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Cancer-Related Fatigue: Risk Factors and Assessment

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Background

The National Comprehensive Cancer Network (NCCN) defines cancer-related fatigue (CRF) as “a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”1

Compared with fatigue reported by healthy people, CRF is described as more distressing, as interfering with usual functioning, and as less likely to be relieved by rest. Most importantly, if left untreated, CRF is a major factor in patient quality of life scores.

Although reported by 60% to 100% of patients undergoing therapy for CRC, fatigue is still considered an underreported symptom for which there are multiple overlapping etiologies, confounding an explanation of its specific pathophysiologic mechanisms.2

 

Possible Causes of CRFRule

CRF has a complex etiology, possibly regulated by physiologic, psychologic, and situational factors2:

  • Changes in the production and balance of muscle proteins, glucose, electrolytes, and hormones3
  • A catabolic process resulting from decreased daily energy expenditure and bed rest4
  • Disease and treatment-induced anemia

Distinguishing between fatigue and depression is an important aspect of fatigue evaluation

  • Risk factors for CRF include2-7
    • Poor nutrition
    • Sleep disorders
    • Stress
    • Comorbidities: cardiac, pulmonary, renal, liver, neurologic, thyroid, and endocrine, and associated medications
    • Hypoxia
    • Pain
    • Infection
    • Deconditioning
    • Ongoing therapy

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Approaches to Minimizing CRF

  • Identify and manage causative factors
  • Conserve energy
  • Balance activity and rest
  • Correct anemia

CRF can be one of the most difficult and frustrating symptoms to treat. Apart from treating anemia, offering energy conservation tips, and treating depression related to CRF, little has been available to assist patients through this distressing experience. Although CRF is prevalent, it is often not discussed with the patient.3

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Questions to Assess Impact of CRF on Quality of Life

Because fatigue is believed to be multifactoral and is experienced physically, emotionally, and spiritually, nurses must first focus their assessment of the impact of CRF on quality of life by asking some simple questions6:

  • Are you experiencing any fatigue?
  • If yes, how severe has it been on a scale of 0 to 10 (10 being the highest) during an average day?
  • How is the fatigue interfering with your ability to function?

Additional questions may elicit whether the fatigue worsens at certain times of the day or occurs during certain days of the chemotherapy regimen.

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Tests for Comorbidities

Comorbidities, such as anemia or hypothyroidism, may contribute to CRF, although no tests are specific for the condition. However, the results of tests for causative factors may be helpful:

  • Tests for anemia
  • Tests for other causative factors
    • Endocrine
      • Thyroid function studies
      • Folic acid
      • Vitamin B12
    • Pulmonary function studies
    • Liver function studies
    • Electrolytes
    • Renal
      • Blood urea nitrogen
      • Creatinine clearance
      • Glomerular filtration rate (GFR)

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Assessment Tools

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NCI Common Toxicity Criteria, Version 2, for Fatigue8
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
None
Increased fatigue over baseline, but not altering normal activities
Moderate (eg, decrease in performance status by 1 ECOG level or 20% Karnofsky or Lansky) or difficulty performing some activities
Severe (eg, decrease in performance status by 2 ECOG levels or 40% Karnofsky or Lansky) or loss of ability to perform some activities
Bedridden or disabling

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Fatigue Assessment Survey9-10
0
1,2,3
4,5,6
7,8,9
10
Energetic,
not tired
Mild
Moderate
Extreme
Total exhaustion

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NCCN Guidelines: Cancer-Related Fatigue1,7
0
1–3
4–6
7–9
10
No fatigue
Mild
Moderate*
Severe*
Worse fatigue imagined*
Instruction about fatigue and ways to manage it
Primary evaluation based on history and assessment of factors contributing to fatigue
 
Patient History
Disease state and treatment and current medications;
System assessment;
Fatigue assessment
Contributing Treatable Factors (use interventions for active treatment, long-term follow-up, or end-of-life)
Pain (NCCN guideline); Emotional distress (NCCN guideline); Sleep; Anemia (NCCN guideline); Nutrition; Activity (deconditioning) level; Comorbidities (system review)

*Progressive decrease in physical functioning from 4–9. Score is based on patient's description.
ECOG = Eastern Cooperative Oncology Group; NCCN = National Comprehensive Cancer Network;
NCI = National Cancer Institute;

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Clinical Practice Guidelines for Fatigue and Anemia:

National Comprehensive Cancer Network (NCCN)

http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf.
http://www.nccn.org/professionals/physician_gls/PDF/anemia.pdf.

