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Table of Contents Introduction
Overview
Causes
Factors Related to Fatigue
Assessment
Treatment
Posttreatment Considerations
Get More Information From NCI
Changes to This Summary (09/25/2008)
Questions or Comments About This Summary
About PDQ
Introduction
This patient summary on fatigue is adapted from a summary written for health
professionals by cancer experts. This and other credible information about
cancer treatment, screening, prevention, supportive care, and ongoing clinical
trials is available from the National Cancer Institute. Fatigue is one of the
most common complaints of people diagnosed with cancer and cancer survivors. This brief summary
describes fatigue, its causes and treatment.
 Back to Top Overview
Fatigue occurs in 14% to 96% of people with cancer, especially those receiving
treatment for their cancer. Fatigue is complex, and has biological, psychological, and behavioral causes. Fatigue is difficult to describe and
people with cancer may express it in different ways, such as saying they feel
tired, weak, exhausted, weary, worn-out, heavy, or slow. Health
professionals may use terms such as asthenia, fatigue, lassitude, prostration,
exercise intolerance, lack of energy, and weakness to describe fatigue.
Fatigue can be described as a condition that causes distress and decreased
ability to function due to a lack of energy. Specific symptoms may be
physical, psychological, or emotional. To be treated effectively, fatigue
related to cancer and cancer treatment needs to be distinguished from other
kinds of fatigue.
Fatigue may be acute or chronic. Acute fatigue is normal tiredness with
occasional symptoms that begin quickly and last for a short time. Rest may
alleviate fatigue and allow a return to a normal level of functioning in a
healthy individual, but this ability is diminished in people who have cancer.
Chronic fatigue is long lasting. Chronic fatigue syndrome describes prolonged
debilitating fatigue that may persist or relapse. This illness is sometimes diagnosed in people who do not have cancer. Although many treatment- and
disease-related factors may cause fatigue, the exact process of fatigue in
people with cancer is not known.
Fatigue can become a very important issue in the life of a person with cancer.
It may affect how the person feels about him- or herself, his or her daily
activities and relationships with others, and whether he or she continues with
cancer treatment. Patients receiving some cancer treatments may miss work,
withdraw from friends, need more sleep, and, in some cases, may not be able to
perform any physical activities because of fatigue. Finances can become
difficult if people with fatigue need to take disability leave or stop working
completely. Job loss may result in the loss of health insurance or the
inability to get medical care. Understanding fatigue and its causes is
important in determining effective treatment and in helping people with cancer cope with fatigue. Tests that measure the level of fatigue have been
developed.
Back to Top Causes
The causes of fatigue in people with cancer are not known. Fatigue commonly is
an indicator of disease progression and is frequently one of the first symptoms of cancer in both children and adults. For example, parents of a child diagnosed with acute lymphocytic leukemia or non-Hodgkin lymphoma frequently
seek medical care because of the child's extreme fatigue. Tumors can cause
fatigue directly or indirectly by spreading to the bone marrow, causing anemia,
and by forming toxic substances in the body that interfere with normal cell functions. People who are having problems breathing, another symptom of some
cancers, may also experience fatigue.
Fatigue can occur for many reasons. The extreme stress that people with cancer
experience over a long period of time can cause them to use more energy,
leading to fatigue. However, there may be other reasons that patients with cancer
suffer from fatigue. The central nervous system (the brain and spinal cord)
may be affected by the cancer or the cancer therapy (especially biological
therapy) and cause fatigue. Medication to treat pain, depression, vomiting, seizures, and other problems related to cancer may also cause fatigue. Tumor
necrosis factor (TNF), a protein made mainly by white blood cells, can cause necrosis (death) of some types of tumor cells and may be
given to a patient as a cancer treatment. TNF may cause the loss of protein stores in muscles, making the body work harder to
perform normal functions and causing fatigue. There are many chemical, physical, and behavioral factors that are thought to cause fatigue.
Back to Top Factors Related to Fatigue
It is not always possible to determine the factors that cause fatigue in
patients with cancer. Possible factors include the following:
- Cancer treatment.
- Anemia.
- Medications.
- Weight loss and loss of appetite.
- Changes in metabolism.
- Decreased
levels of hormones.
- Emotional distress.
- Difficulty sleeping.
- Inactivity.
- Difficulty breathing.
- Loss of strength and muscle coordination.
- Pain.
- Infection.
- Having other medical conditions in addition to cancer.
Cancer treatment
Fatigue is a common symptom following radiation therapy or chemotherapy. It
may be caused by anemia, or the collection of toxic substances produced by cells. In the case of radiation, it may be caused by the increased energy
needed to repair damaged skin tissue.
Several factors have been linked with fatigue caused by chemotherapy. Some
people may respond to the diagnosis and treatment of cancer with mood changes
and disrupted sleep patterns. Nausea, vomiting, chronic pain, and weight loss
can also cause fatigue.
Fatigue has long been associated with radiation therapy although the connection
between them is not well understood. Fatigue usually lessens after the therapy is completed, although not all patients return to their normal level of energy.
