“Cancer’s paint box includes many shades of fatigue.”
—Dana Jennings, a patient with prostate cancer who blogs for The New York Times
The shock of a cancer diagnosis. Countless appointments and tests. Sleepless nights filled with worry. The stress of making decisions about treatment. Pain. Sedative effects of medications and treatments. The disease itself. All of these things and more contribute to a widespread yet unpredictable symptom of cancer—fatigue.
Fatigue affects 80%-100% of patients with cancer during treatment and even for many years afterward (Lawrence, Kupelnick, Miller, Devine, & Lau, 2004). Because cancer-related fatigue can last for years after treatment, nurses in all settings are likely to encounter it in their patients. The symptom diminishes quality of life and prevents people from working, socializing, caring for their families, and focusing on their health and treatment. Yet fatigue is unpredictable, fluctuating according to Jennings, “week to week, day to day, even hour to hour.”
The National Comprehensive Cancer Network (2009, p. FT-1) defines cancer-related fatigue as “a distressing persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual function.”
Because cancer-related fatigue is so widespread, nurses in all settings should assess for the symptom and be aware of interventions and treatments that fight fatigue.
To promote nursing interventions that are backed by evidence, the Oncology Nursing Society (ONS) launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams of advanced practice nurses, staff nurses, and a nurse scientist reviewed the evidence in the literature to determine what treatments and interventions alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice (Gobel & Tipton, 2009). Rutledge and Grant (2002) defined evidence-based practice as “care that integrates best scientific evidence with clinical expertise, knowledge of pathophysiology, knowledge of psychosocial issues, and decision-making preferences of patients and families” (p. 1). The ONS PEP resources provide a synthesis of the scientific evidence component of evidence-based practice.
Recommended for practice
The ONS PEP team that studied fatigue found only one intervention that has strong enough evidence to be recommended for practice—exercise. Benefits have not always been consistent across studies, but a general pattern of results in controlled trials has shown that exercise can reduce fatigue in patients during and after treatment for cancer.
Walking, swimming, cycling, resistance exercise, and a combination of aerobic and resistance training were all found to reduce fatigue during and after cancer treatment. Studies used anywhere from twice weekly to twice daily exercise regimens. Generally, exercise performed several times per week benefitted patients with breast cancer, prostate cancer, or mixed solid tumors, as well as recipients of stem cell transplants.
The ONS PEP fatigue team noted that more research is needed to determine the types, intensity, frequency of exercise that are most effective, as well as degree of supervision needed. Research also is needed in terms of the safety and efficacy of aerobic exercise and strength training in various cancer subpopulations (Mitchell, Beck, & Eaton, 2009).
Likely to be effective
The National Comprehensive Cancer Network (NCCN, 2005) and other experts recommend that healthcare professionals screen patients with fatigue for treatable etiologies and then treat accordingly. For example, distressing symptoms such as pain, nausea, and depression, can contribute to fatigue, and effective methods are available to alleviate specific symptoms. Other etiologies for fatigue may include hypothyroidism, hypogonadism, cardiomyopathy, adrenal insufficiency, pulmonary dysfunction, anemia, sleep disturbance, fluid and electrolyte imbalances, emotional distress, and sedation effects of medications.
Also likely to be effective according to the ONS PEP team’s research are energy conservation and activity management. Healthcare professionals can coach patients to balance rest and activity by planning ahead, setting priorities for limited amounts of energy, and delegating when possible. Educating patients to optimize their sleep quality also is likely to be effective. For example, patients should avoid naps, caffeine, and stimulating activity late in the day; go to bed only when they are sleepy; limit time in bed to sleeping only; and set a consistent sleeping schedule and a bedtime routine.
According to small randomized studies, progressive muscle relaxation and relaxation breathing combined with yoga-like positioning may reduce fatigue. Massage therapy and healing touch (an energy therapy) also are likely to be effective, according to research found by the ONS PEP team.
Patients with cancer may try everything from sleeps aids to herbal medicines to art therapy to hypnosis. Although many such interventions are supported by limited evidence, exercise is backed by strong evidence as a way to fight fatigue, and many other options are likely to be effective.