Oncology Nursing Society (ONS)

A new resource called Putting Evidence into Practice (PEP) is available through The Oncology Nursing Society (ONS). PEP information is available through the ONS Web site or on pocket cards for purchase. Clinical practice questions, suggested interventions and practice recommendations are based on a level of evidence. To learn more about evidence-based information for fatigue click here

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Patient Care Management Protocols or Algorithms

ONS Web site has a number of suggestions for nonpharmacologic management of CRF:

http://www.cancersymptoms.org/fatigue/suggested.shtml

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References

  1. National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology: cancer-related fatigue, v1.2006. Available at: http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf. Accessed December 18, 2006.
  2. Fu MR, McDaniel RW, Rhodes, VA. Fatigue. In: Yarbro CH, Frogge MH, Goodman M, Groenwald SL, eds. Cancer Nursing: Principles and Practice. 6th ed. Sudbury, Mass: Jones & Bartlett; 2005:741-760.
  3. Nail LM. Fatigue. In: Yarbro CH, Frogge MH, Goodman M, Groenwald SL, eds. Cancer Nursing: Principles and Practice. 4th ed. Sudbury, Mass: Jones & Bartlett; 1997:640-654.
  4. Winningham ML. The foundation of energetics: fatigue, fuel, and functioning. In: Winningham ML, Barton-Burke M, eds. Fatigue in Cancer. Sudbury, Mass: Jones & Bartlett; 2000.
  5. Madden J, Newton S. Why am I so tired all the time? Understanding cancer-related fatigue. Clin J Oncol Nurs. 2006;10:659-661.
  6. Portenoy RK, Itri LM. Cancer-related fatigue: guidelines for evaluation and management. Oncologist. 1999;4:1-10
  7. Mock V. Evidence-based treatment for cancer-related fatigue. J Natl Cancer Inst Monogr. 2004;32:112-118. [Pub Med]
  8. National Cancer Institute. Common toxicity critieria, version 2. Available at: http://www.fda.gov/cder/cancer/toxicityframe.htm. Accessed December 18, 2006
  9. Polovich M, White J, Kelleher L, eds. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. Pittsburgh, Pa: Oncology Nursing Society; 2005:140-144.
  10. Quick M, Fonteyn M. Development and implementation of a clinical survey for cancer-related fatigue assessment. Clin J Oncol Nurs. 2005;4:435-439. [Pub Med
  11. Mock V. Evidence-based treatment for cancer-related fatigue. J Natl Cancer Inst Monogr. 2004;32:112-118. [Pub Med]

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Key Definitions

Catabolic—destructive metabolism involving the release of energy and resulting in the breakdown of complex materials within the organism

Deconditioning—a loss of physical fitness

Etiologies—causing or contributing to the cause of a disease or condition

Ferritin—a crystalline iron-containing protein that functions in the storage of iron and is found especially in the liver and spleen

Hypoxia—a deficiency of oxygen reaching the tissues of the body

Total iron-binding capacity (TIBC)—a blood test that measures the total iron binding capacity (TIBC) as an indirect measure of transferrin

Transferrin—A plasma protein that transports iron through the blood to the liver, spleen and bone marrow. The blood transferrin level is tested for diverse reasons: to determine the cause of anemia, and to determine the iron-carrying capacity of the blood. Low transferrin can be due to: (1) poor production of transferrin by the liver, (2) excessive loss of transferrin through the kidneys into the urine and, (3) lead to anemia. Many conditions including inflammation, infection and malignancy can depress transferrin levels. Transferrin levels are abnormally high in iron deficiency anemia.

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This page was last modified on 3/1/2007, at 10:41:45 am ET.