A Clinician's Approach to A Clinician's Approach to Fatigue of Cancer PatientsFatigue of Cancer Patients

Jau-Yih TsauoPT, PhD, ProfessorNational Taiwan University

OutlineOutlineStandards of care of cancer-

related fatigueCRF screening & assessmentCRF managementConclusions

ICD-10 criteria for CRFICD-10 criteria for CRFThe following symptoms have been present every day or nearly

every day during the same 2-week period in the past month: Significant fatigue, diminished energy, or increased need to rest,

disproportionate to any recent change in activity level, plus five or more of the following: ◦ Complaints of generalized weakness, limb heaviness. ◦ Diminished concentration or attention.◦ Decreased motivation or interest to engage in usual activities.◦ Insomnia or hypersomnia.◦ Experience of sleep as unrefreshing or nonrestorative.◦ Perceived need to struggle to overcome inactivity.◦ Marked emotional reactivity (e.g., sadness, frustration, or irritability) to

feeling fatigued.◦ Difficulty completing daily tasks attributed to feeling fatigued.◦ Perceived problems with short-term memory.◦ Postexertional fatigue lasting several hours.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

There is evidence from the history, physical examination, or laboratory findings that the symptoms are a consequence of cancer or cancer therapy.

The symptoms are not primarily a consequence of comorbid psychiatric disorders such as major depression, somatization disorder, somatoform disorder, or delirium.

What is Cancer-related What is Cancer-related Fatigue?Fatigue?CRF is related to cancer or cancer

treatment which causes physical, emotional and /or cognitive tiredness or exhaustion and interferes patients’ functioning.

CRF is reported at all age groups and all stages of the cancer, prior to, during and following treatment.

So, CRF should be screened, assessed and managed for all the cancer patients.

Standards of Care of CRFStandards of Care of CRF

NCCN Clinical Practice Guidelines

Screening & AssessmentScreening & AssessmentAge 5-6 y/o: not tired, tiredAge 7-12 y/o: 1-5 scale

◦1-2: mild◦3: moderate◦4-5: severe

Age >12 y/o: 0-10 scale◦0-3: none to mild◦4-6: moderate◦7-10: severe

Non to MildNon to MildNot tired in age 5-6, scores 1-2 in

age 7-12, or scores 0-3 in age>12Education

◦Active treatment◦Post treatment◦End of life

General strategies to manage fatigue◦Active treatment◦Post treatment◦End of life

Non to Mild: Active Non to Mild: Active TreatmentTreatment

Non to Mild: Post Non to Mild: Post TreatmentTreatment

Non to Mild: End of LifeNon to Mild: End of Life

Moderate to SevereModerate to SevereTired in age 5-6, scores 3-5 in age

7-12, or scores 4-10 in age>12Education

◦Fatigue is not an indicator of disease progression

◦Self-monitoring of the fatigue level◦Expected the end-of life symptom and

the fatigue intensity may varyPrimary evaluationInterventions

Primary EvaluationPrimary Evaluation

Interventions: Active Interventions: Active TreatmentTreatment

Interventions: Post Interventions: Post TreatmentTreatment

Interventions: End of LifeInterventions: End of Life

Activity Enhancement (I)Activity Enhancement (I)Fatigue: **

◦during cancer treatment◦following cancer treatment

Aerobic capacity:◦11/22: significant difference between

intervention and control group◦3/22: significant pre-post difference◦8/22: non significant difference

Quality of life: --Anxiety: --Depression: --

Cramp et al, 2008

Activity Enhancement (II)Activity Enhancement (II)↑ functional capacity so↓effort in activities15~45min/session (no more than I hour)1-5 sessions/week3~32 weeks, average: 12 weeks25~80% age-predicted HRmax (220-age)walk, bicycle, ergometer, treadmill, yoga,

tai-chi, multidimensional (aerobic+stretching+resistance exercise)

group/individualized, supervised/home-based , mixture of supervised and home-based

Psychosocial InterventionsPsychosocial InterventionsEducation:

◦energy conservation and activity management to balance rest and activity

◦planning, delegating, prioritizing, pacing, resting

Support groupIndividual counselingComprehensive coping strategyStress management trainingBehavioral intervention

Sleep TherapySleep TherapyStimulus control

◦go to bed when sleepy, get out of bed after 20 min of wakefulness

◦Have a routine bedtime and rising timeSleep restriction

◦avoidance of long or late day naps◦Limiting total time in bed

Sleep hygiene◦caffeine and exercise avoidance near

bedtime◦comfortable sleep surroundings (dark,

relaxing…)◦soothing activities at bedtime (music, …)

Conclusions

Thank you for your attention!

Questions?