness of these drugs for this purpose. These medications, which appear to decrease fatigue, increase appetite and promote a sense of well-being, also counteract the sedating effects of painkillers such as morphine. Corticosteroids such as dexamethasone or prednisone may also be given, although long-term steroid therapy is usually reserved for patients with advanced disease.

• Exercise - Numerous studies have suggested that aerobic exercise, including light-to-moderate intensity walking programs, can be useful in minimizing or improving the symptoms of cancer-related fatigue, especially during the time that patients are undergoing chemotherapy or radiation treatments. Exercise programs must be tailored to the individual according to age, gender, and physical and medical condition, and frequent rest periods are recommended. A daily diary can identify specific activities that increase fatigue, or particular times of the day when fatigue is more pronounced, allowing the patient to utilize energy conservation measures such as alternating strenuous pursuits with more sedentary ones.

• Diet - A healthful diet containing plenty of fruits, vegetables, and iron-rich foods can help maintain energy levels. Adequate fluid intake is important in preventing dehydration and hypotension, which tends to intensify feelings of fatigue.

• Stress management - Other basic self-help skills include the use of stress management techniques (relaxation, deep breathing, meditation), which can be useful in reducing anxiety, enhancing coping skills and increasing energy levels. It's also important to learn to ask for help when you need it and to educate yourself about the nature and treatment of fatigue symptoms

Chemotherapy drugs can cause some side effects that are painful. The drugs can damage nerves, leading to burning, numbness, tingling, or shooting pain, most often in the fingers or toes. Some drugs can also cause mouth sores, headaches, muscle pains, and stomach pains.

Not everyone with cancer or who receives chemotherapy experiences pain from the disease or its treatment. But if you do, it can be relieved. The first step is to talk with your doctor, nurse, or pharmacist about your pain. They need to know as many details about your pain as possible. You may want to describe your pain to your family and friends. They can help you talk to your caregivers about your pain, especially if you are too tired or in too much pain to talk to them yourself.

You need to tell your doctor, nurse, or pharmacist and family or friends:

• Where you feel pain What it feels like-sharp, dull, throbbing, steady 

• How strong the pain feels 

• How long it lasts 

• What eases the pain, what makes the pain worse 

• What medicines you are taking for the pain and how much relief you get from them

Using a pain scale is helpful in describing how much pain you are feeling. Try to assign a number from 0 to 10 to your pain level. If you have no pain, use a 0. As the numbers get higher, this means that your pain is getting worse. A 10 means the pain is as bad as it can be. You may wish to use your own pain scale using numbers from 0 to 5 or even 0 to 100. Be sure to let others know what pain scale you are using and use the same scale each time, for example, "My pain is 7 on a scale of 0 to 10."

Preventing and treating pain: The goal of pain control is to prevent pain that can be prevented, and treat the pain that can't. To do this:

If you have persistent or chronic pain, take your pain medicine on a regular schedule (by the clock). Do not skip doses of your scheduled pain medicine. If you wait to take pain medicine until you feel pain, it is harder to control. Try using relaxation exercises in addition to taking medicine for the pain. This may help to lessen tension, reduce anxiety, and manage pain. Some people with chronic or persistent pain that is usually controlled by medicine can have breakthrough pain. This occurs when moderate to severe pain "breaks through" or is felt for a short time. If you experience this pain, use a short-acting medicine ordered by your doctor. Don't wait for the pain to get worse. If you do, it may be harder to control.

There are many different medicines and methods available to control cancer pain. You should expect your doctor to seek all the information and resources necessary to make you as comfortable as possible. If you are in pain and your doctor has no further suggestions, ask to see a pain specialist or have your doctor consult with a pain specialist. A pain specialist may be an oncologist, anesthesiologist, neurologist, neurosurgeon, other doctor, nurse, or pharmacist. (National Cancer Institute)