Note. For more information about the ONS PEP program, including results for all 16 nursing-sensitive patient outcomes studied, visit www.ons.org/Research/PEP or refer to the new ONS book Putting Evidence Into Practice: Improving Oncology Patient Outcomes (Eaton and Tipton, 2009).
Keightley Amen is a staff editor on the Publishing Team at the Oncology Nursing Society.
Table: Tools you can use
Assessing Fatigue (Based on information from Mitchell et al., 2009)
Fatigue is subjective and should be evaluated from the patient’s perspective. Ask your patient about the following physical symptoms.
- General lack of energy
- Heart palpitations
- Shortness of breath
Also assess for the following risk factors and conditions that may contribute to fatigue.
- Adrenal insufficiency
- Depressed mood
- Emotional distress
- Fluid and electrolyte imbalances
- Pulmonary dysfunction
- Sedation from medications
- Sleep disturbances
The Oncology Nursing Society Putting Evidence Into Practice fatigue authors recommend the following tools to measure fatigue.
- Brief Fatigue Inventory (Mendoza et al., 1999)
- A numeric rating scale that asks the patient to rate his or her fatigue from 1-10
- The Revised Piper Fatigue Scale (Piper et al., 1998)
What interventions are effective in preventing and treating cancer-related fatigue? (Based on information from Mitchell et al., 2009)
Recommended for practice: exercise
Likely to be effective: screening for possible causes and managing as appropriate, energy conservation and activity management, education and information provision, measures to optimize sleep quality, relaxation, massage, healing touch, polarity therapy, and haptotherapy
Benefits balanced with harms: correction of anemia with erythropoiesis-stimulating agents
Effectiveness not established: structured rehabilitation, individual and group psychotherapy, cognitive-behavioral therapy for fatigue, cognitive-behavioral therapy for concurrent symptoms, expressive writing, hypnosis, paroxetine, methylphenidate, donezapil, sustained-release bupropion, modafinil, venlafaxine, sertraline, targeted anticytokine therapy, Reiki, yoga, mindfulness-based stress reduction, acupuncture, art therapy, music therapy, animal-assisted therapy, distraction/virtual reality immersion, levocarnitine supplementation, vitamin supplementation, adenosine 5’ triphosphate infusion, lectin-standardized mistletoe extract, essaic, Chinese medicinal herbs, omega-3 fatty acid supplementation, combination therapy of dietary and antioxidant supplements and lipid replacement, combination of aromatherapy, foot soak, and reflexology
Eaton, L.H. & Tipton, J.M. (2009). Putting Evidence Into Practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Gobel, B.H., Tipton, J. M. (2009). PEP up your practice. In L.H. Eaton J.M. & Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 1 – 8). Pittsburgh, PA: Oncology Nursing Society.
Jennings, D. (2009, February 17). The many shades of cancer fatigue. The New York Times. Retrieved May 22, 2009, from http://well.blogs.nytimes.com/2009/02/17/the-many-shades-of-cancer-fatigue/
Lawrence, D.P., Kupelnick, B., Miller, K., Devine, D., & Lau, J. (2004). Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients. Journal of the National Cancer Institute Monographs, 2004(32), 40-50.
Mendoza, T.R., Wang, X.S., Cleeland, C.S., Morrissey, M., Johnson, B.A., Wendt, J.K., et al. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85(5), 1186–1196.
Mitchell, S.A., Beck, S.L., & Eaton, L.H. (2009). Fatigue. In L.H. Eaton J.M. & Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 155-174). Pittsburgh, PA: Oncology Nursing Society.
National Comprehensive Cancer Network. (2009). NCCN Clinical Practice Guidelines in Oncology™: Cancer-related fatigue [v.1.2009]. Retrieved May 22, 2009, from http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf
Piper, B.F., Dibble, S.L., Dodd, M.J., Weiss, M.C., Slaughter, R.E., & Paul, S.M. (1998). The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncology Nursing Forum, 25(4), 677-684.
Rutledge, D.N., & Grant, M. (2002). Introduction. Seminars in Oncology Nursing. 18(1), 1-2.