Treatment-Related Fatigue Widespread, But Undertreated, Seldom Discussed

BETHESDA, Maryland—Fatigue among cancer patients "is an important problem, and it’s a legitimate topic for clinical investigation," National Cancer Institute Clinical Director Gregory A. Curt, MD, told Oncology News International, lamenting, " I don’t think it’s high on the radar for the physicians."

This seems to be borne out by an accounting of the abstracts presented at the annual meeting of the American Society of Clinical Oncology. Of 3,127 abstracts, only 13 focused on cancer-related fatigue. Yet fatigue is the most prevalent side effect of chemotherapy, affecting more people and lasting longer than pain, nausea, and vomiting, according to a telephone survey of 379 cancer patients sponsored by The Fatigue Coalition.

Dr. Curt said that physicians and patients often don’t talk about cancer-related fatigue because they think nothing can be done about it. That’s not true, he countered, and physicians need to start considering options now that pain, nausea, and vomiting are yielding to treatment. Commenting on the survey, he remarked: "Most oncologists thought pain was more important than fatigue, but patients thought fatigue was more important than pain."

Survey Results

The survey was the second conducted by The Fatigue Coalition, a multidisciplinary group of practitioners, researchers, and patient advocates working to develop diagnosis and treatment guidelines. The first survey concluded that fatigue was undertreated and seldom discussed. Major findings of the new study are listed below.

76% of all cancer patients who responded experienced fatigue at least a few days each month during their most recent chemotherapy and 30% were fatigued every day.

91% of patients experiencing fatigue said it prevented a "normal" life and 85% changed their daily routine as a result.

75% of patients who held jobs said fatigue made them change their employment status in ways ranging from taking sick or vacation days to going on disability or quitting work.

65% of all patients who responded said that their fatigue caused a caregiver to take at least 1 day off work in a typical month.

One of the most surprising findings for Dr. Curt was that some patients complained of fatigue as long as 2 years after treatment. He said he does not know the cause.

While most patients (79%) discussed fatigue with their physicians, nearly half (45%) of the patients did not believe anything could be done about their fatigue and 40% said they received no recommendation in response. Among those who did receive recommendations, the most common suggestion was bed rest or relaxation (37%). Yet according to Dr. Curt, rest "is one of the worst things to do. You get deconditioned."

Other suggestions were diet or nutrition (11%), vitamins (7%), and prescription drugs (6%).

Range of Remedies

The problem of fatigue is complex, Dr. Curt acknowledged. Patients are tired because they are sick, and they are receiving strong therapies that can also cause fatigue. Yet fatigue can be addressed, he noted, citing the work of Russell K. Portenoy, MD, of Beth Israel Medical Center in New York City.

Physicians should first try to ascertain why the patient is fatigued, Dr. Curt said. The range of remedies now available includes light exercise, cutting out daytime naps, and creating a nighttime routine around a hot bath and warm milk to promote sound sleep at night. For some patients, treatment of anemia should be considered, Dr. Curt advised. If a patient is taking a narcotic for pain relief, the medication might be titrated to a lower dose or balanced with a stimulant, he said.

Although fatigue is still by and large neglected, Dr. Curt was optimistic that it will receive more attention as other chemotherapy side effects become less onerous. "We are in the same phase of treating cancer-related fatigue, as we were in treating nausea and vomiting 15 years ago and pain 10 years ago." he said "I remember when the first drugs that were really good at treating nausea and vomiting came out, oncologists were really worried that the chemotherapy wasn’t working because the patients weren’t getting sick. Sometimes we associate side effects of our drugs with the good effect of our drugs, but I think that both in pain research and nausea and vomiting research, we’ve shown that the two can be de-linked."

Future cancer patients will seek out oncologists who pay more attention to the patient’s needs, he predicted. Before that can happen, however, Dr. Curt said more research is needed. "Knowing what the most common causes of cancer related fatigue are and then knowing which of those respond best to specific interventions—we don’t have the foggiest notion about that now," he said.