Patients who are older, have advanced disease, or receive combination therapy
(for example, chemotherapy plus radiation therapy) are at a higher risk for
developing long-term fatigue.
Biological therapy frequently causes fatigue. In this setting, fatigue is one
of a group of side effects known as flu-like syndrome. This syndrome also
includes fever, chills, muscle pain, headache, and a sense of generally not
feeling well. Some patients may also experience problems with their ability to
think clearly. The type of biological therapy used may determine the type and
pattern of fatigue experienced.
Many people with cancer undergo surgery for diagnosis or treatment. Fatigue is
a problem following surgery, but fatigue from surgery improves with time. It
can be made worse, however, when combined with the fatigue caused by other
cancer treatments.
Anemia
Anemia may be a major factor in cancer-related fatigue and quality of life in
people with cancer. Anemia may be caused by the cancer, cancer treatment, or
may be related to other medical causes.
Nutrition factors
Fatigue often occurs when the body needs more energy than the amount being
supplied from the patient's diet. In people with cancer, 3 major factors may
be involved: a change in the body's ability to process food normally, an
increased need by the body for energy (due to tumor growth, infection, fever,
or problems with breathing), and a decrease in the amount of food eaten (due to
lack of appetite, nausea, vomiting, diarrhea, or bowel obstruction).
Psychological factors
The moods, beliefs, attitudes, and reactions to stress of people with cancer
can contribute to the development of fatigue. Approximately 40% to 60% of the
cases of fatigue among all patients (patients with cancer as well as other patients)
are not caused by disease or other physical reasons. Anxiety and depression are the most common psychological disorders that cause fatigue.
Depression may be a disabling illness that affects approximately 15% to 25% of
people who have cancer. When patients experience depression (loss of interest,
difficulty concentrating, mental and physical tiredness, and feelings of
hopelessness), the fatigue from physical causes can become worse and last
longer than usual, even after the physical causes are gone. Anxiety and fear
associated with a cancer diagnosis, as well as its impact on a person's
physical, mental, social, and financial well-being are sources of emotional
stress. Distress from being diagnosed with cancer may be all that is needed to
trigger fatigue. (Refer to the PDQ summaries on Depression and on Anxiety for
more information.)
Mental ability factors
Decreased attention span and difficulty understanding and thinking are often
associated with fatigue. Attention problems are common during and after cancer
treatment. Attention may be restored by activities that encourage rest. Sleep
is also necessary for relieving attention problems but it is not always enough.
Sleep disorders and inactivity
Disrupted sleep, poor sleep habits, less sleep at night, sleeping a lot during
the day, or no activity during the day may contribute to cancer-related
fatigue. Patients who are less active during the daytime and awaken frequently
during the night report higher levels of cancer-related fatigue.
Medications
Medications other than those used in chemotherapy may also contribute to
fatigue. Opioids used in treating cancer-related pain often cause drowsiness,
the extent of which may vary depending on the individual. Other types of
medications such as tricyclic antidepressants and antihistamines may also
produce the side effect of drowsiness. Taking several medications may compound
fatigue symptoms.
Back to Top Assessment
To determine the cause and best treatment for fatigue, the person's fatigue
pattern must be determined, and all of the factors causing the fatigue must be
identified. The following factors must be included:
- Fatigue pattern, including how and when it started, how long it has lasted,
and its severity, plus any factors that make fatigue worse or better.
- Type and degree of disease and of treatment-related symptoms and/or side
effects.
- Treatment history.
- Current medications.
- Sleep and/or rest patterns and relaxation habits.
- Eating habits and appetite or weight changes.
- Effects of fatigue on activities of daily living and lifestyle.
- Psychological profile, including an evaluation for depression.
- Complete physical examination that includes evaluation of walking
patterns, posture, and joint movements.
- How well the patient is able to follow the recommended treatment.
- Job performance.
- Financial resources.
- Other factors (for example, anemia, breathing problems, decreased muscle
strength).
Underlying factors that contribute to fatigue should be evaluated and treated
when possible. Contributing factors include anemia, depression, anxiety, pain, dehydration, nutritional deficiencies, sedating medications, and therapies that
may have poorly tolerated side effects. Patients should tell their doctors
when they are experiencing fatigue and ask for information about fatigue
related to underlying causes and treatment side effects.
Anemia evaluation
There are different kinds of anemia. A medical history, a physical
examination, and blood tests may be used to determine the kind and extent of
anemia that a person may have. In people with cancer there may be several
causes.
Back to Top Treatment
Most of the treatments for fatigue in cancer patients are for treating symptoms and providing emotional support because the causes of fatigue that are
specifically related to cancer have not been determined. Some of these
symptom-related treatments may include adjusting the dosages of pain medications, administering red blood cell transfusions or blood cell growth
factors, diet supplementation with iron and vitamins, and antidepressants or psychostimulants.
