Head-to-Toe Review May Find Reversible Cause of Fatigue in Ca Patient

n NEW YORK--Roughly 70% of cancer patients complain of fatigueat some point in their illness, and a search for reversible causesand multiple etiologies of such fatigue should be a part of standardpractice, Ronald Blum, MD, said at a a symposium on fatigue incancer sponsored by Cancer Care, Inc.

Dr. Blum, deputy director, Kaplan Comprehensive Cancer Center,New York University Medical Center, suggested a thorough assessmentas the first step when patients report fatigue.

When taking the history, "we can probe with the word fatigueor a synonym. What has been the change in fatigue over time? Isit getting better? Get a global assessment, like the KarnofskyPerformance Scale," he said. A review of medications, manyof which have fatigue as a side effect, is also important.

Dr. Blum suggests reviewing systems to gauge the cause of fatigue."I tell patients I'm going to start at your head and workto your toes. I'm usually overwhelmed by the information I pickup that patients have forgotten to tell me."

Headache-related fatigue in a cancer patient could be a sign ofbrain metasta-ses. "I saw a patient whose presenting symptomwas tiredness. He wasn't sleeping because of recurring headaches.It turned out to be a brain mass," he said.

Often people with metastatic brain disease will have very subtleneurologic signs, including depression, confusion, and lethargy,but the main symptom these patients have is generally fatigue,he said.

Shortness of breath may indicate cardiopulmonary problems. "Peoplemay have pulmonary metastases or pneumonia," he said. Oneof his patients whose presenting symptom was fatigue turned outto have an intercardiac sarcoma that was obstructing flow intohis lungs.

Patients with myocardial infarcts or irregular heartbeats as aresult of their cancer or other ongoing heart disease may presentwith fatigue, he said. Pericardial involvement should also beconsidered.

Gastrointestinal issues related to fatigue include poor appetite,nausea and vomiting, and diarrhea. "Certainly people whohave weight loss, intentional or unintentional, will be tired.People who are starving are tired," Dr. Blum said. "Obviously,nutrition is an important intervention. We need to find out ifpatients are taking enough calories to support their metabolicneeds."

Metabolic causes of fatigue are very common, hypercalcemia inparticular, he said. Fundamentally, hypercalcemia is due to increasedmobilization of calcium, which occurs either because of bone destructionin metastatic disease or increased secretion of parathormone,which drives calcium out of the bone.

"Patients have an increased osmotic load so they have tourinate more. They have to drink more, and what you commonly seeare patients who have a tremendous thirst as if they were diabetic.You might pick up on the fact that they're getting up at nightto urinate. They're tired because they're not sleeping, and itall begins to fit together."

Uremia-induced Fatigue

Similarly, uremia-induced fatigue in cancer patients can stemfrom a variety of causes, Dr. Blum said, including a decreasein blood flow to the kidneys leading to an inability to secretemetabolic products, a kidney tumor, or use of nephrotoxic drugs.

From a psychosocial point of view the disruption of sleep alsohas a big impact, and long-acting narcotics that allow the patientto sleep through the night will mean much to the patient and hisor her caregiver, Dr. Blum commented.

Chronic anemia is another important cause of fatigue in cancerpatients. Arguing that anemia is not an absolute level of hematocritor hemoglobin but, rather, a manifestation of total body functioning,Dr. Blum advised physicians to look for a number of signs--pulse,particularly after exertion, orthostasis, hypovolemia, and overallimpaired function.

The treatment alternatives for chronic anemia include transfusions."But as soon as you recommend that, patients say no. I'mafraid of getting AIDS and hepatitis."

However, transfusion is a safe way to replete the red blood cellvolume, he said. The incidence of side effects associated withtransfusions is about one in five, and often these are relativelymild fever and chills that can be dealt with prophylacticallywith acetaminophen or Bena-dryl. Occasionally. patients get arash because of minor incompatibilities in white cells. Viralexposure is rare, he said.

Recombinant erythropoietin represents a newer treatment alternativefor chronic anemia, Dr. Blum said, "If you put together allthe clinical trials, it's clear that on average about half thepeople who get recombinant erythropoietin have a response."Hematocrit levels go up in patients who respond, and quality oflife is improved, specifically energy level and ability to carryout daily activities.