Background
Fatigue is an extremely common problem amongst palliative care patients and causes significant distress, but our understanding of its natural history and causes is still evolving. [1] A systematic review of symptoms in patients with advanced cancer indicated that over half of the patients studied experienced fatigue. [2] It is likely that the presence and intensity of symptoms increases as the disease progresses. The negative impact on quality of life of patients and their caregivers is substantial. [1] The prevalence of fatigue is likely to be similar in patients with other progressive chronic diseases, including HIV-AIDS, heart disease, chronic obstructive pulmonary disease, and renal disease. [3] Guidelines for the management of cancer related fatigue are developing, [4] although few studies have included patients with fatigue associated with advanced disease.
Fatigue: the palliative context
- Advanced cancer
- End stage chronic disease
- HIV-AIDS
Important contributing factors
- Anaemia
- Cachexia and nutritional deficiencies
- Dyspnoea
- Hypothyroidism, hypogonadism, adrenal insufficiency
- Metabolic disorders
- Reduced activity and deconditioning
- Pain
- Depression or emotional distress
- Insomnia
- Chemotherapy and radiotherapy
- Adverse effects of medications
Key messages
Fatigue is common, distressing and is often inadequately assessed.[5]
Simple self-report scales should be used to routinely assess fatigue. [5]
Regular assessment, attention to reversible factors, and multidisciplinary approaches to treating fatigue are essential. [4]
There is some evidence to support the effectiveness of psychosocial interventions for cancer related fatigue. Interventions that were identified as effective include stress management and counselling. [4] However, these studies did not relate to patients with advanced disease, and active interventions may not be as feasible in a palliative care population.
Active research areas / controversies
Cancer related fatigue has been identified as an important symptom for research. Issues being studied include mechanisms and causes, prevalence patterns and outcomes of cancer related fatigue, and the social and economic impact on both patients and caregivers. There appears to be an overlap between fatigue and problems of psychological distress, reduced functional ability and pain; the causal links between these problems have not yet been clarified. [1] These overlaps can present difficulties in diagnosis and assessment. Careful assessment is needed to ensure appropriate diagnosis of fatigue and depression.
Previous recommendations that supported the use of erythyropoiesis stimulating agents (ESAs) such as epoetin alfa or darbepoetin alfa, to treat fatigue related to anaemia have been reviewed because of safety concerns. ESAs are no longer thought to be safe for use in advanced cancer except during the treatment period while the patient is receiving chemotherapy or radiotherapy. They have been associated with decreased survival, and more rapid disease progression. [6]
Cochrane systematic reviews are underway to assess drug therapies for fatigue in both cancer and palliative care, [7, 8] and the role of exercise in cancer related fatigue. [9] Medications that have been used for treating fatigue include psychostimulants (such as methylphenidate and modafinil), steroids, megestrol acetate and antidepressants. None of these medications are currently licensed for this indication in Australia.
What is known
Fatigue is a multidimensional problem that causes a combination of physical, emotional and cognitive difficulties. [5]
Implications for practice
- Fatigue should be recognised as a major problem for palliative care patients, and is often under reported. It should therefore be routinely asked about. Fatigue is one of the symptoms screened for by the Symptom Assessment Scale in the PCOC dataset, which is routinely used by many palliative care services in Australia. Other more detailed assessment tools are also available. [10]
- Validated assessment tools are available for adolescents. Younger children can be asked if they are 'tired or not tired'. [4]
- A multidisciplinary approach allows clinicians to identify and manage the full range of issues for patients with fatigue. Strategies [4] may include :
- Activity enhancement / exercise
- Energy conservation and provision of aids and equipment
- Nutritional assessment and support
- Psychosocial support
- Distraction and concentration techniques
- Addressing sleeping problems.
- There is little evidence from placebo control studies to guide pharmacological management of fatigue. Treatment of depression with antidepressants has not so far been shown to improve fatigue in randomised control trials. Glucocorticoids and psychostimulants have been used empirically, and some evidence is available to support this, but their side effect profile should also be considered. [11] Whilst haematopoiesis stimulating agents (epoetin alfa and darbepoetin alfa) improved fatigue in some studies, recent safety concerns suggest they should now only be offered to patients having active cancer treatment. [5]
- Research on management of this symptom has mainly studied cancer related fatigue and HIV / AIDS. There is little specific evidence regarding the management of fatigue in other advanced non-malignant conditions.
Finding out more
Guidelines
Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.
Overview articles
Related CareSearch pages
References
- Curt, G., et al., Impact of cancer-related fatigue on the lives of patients: New findings from the Fatigue Coalition. The Oncologist, 2000. 5: p. 353-360.
- Teunissen, S.C., et al., Symptom prevalence in patients with incurable cancer: a systematic review. Journal of Pain & Symptom Management, 2007. 34(1): p. 94-104.
- Solano, J.P., B. Gomes, and I. Higginson, A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonarry disease, and renal disease. Journal of Pain and Symptom Management, 2006. 31(1): p. 58-699.
- NCCN. Cancer-Related Fatigue. NCCN Clinical Practice Guidelines in Oncology 2007 09/28/07 [cited 2008 January 9]; v.4.2007 [Available: www.nccn.org]
- NIH, Symptom management in cancer: pain, depression and fatigue: State-of-the-Science Conference Statement. Journal of Pain & Palliative Care Pharmacotherapy, 2003. 17(1): p. 77-97.
- NCCN. Cancer - and Treatment-related Anemia. NCCN Clinical Practice Guidelines in Oncology 2008 12./17/07 [cited 2008 January 9]; v.1.2008 [Available: http://www.nccn.org/]
- Radbruch, L., et al., Drugs for the treatment of fatigue in palliative care (protocol). Cochrane Database of Systematic Reviews, 2007. Issue 4(Art no CD 006788).
- Minton O, Stone P, Richardson A, Sharpe M, Hotopf M.Drug therapy for the management of cancer related fatigue.Cochrane Database Syst Rev. 2008 Jan 23;(1):CD006704,
- Cramp F, Daniel J.Exercise for the management of cancer-related fatigue in adults.Cochrane Database Syst Rev. 2008 Apr 16;(2):CD006145.
- Jacobsen, P.B., Assessment of fatigue in cancer patients. Journal of the National Cancer Institute, 2004. Monographs (32): p. 93-7.
- Carroll, J., et al., Pharmacologic treatment of cancer-related fatigue. The Oncologist, 2007. 12(S1): p. 43-51.
This page was created on 4 April 2008 and will be reviewed in April 2010
Last updated 27 October 2008