Psychostimulant drugs
Although fatigue is one of the most common symptoms in cancer, few medications
are effective in treating it. A healthcare provider may prescribe medication
in low doses that may help patients who are depressed, unresponsive, tired,
distracted, or weak. These drugs (psychostimulants) can give a sense of
well-being, decrease fatigue, and increase appetite. They are also helpful in
reversing the sedating effects of morphine, and they work quickly. However,
these drugs can also cause sleeplessness, euphoria, and mood changes. High
doses and long-term use may cause loss of appetite, nightmares, sleeplessness,
euphoria, paranoid behavior, and possible heart problems.
Treatment for anemia
Treatment for fatigue that is related to anemia may include red blood cell
transfusions. Transfusions are an effective treatment for anemia; however
possible side effects include infection, immediate transfusion reaction, graft-versus-host disease, and changes in immunity.
Treatment for anemia-related fatigue in patients undergoing chemotherapy may also include drugs, such as epoetin alfa, that cause the bone marrow to make more red blood cells.
This type of drug may shorten survival time or may cause some tumors to grow faster. Patients should discuss the risks and benefits of these drugs with their doctors.
Exercise
Exercise (including light- to moderate-intensity walking programs) helps many
people with cancer. People with cancer who exercise may have more physical
energy, improved appetite, improved ability to function, improved quality of
life, improved outlook, improved sense of well-being, enhanced sense of
commitment, and improved ability to meet the challenges of cancer and cancer
treatment.
Exercise may also help patients with advanced cancer, even those in hospice care. More benefit may result when family members are involved with the
patient in the physical therapy program.
Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) is a method used by therapists to treat a variety of psychological disorders, including post-cancer treatment fatigue that has no physical cause. CBT aims to change a patient's awareness (the cognitive) in order to change the way he acts (the behavior). CBT sessions may be helpful in decreasing a patient's fatigue following cancer treatment by focusing on factors such as:
- Stress from coping with the experience of having cancer.
- Fear that the cancer may come back.
- Abnormal attitudes about fatigue.
- Irregular sleep or activity patterns.
- Lack of social support.
Activity and rest
Any changes in daily routine require the body to use more energy. People with
cancer should set priorities and keep a reasonable schedule. Health
professionals can help patients by providing information about support services
to help with daily activities and responsibilities. An activity and rest
program can be developed with a health care professional to make the most of a
patient's energy. Practicing sleep habits such as not lying down at times
other than for sleep, taking short naps no longer than one hour, and limiting
distracting noise (tv, radio) during sleep may improve sleep and allow more
activity during the day.
Patient education
Treating chronic fatigue in patients with cancer means accepting the condition and
learning how to cope with it. People with cancer may find that fatigue becomes
a chronic disability. Although fatigue is frequently an expected, temporary
side effect of treatment, other factors may cause it to continue.
Since fatigue is the most common symptom in people receiving outpatient chemotherapy, patients should learn ways to manage the fatigue. Patients
should be taught the following:
- The difference between fatigue and depression
- Possible medical causes of fatigue (not enough fluids, electrolyte imbalance, breathing problems, anemia)
- To observe their rest and activity patterns during the day and over time
- To engage in attention-restoring activities (walking, gardening,
bird-watching)
- To recognize fatigue that is a side effect of certain therapies
- To participate in exercise programs that are realistic
- To identify activities which cause fatigue and develop ways to avoid or
modify those activities
- To identify environmental or activity changes that may help decrease
fatigue
- The importance of eating enough food and drinking enough fluids
- Physical therapy may help with nerve or muscle weakness
- Respiratory therapy may help with breathing problems
- To schedule important daily activities during times of less fatigue, and
cancel unimportant activities that cause stress
- To avoid or change a situation that causes stress
- To observe whether treatments being used to help fatigue are working
Back to Top Posttreatment Considerations
This section is for patients who have had no cancer treatment for at least 6
months. The causes of fatigue are different for patients who are receiving therapy compared to those who have completed therapy. Also, the treatment for
fatigue may be different for patients who are no longer receiving treatment for
cancer.
Fatigue in people who have completed treatment for cancer and who are
considered to be disease-free is a different condition than the fatigue
experienced by patients receiving therapy. Fatigue may significantly affect
the quality of life of cancer survivors. Studies show that some patients
continue to have moderate-to-severe fatigue for up to 18 years after bone
marrow transplantation. Long-term therapies such as tamoxifen can also cause
fatigue. Fatigue can cause poor school performance years later in children who
were treated for brain tumors and cured. Long-term follow-up care is important
for patients after cancer therapy. Physical causes should be ruled out when
trying to determine the cause of fatigue in cancer survivors.
Back to Top Get More Information From NCI
Call 1-800-4-CANCER
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Back to Top Changes to This Summary (09/25/2008)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Editorial changes were made to this summary.
Back to Top Questions or Comments About This Summary
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Back to Top About PDQ
PDQ is a comprehensive cancer database available on NCI's Web site.
PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site. PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.
PDQ contains cancer information summaries.
The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.
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Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.
PDQ also contains information on clinical trials.
A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.
Listings of clinical trials are included in PDQ and are available online at NCI's Web site. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.
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