Cancer-Related Fatigue

1. Cancer-Related Fatigue 慈濟醫院血液腫瘤科 高瑞和醫師

2. DEFINITION OF CANCER-RELATED FATIGUE Cancer-related fatigue is a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning. 中文：疲憊，疲累

3. Cancer-Related Fatigue • Acute fatigue: physiologic response, recoverable • Chronic fatigue: pathologic condition, unable to recover even after rest • Affect body and mind: physical, emotional, mental • 身心憔悴

4. Cancer-Related Fatigue • Temporal relationship with intervention • Chemotherapy peaks within days • Radiation therapy peaks after weeks • May persist for prolonged period • Almost universal with biologic response modifiers

5. Causes of Cancer-Related Fatigue Physiologic Underlying neoplasm Antineoplastic treatment Concomitant systemic disease Sleep disorders Immobility and lack of exercise Chronic pain Psychological Anxiety, depression

6. Cancer-related pathophysiology that cause fatigue Symptoms related to energy imbalance Pain and pain treatment Anemia Cachexia Infection Paraneoplastic syndrome Metabolic disorder Stress and mood Fatigue induced by cancer therapy

7. Signs of Cancer-Related Fatigue • Feeling tired, weary or exhausted even after sleeping • Lacking energy to do your regular activities • Having trouble concentrating, thinking clearly, or remembering • Feeling negative, irritable, impatient, or unmotivated • Lacking interest in normal day-to-day activities • Spending less attention on personal appearance • Spending more time in bed or sleeping

8. Diagnosis of Cancer-Related Fatigue • Ask the patient • Do you feel tired or fatigued? • Does fatigue make you change your activities? Patient self-report is the best diagnostic tool

9. Prevalence of Cancer-Related Fatigue Fatigue-1 & Fatigue-2 studies • 50% at diagnosis, 75% if bone metastasis • Patient with chemotherapy 80-96% • Patient with radiotherapy 60-93% *Cox et al: In general population, 20% men and 30% women always feel tired.

10. Impact on QOL Fatigue-1 study 1996 • 2/3 patients considered that fatigue affected their • performance of normal daily activities • 61% patients claimed that fatigue influenced their • life more than pain

11. Impact on QOL Fatigue-2 Study 1998 • Fatigue (25%) other than nausea (13%) as the main • symptom after chemotherapy • Loss of emotional control: 90% • A feeling of isolation and solitude: 74% • Dejection: 72% • Marked effect on employment and financial status: • 75% had changed employment • The effects on care-giver: more working breaks (20%)

12. Extent of The Problem Stone et al Ann Oncol 2000 538 cancer patients • 52% never reported fatigue to their oncologist • Only 14% had received treatment or advice on • how to manage fatigue • 33% with fatigue declared they had not received • adequate treatment

13. Extent of The Problem Oncologist’s view: pain in more clinically relevant than fatigue (61% vs 37%) Patient’s view: fatigue affects everyday life much more than pain (61% vs 19%)

14. Screening • Primary evaluation • Interventions • Reevaluation

15. SCREENING

16. Primary Evaluation Phase Focused History:  Disease status and treatment Rule out recurrence or progression Current medications/medication changes  Review of systems  In-depth fatigue assessment Onset, pattern, duration Change over time Associated or alleviating factors Interference with function

17. How is Fatigue Assessed? • When did the fatigue first start? • When did you first realize that it is an unusual type of fatigue for you? • How has it progressed over the course of your treatment or since your diagnosis? • What help relieve your fatigue? • What makes your fatigue worse? • How has the fatigue affected your daily activities or the activities that give meaning and enjoyment to your life?

19. Assessment of Treatable Contributing Factors • Pain • Emotional distress: depression • Sleep disturbance • Anemia • Nutrition assessment: • weight/calori intake change • fluid, electrolyte imbalance • Activity level: changes in exercise or activity pattern, • deconditioning • Comorbidities: infection, cardiac, pulmonary, renal, • hepatic, neurologic, endocrine, hypothyroidism

21. Anemia and Cancer-Related Fatigue Correlation between Hb levels ( 12g/dL vs.  12g/dL) and fatigue QOL parametersP value Higher QOL scores 0.003 Less fatigue 0.01 Fewer symptoms of anemia 0.02 Better sensation of physical well being 0.003 Better sensatin of function al well being 0.001 QOL: quality of life Sobreo et al. Semin Hemato 2001, 28:15-18

22. Treatment of Anemia-related Fatigue • Iron, folic acid replacement • Blood transfusion • Erythropoietin therapy: supported by strong • clinical evidence • 10,000 units sc tiw or • 40,000 units sc weekly

23. INTERVENTION-1 Patient/Family Education

24. INTERVENTION-2 Common Strategies for Management of Fatigue

25. INTERVENTION-3 Non-Pharmacologic

26. INTERVENTION-4 Pharmacologic

27. Re-evaluation

28. Patient Self-Care What to look for? • Feeling like you have no energy • Increased sleeping • Lack of desire to do normal activities • Decreased attention to personal appearance • Feeling tired even after sleeping • Difficulty concentrating

29. Patient Self-Care What to do? • Plan rest periods to conserve energy for important things • Schedule necessary activities throughout the day rather than all at once • Engage in light activity • Get enough rest and sleep • Eat a nutritious diet including plenty of liquids • Remember that fatigue caused by treatment side effects is temporary and that energy will

30. Finale Fatigue is common in cancer patients which should be recognized, evaluated, monitored, documented and treated promptly at all stages of the disease, both during and after treatment.

31. 誌謝PPTT Members 王玉祥 王全正 王宏銘 王正旭 邱昌芳 巫宏博 林炯森 林哲斌 林勝豐 吳銘芳 高瑞和 張正雄 張明志 張義芳 郭集慶 陳仁熙陳彥仰 陳博明 曹朝榮 黃文豊 黃文聰黃承華 黃叔牧 黃明立 葉士芃 葉光揚 馮盈勳 葉坤輝 趙大中 蕭士銓 蕭惠樺鄭丞傑 劉青山 謝瑞坤 謝長堯 顏家瑞

32. The End