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Commentary: Cancer Related Fatigue

Fatigue2by Doris Howell, RN, PhD 

Read the article in the Current Oncology Journal:

A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue

Cancer-related fatigue (CRF) is a universal side effect of most cancer treatments, particularly chemotherapy, radiotherapy, or immune therapies. 1-3 About a third of post-treatment survivors, will also experience persistent or chronic fatigue for years. 4-6 Fatigue is described by patients as one of the most distressing symptoms of cancer as it interferes with daily living, affects cognitive functioning, work performance, and negatively impacts quality of life (QoL).7-10 CRF has also been described as the most under-acknowledged and under-treated cancer symptom.11 It is often cited that there is no effective medical treatment for fatigue since its etiology is not yet fully explained.12 This is often reinforced in health care communication to patients and can lead to under-reporting of CRF as patients assume it is untreatable and must be tolerated.13 Yet, our review of the evidence in the pan-Canadian practice guideline for assessment and management of fatiguetargeted to health care practitioners shows there are effective interventions that can improve the patients’ subjective experience of fatigue.14 Moreover, emerging research suggests that many of these interventions (i.e. exercise) may also play a role in altering the biological mechanisms that are hypothesized to cause CRF and its persistence long after treatment ends.15,16 More recent reviews provide further compelling evidence of the efficacy of interventions, particularly activity or exercise-based interventions, on reducing fatigue.17,18 In spite of this evidence, patients may still not be receiving the best advice to manage fatigue.19

In our national stakeholder review to obtain input regarding the evidence-based recommendations in the pan-Canadian fatigue guideline, it became evident that practitioners agreed with the evidence but reported that it was unlikely the recommendations would be applied in practice and identified implementation issues such as time constraints due to ambulatory cancer care delivery. Thus, in this commentary, some of the practical approaches that can be used by health care practitioners and/or cancer programs to facilitate use of the recommendations in routine practice are highlighted. In addition, the often forgotten side of the health care equation, namely the patients’ role in managing symptoms, and considerations for activating patients in self-management of CRF are described.


Application of the Evidence in Routine Oncology Practice:

A number of strategies may be useful for facilitating the application of the “evidence-based” recommendations in the fatigue guideline in routine practice as follows: (1) routine screening for and assessment of fatigue can be implemented using electronic platforms for self-report using valid screening (case-finding) tools or patient-reported outcome measures for a more comprehensive assessment of fatigue.20 This makes fatigue visible to practitioners and it is difficult to ignore this data when it shows that fatigue is a moderate or severe problem for the patient. Linking actions taken and electronic health record documentation by practitioners in response to screening data makes it difficult to not treat fatigue. The algorithm can be used to establish standard order sets for ruling out medical problems that can contribute to fatigue i.e. anemia. The algorithm can easily be turned into an assessment or management strategy checklist or documentation tool and could be used for quality audit of practice for monitoring the quality of fatigue care and reported back to teams as part of an audit and feedback strategy or for case review; (2) non-pharmacological interventions such as enhanced physical activity or exercise can be implemented in a number of ways including: (a) linking patients to community peer support programs, which often have exercise specialists and individualized and group programs available. Some programs have established partnerships with the YMCA or Curves to develop programs tailored to cancer patients. In addition, exercise programs are now emerging as part of enhanced survivorship programs that integrate a cancer rehabilitation focus; (b) educating patients about exercise as an effective intervention and ensuring access to an exercise specialist who can provide a graded program tailored to the patient and disease characteristics is key. Patients are often unaware that exercise can actually improve fatigue and may worry that is unsafe to exercise during cancer treatment. Psychological interventions such as Cognitive-Behavioral Therapy or psycho-education interventions are also effective in reducing fatigue21 and are becoming increasingly accessible as on-line interventions22 and practitionerscan be trained to incorporate these approaches even in short, episodic care practices.23,24 Patients identify the need for a list of reliable resources endorsed by their health care team; and (3) cancer organizations can ensure the guidelines are accessible to clinicians but must recognize that passive dissemination of guidelines or didactic education for facilitating guideline uptake is rarely effective.25 For instance, Cancer Care Ontario has developed pocket cards for easy access to guideline recommendations and “APPs” for quick reference to guideline recommendations to support clinical decision-making ( Effective approaches for facilitating implementation of guidelines have also been summarized in a recent publication26 and in the “Screening for Distress, the 6th vital sign: a guide to implementing best practices in person-centered care” in the section on guideline implementation (see

Finally, it must be recognized that ultimately it is the patient who must assume responsibility for the management of fatigue and practitioners may need training in patient-centered communication approaches27 or in the use of practical health coaching techniques that can support patient self-management.28, 29


Patient Activation for the Self-Management of CRF:

