Commentary (Berger): Understanding and Treating Cancer-Related Fatigue

Management of cancer-related fatigue (fatigue) poses unique challenges to clinicians. The etiology of fatigue is poorly understood. Knowledge to date suggests that many factors can contribute to perceptions of fatigue. Attempts to correct identified related factors do not consistently relieve fatigue. In fact, pharmacological treatment for pain and depression may result in increased perceptions of fatigue. Translational research is needed to discover the etiology of fatigue in some of the most common cancer types and stages (ie, early breast cancer), to develop and test targeted and effective interventions, and to disseminate this knowledge.

Until knowledge regarding the etiology of fatigue is available, clinicians can use resources currently available. The National Comprehensive Cancer Network (NCCN) guidelines (www.nccn.org) recommend that fatigue be monitored on a routine basis in the clinical setting.[1] Despite the ease of using a 0-to-10 visual analog scale (VAS), routine assessment of fatigue is currently not a standard practice in oncology clinics. When opportunities to modify fatigue are missed, it can increase in severity and result in a need for more complex interventions. The adoption of routine assessment of fatigue, in addition to pain, must occur if fatigue is to be recognized and managed. The recommendation by Dr. Schwartz that patients with a 1-point increase in fatigue should be identified and receive some intervention is strongly supported by this reviewer.

Clinicians are encouraged to develop methods to record and track fatigue scores from each clinical visit. As suggested by Dr. Schwartz, the formal screening needs to include a review of symptoms (eg, pain, distress, sleep disturbances, anemia), an evaluation of disease status (eg, cancer, thyroid function), and a review of all current medications (prescription, over-the-counter, herbal). If sedating medications are being used, consideration of switching to less-sedating medications is highly recommended. If this is not possible, interventions to increase daytime alertness through pharmacologic and nonpharmacologic therapies may be appropriate. Clinicians are encouraged to use the ICD (International Classification of Diseases)-10 criteria to diagnose fatigue and a VAS for follow-up evaluation and treatment planning.[2]

The availability of Evidence-Based Practice (EBP) guidelines has provided clinicians with current information regarding recommended interventions. Dr. Schwartz provided information about the NCCN fatigue guidelines. It is important for clinicians to be aware of all NCCN supportive care guidelines, particularly those developed for pain and distress. The Oncology Nursing Society has developed EBP guidelines, referred to as ONS-PEP, that are available online and as pocket-sized cards that provide clinicians with interventions that are "Recommendations for Practice" for many symptoms, including fatigue (www.ons.org/outcomes).[3] Exercise has been recommended to relieve fatigue, and needs to be considered when planning treatment for most patients with this symptom.[4] The American Pain Society, the American Academy of Sleep Medicine, the American Society of Clinical Oncology, and Cochrane Reviews are additional recommended online resources to access current EBP guidelines.

Current knowledge needs to be moved to action in clinical oncology settings. Understanding of the methods by which to most effectively and efficiently translate knowledge into practice is a current and critical need in nursing.[5] Predicting research utilization among nurses has been evaluated, taking into account the influence at individual nurse, specialty, and hospital levels. The individual nurse level was found to be more influential than the specialty or hospital levels, and predicted by more time spent on the internet and lower levels of emotional exhaustion.[6] As Dr. Schwartz has suggested, nurses are in an ideal position to take a leadership role in assessing and managing fatigue. This reviewer challenges nurses to get involved in creating a clinical environment that promotes their emotional well-being and routine use of EBP guidelines in patients' fatigue-management plans.

References:

1. National Comprehensive Cancer Network: Practice guidelines. Cancer-related fatigue panel 2007 Guidelines, version 3.2007, August 2007. Rockledge, Pennsylvania. Available at: http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf. Accessed September 9, 2007.

2. Van Belle S, Paridaens R, Evers G, et al: Comparison of proposed diagnostic criteria with FACT-F and VAS for cancer-related fatigue: Proposal for use as a screening tool. Support Care Cancer 13(4): 246-254, 2005.

3. Oncology Nursing Society: Putting evidence into practice: Fatigue. Available at: http://www.ons.org/outcomes/volume1/fatigue.shtml. Accessed September 9, 2007.

4. Mitchell S, Beck S, Hood L, et al: Putting evidence into practice: Evidence-based interventions for fatigue during and following cancer and its treatment. Clin J Oncol Nurs 11(1):99-113, 2007.

5. Estabrooks C: Prologue: A program of research in knowledge translation. Nurs Res 56(4 suppl):S4-S6, 2007.

6. Estabrooks C, Midodzi W, Cummings G, et al: Predicting research use in nursing organizations: A multilevel analysis. Nurs Res 56(4 suppl):S7-S23, 2007.