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February 2018 VOL 9, NO 2
Managing Fatigue Associated with Advanced Cancer
The prevalence of fatigue is very high across the cancer continuum, with approximately 60% of advanced cancer patients experiencing this condition. Even for patients with curable cancer, however, fatigue can persist well into survivorship. According to Sandra A. Mitchell, PhD, AOCN, National Cancer Institute, fatigue has consequences for physical, vocational, cognitive, and social functioning and can affect treatment adherence and long-term survival outcomes as well. Nevertheless, there is a large body of evidence-based interventions that can improve fatigue outcomes. At the 2017 Palliative and Supportive Care in Oncology Symposium, Dr Mitchell discussed evaluation and management of fatigue during and following cancer treatment.
“Fatigue is multidimensional, and it’s experienced and reported differently by each individual, but its central features are loss of efficiency, mental fogginess, inertia, and nonrestorative sleep,” said Dr Mitchell, who noted that fatigue may occur as an isolated symptom or as one component within a cluster that includes pain, depression, and sleep disturbances. “It can be challenging to distinguish fatigue from depression, cognitive dysfunction, or asthenia, and personality and coping style may influence fatigue experiences.”
As Dr Mitchell reported, the National Comprehensive Cancer Network guideline recommends that every patient be screened for the presence of fatigue at regular intervals. Furthermore, if present, fatigue should be assessed quantitatively on a 0-to-10 scale, she said, with a severity of 4 or worse warranting expanded evaluation, including history and physical.
Evidence-Based Fatigue Management
Numerous trials have demonstrated robust and consistent evidence of efficacy for several interventions, said Dr Mitchell, but exercise, in particular, is likely to be effective. Patients experiencing fatigue should build to 150 minutes of weekly, moderate intensity activity (eg, brisk walking, bicycling, swimming, deep water walking/running) over at least 1 month and then add strength training to the regimen. She also suggested referral to an exercise physiologist, trainer, physiatrist, or physical therapist for specific and detailed recommendations about the type, intensity, and frequency of exercise.
“As functional capacity improves, the exercise program should advance,” said Dr Mitchell, who added that mobile health tools such as activity monitors and apps may strengthen motivation and adherence.
There is also strong evidence that yoga improves fatigue outcomes, said Dr Mitchell, particularly in survivors, although the evidence is “less compelling” for yoga while on treatment. In addition, progressive muscle relaxation has been shown to improve fatigue outcomes across a range of populations, including patients with advanced disease.
According to Dr Mitchell, although effect sizes may be small, there is also fairly consistent evidence that psychoeducational interventions improve fatigue outcomes. Psychoeducation for fatigue includes anticipatory guidance, energy conservation, coaching to enhance self-
efficacy, goal-setting, and emotional support.
Cognitive behavioral interventions for sleep have demonstrated beneficial effects across a wide range of patient populations as well. This multicomponent intervention includes relaxation, sleep consolidation, stimulus control, and reducing cognitive emotional arousal and can be effectively delivered individually, in groups, and via eHealth formats.
Furthermore, said Dr Mitchell, there is robust and consistent evidence that meditation and mindfulness-based stress reduction interventions improve fatigue, reduce
fatigue-related daytime interference, and favorably affect fatigue-related biomarkers. Systematic symptom monitoring with advanced practice nurse interventions and palliative care consultation has also been shown to reduce symptom burden and improve fatigue outcomes. Finally, cognitive behavioral therapy for fatigue, depression, and pain, with and without hypnosis, improved fatigue across a wide range of patient populations in several studies.
“The fatigue management plan should be individualized in accordance with patient goals, tolerance, and response to interventions,” said Dr Mitchell, who noted that, in individual circumstances, providers may also consider recommending massage, acupuncture, bright light therapy, or Tai Chi/Qigong.
“There is some preliminary evidence supporting these interventions, but providers need to evaluate effectiveness carefully,” she concluded.
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