Patients report that advice given for the management of fatigue is unhelpful or counterproductive (i.e. take more frequent rests) exacerbating fatigue.19 While we included “patient education” in the guideline as a standard of supportive care for all patients experiencing it, it must be recognized that traditional patient education that involves dissemination of information and knowledge is less effective than education that is oriented towards the patients’ adoption of self-management behaviors for the management of fatigue.30 There is emerging evidence that self-management interventions that target uptake of behaviors and increase self-efficacy based on social cognitive theories are effective for reducing CRF.31 However, misinterpretation of “self-management” in education programs is common and many programs do not attend to the core skills essential to the adoption of behaviors.32 Self-management is defined as, the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition.33 Health care professionals may also lack the necessary skills and knowledge to facilitate patient adoption of self-management behaviors.34 The booklet, “Manage cancer related fatigue: For people affected by cancer” developed by the Canadian Partnership Against Cancer may be a starting point for providing standardized patient education on fatigue and for focusing attention on the patients role in the self-management of fatigue. However, fatigue-based health coaching may be needed to facilitate patient adoption of essential behaviors for self-management of fatigue. Self-management programs that target core self-management skills to manage cancer symptoms including fatigue such as the “Cancer Thriving and Surviving” program based on the Stanford chronic disease self-management program model may be particularly effective and available for organizations to offer in partnership in the future.

Exercise and Physical Activity as Treatment for Cancer Related Fatigue






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dorishowellDr. Doris Howell RN, PhD is the RBC Chair, Oncology Nursing Research and Education, University Health Network (UHN) (Princess Margaret Hospital), Toronto, ON & Associate Professor, Lawrence Bloomberg Faculty of Nursing with cross-appointments in the Department of Health Policy, Management & Evaluation & Dalla Lana School of Public Health. She also holds an Adjunct Appointment at the Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON.

Dr. Howell is also a Senior Scientist in the Ontario Cancer Institute, Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital and is the Co-Director of the Ontario Symptom Management and Toxicity Applied Cancer Research Unit, Ontario Cancer Research Institute/Cancer Care Ontario. She has an Affiliate Appointment at the ELLICSR: Health, Wellness & Cancer Survivorship Centre at UHN.



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One Response to Commentary: Cancer Related Fatigue

  1. Ken Martin says:

    We can exercise before and during treatment, even when we don’t feel like it. In fact, I felt the best throughout treatment while on the treadmill because it increased my treatment related low blood pressure. Getting patients to wrap their head around this is key, it is counter intuitive, and in the old days patients were told to take it easy, the same in cardiology. Oncology needs to catch up to cardiology regarding exercise. I exercised not because I felt like it throughout treatment but because I saw it as medicine and as a part of my treatment, and not as something optional or to empower me, although it did that too.

    Mt Everest and cancer?

    Does there need to be a paradigm shift in how exercise is used in oncology? I was reviewing my blood work after my recent stem cell transplant (April 16th) and noticed that my hemoglobin and red blood cells had dropped 47% from my normal health last fall to their lowest values two weeks after my transplant. I then checked what altitude a 50% drop in the partial pressure of oxygen would correspond to. A 50% drop in oxygen represents an altitude of over 19,000 feet. Mt. Everest south base camp is 16,700 feet. I spoke with an altitude and exercise expert to confirm my comparison. He suggested that in many ways a chemotherapy related drop in hemoglobin would be more difficult than the physical challenge of a drop in the partial pressure of oxygen at high altitude. No wonder many cancer patients have a difficult time with some chemotherapies, even more so the sedentary.

    Furthermore, if one is to factor in cachexia (muscle wasting common with cancer), a decrease activity level due to cancer related fatigue, and hospital bed rest, then by the time some patients’ hemoglobin drops below 8.0 their cardiovascular fitness has already been significantly impacted. Half this lowered capacity further with some chemotherapies and you have some patients in their fitness training zone (if not maxed out) just walking across a room. This can begin the downward spiral of ongoing cancer treatment related fatigue.

    It would be irresponsible to send someone to Mt. Everest base camp without training them first, but it is common practice in oncology to physically challenge patients in a similar manner without training them for the difficulty to come. Instead, we nurse patients through the treatment challenge, cheer when they are finished, then send them off to physical therapy to address the injuries. This is not a success story, rather, this is poor survivorship care planning. The emphasis on post-treatment survivorship care plans in oncology is like having someone train for Mt. Everest after they return from climbing it – clearly, some of the training must occur before the ordeal.

    There often is time between cancer diagnosis and first treatment to implement a survivorship care plan that includes exercise. One might even go farther back, possibly to the first encounter with a primary care physician because of symptoms or perhaps to the first biopsy. Additionally, patients frequently seek second opinions, get an additional whole node biopsy, consult with another specialist, and weigh treatment options before finally having their first treatment scheduled. All of this can take weeks. Is this enough time for an exercise intervention to significantly effect treatment outcomes – including Response Rates, or at least to maintain fitness and avoid detraining? If the focus in oncology remains on post-treatment rehabilitation then we may never know, and patients will continue to struggle more than they may have to through treatments that may be more demanding than we currently realize.

    If patients are willing to have their bodies ravaged by surgery, radiation, and chemotherapy, all of which can decrease physical function, then it shouldn’t be too much to do 30 minutes of physical activity a day – how ever one wants to carve that time up as a part of cancer treatment plans or at least as a part of survivorship care planning. Like the improvements in outcomes that pediatric oncology experienced due to changes in dosing and treatment schedules, with better planning prior to first treatment maybe exercise can improve cancer treatments and reduce treatment side effects, including cancer related fatigue, which appears to be more debilitating than we thought.

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