Cancer related fatigue – What do we know and how do we help our patients?

1. Cancer related fatigue – What do we know and how do we help our patients? Randi Gjessing Departement of clinical service Division of Surgery, Transplantation and Cancer medicine. Some slides are provided by professor Jon Håvard Loge National resource centre for late effects after cancer treatment Gjessing, SSG, Helsinki 2013

2. Outline - Fatigue - what is it? - Prevalence - Assosiations & possible mechanisms - What can be done? Gjessing, SSG, Helsinki 2013

3. FATIGUE English word from latin (Fatigare) Oxford Dictionary: Lassitude or weariness resulting from bodily or mental exertion Gjessing, SSG, Helsinki 2013

4. What is fatigue? • A subjective experience • A physical, emotional and / or a psychophysical symptom • Observed in most psychiatric / somatic disorders – being ill? • Feeling of tiredness or lack of energy • Patients say "The batteries are not charging Gjessing, SSG, Helsinki 2013

5. Acute fatigue: experienced by everyone It is normal to feel tired! • Chronic fatigue • Duration > 6 months / after stimuli has ended Gjessing, SSG, Helsinki 2013

6. Different dimensions • Mental fatigue – memory/concentration • Physical fatigue – feeling empty/lacking energy Gjessing, SSG, Helsinki 2013

7. Cancer-related fatigue = a symptom • Not a diagnosis • Not a specific condition/disorder • Acute or chronic • Acute in relation to active disease/treatment • Chronic as observed in survivors Gjessing, SSG, Helsinki 2013

8. Mosso’s ergograph Gjessing, SSG, Helsinki 2013

9. How to measure fatigue? 0 2 3 1 Phys. fatigue Total fatigue score Mental fatigue Higher score - more fatigue Chalder,1993 Nasjonalt kompetansesenter for seneffekter etter kreftbehandling

10. How to measure fatigue? - 2 0 1 1 0 Chronic fatigue: Sum score ≥ 4 + duration ≥ 6 months Chalder,1993 Nasjonalt kompetansesenter for seneffekter etter kreftbehandling

11. Fatigue in the general population Gjessing, SSG, Helsinki 2013

12. Fatigue in the general population - by age and gender 14 13 12 Fatigue scores with 95% CI Male Female 11 10 0 29 yrs. or less 30-39 yrs 40-49 yrs 50-59 yrs 60 yrs. or more Age-groups Nasjonalt kompetansesenter for seneffekter etter kreftbehandling Loge et al., 1998

13. Fatigue in somatic disorders • Inflammatory diseases • Infections • Systemic lupus, rheumatoid arthritis ….. • Heart failure • Difficult to separate from dyspnoea • Kidney diseases • Cancers • Multiple sclerosis Gjessing, SSG, Helsinki 2013

14. Fatigue in cancer survivors • Most common late effect • Patients say :"I was not prepared for this” • “What is wrong with we?” • “Everyone says I look so well” • “Have I got relapse from my cancer?” Gjessing, SSG, Helsinki 2013

15. Chronic fatigue (> 6 months): - Cancer survivors and general population N=459 N=249 N=791 N=2323 Median obs tid: 12 år 4 år 12 år Loge 1999, Reinertsen 2010, Fosså 2003 Nasjonalt kompetansesenter for seneffekter etter kreftbehandling

16. Different prevalence across survivors • Hodgkin’s disease survivors highest prevalence? • Sarcomas? • Still relatively few comparative studies • Lack data from large groups of survivors Gjessing, SSG, Helsinki 2013

17. Cancer patients - both acute and chronic fatigue: • During chemotherapy:> 50% (100%?) • During irradiation,> 50% (100%?) • After curative treatment: 10 -35% • The most frequent symptom of fatal cancer: 80-90 + +% Gjessing, SSG, Helsinki 2013

18. Fatigue – potential mechanims Ganz, 2007 Nasjonalt kompetansesenter for seneffekter etter kreftbehandling

19. Cancer related fatigue What can be done? Gjessing, SSG, Helsinki 2013

20. Listen to patient - believe in patient ! Gjessing, SSG, Helsinki 2013

21. Ask the patients if their fatigue has any pattern. • What helps? What makes it worse? • What does the patient think about it? Gjessing, SSG, Helsinki 2013

22. Activity/rest • Sleeping. • Energy account. • Expectations: “Plan to become tired”. Gjessing, SSG, Helsinki 2013

23. Cognitive behavioral therapy • Mindfullness Gjessing, SSG, Helsinki 2013

24. Graded physical exercise: “Start low, go slow” Gjessing, SSG, Helsinki 2013

25. Aerob exercise - chronic fatigued HL survivors • Aerobic exercise x 3 / week for 20 weeks: 9 / 12 agreed to participate • 6 / 9 adhered to the program • Fatigue scores reduced >40% • Aerobic capacity improved • Acceptable / low-cost / promising results. For some? Nasjonalt kompetansesenter for seneffekter etter kreftbehandling

26. Fatigue Fatigue, physical exercise and cancer Treatment Illness Detraining Sedentary habits Physical training Less fatigue Persistent fatigue Lucia A. et al., The Lanset Oncology, 2003 Nasjonalt kompetansesenter for seneffekter etter kreftbehandling Gjessing, SSG, Helsinki 2013

27. I REALLY NEED TO GET GOING, BUT JUST CAN'T SEEM TO GET MOTIVATED............. Kreft,kirurgi og transplantasjonsklinikken

28. Conclusion • Fatigue is the most common late effect after cancer treatment. • It is most essential to listen to the patients. • There is no “quick fix”, but exercising and maintaining a normal sleep-pattern can help. Gjessing, SSG, Helsinki 2013

29. Thank you for your attention. Nasjonalt kompetansesenter for seneffekter etter kreftbehandling