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Course: Oncology Nursing

Topic: Nursing Management of

Fatigue and Weakness in Cancer Patient

The Nurses International Community

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Module Goals

Learners will be able to:

Define the fatigue and weakness normally experienced by cancer patients.
Describe the methods to assess fatigue and weakness.
Use methods of non-pharmacological and pharmacological interventions to address the fatigue generally experienced by cancer patients.
Identify information for patient education/counselling on fatigue management at home.

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Fatigue

‘Cancer-related fatigue is 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 functioning’.

Berger et al., 2017

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Fatigue

Cancer related fatigue (CRF) is differentiated from fatigue experienced by healthy people.

Healthy fatigue is acute, eventually relieved by sleep and rest.
CRF is chronic fatigue not relieved by sleep or rest.

Most common side-effect of cancer treatment with:

Chemotherapy
Radiation Therapy
Bone marrow transplantation
Selected biologic response modifiers

Patient report fatigue during and after the cancer treatment.
Also common in patient with advanced cancer not undergoing treatment.

National Cancer Institute (2021)

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Fatigue

Viewed as a self-perceived state and patient-reported outcome
Patient may describe fatigues as feeling:

weak
worn-out
exhausted
lazy
weary
slow
heavy
not having any energy or any get-up-go

National Cancer Institute (2021)

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Fatigue

Fatigue has negative impact on all areas of function including:

Mood
physical function
Work performance
Social interaction
Family care
Cognitive performance
School work
Community activities
sense of self
Activities of daily living

National Cancer Institute (2021)

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ICD-10 Criteria for CRF

CRF exists when following symptoms present everyday or nearly everyday 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

National Cancer Institute (2021)

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ICD-10 Criteria for CRF

Continued…

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
Post-exertional fatigue lasting several hours

National Cancer Institute (2021)

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ICD-10 Criteria for CRF

Clinically significant distress or impairment in social, occupational, or other important areas of functioning caused by the symptoms.
Evidence from the history, physical examination, or laboratory findings that the symptoms are a consequence of cancer or cancer therapy.
Symptoms not primarily a consequence of comorbid psychiatric disorders such as major depression, somatization disorder, somatoform disorder, or delirium.

National Cancer Institute (2021)

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Fatigue

Except for treatment-induced anemia, the mechanism responsible for fatigue in cancer patient are not known
Some of the most often implicated contributing factors have been:

Anemia
Nutritional deficiencies
Sleep disorders Dehydration
Metabolic disturbances
Medications
Pain and other symptoms
Excessive inactivity
Psychological factors

National Cancer Institute (2021)

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Fatigue: Assessment

National Cancer Institute (2021)

Screening is the first step of fatigue assessment performed at:

Initial visit
at the beginning and at the end of primary cancer treatments
at least annually during follow-up care
Or, done as clinically indicated

Comprehensive assessment of the patient include:

Status of cancer and its treatment
Review of systems to assess impact of cancer and cancer treatments on other organs and systems
Comprehensive physical exams, including gait, posture, and range of motion

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National Cancer Institute (2021)

Tools for fatigue assessment	Descriptions	As cited in National Cancer Institute (2021)
Visual analog scale (VAS) for fatigue	Uses a 10-cm, 0- to 100-mm line; assesses severity only	Glaus, 1993 [3]
NCCN intensity tool	0–10 scale; assesses severity only	Mock et al., 2007 [2]
Brief Fatigue Inventory (BFI)	9 items; 0–10 numeric scale; measures severity of fatigue in past 24 h	Mendoza et al., 1999 [13]
Fatigue Symptom Inventory (FSI)	9 items; 0–10 numeric scale; measures severity of fatigue in past 24 h	Mendoza et al., 1999 [13]
Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F)	13 items; 5-point, 0–4 scale; measures fatigue severity, duration, and impact on QOL in past 7 d	Yellen et al., 1997 [7]

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National Cancer Institute (2021)

Tools for fatigue assessment	Descriptions	As cited in National Cancer Institute (2021)
Multidimensional Fatigue Inventory (MFI)	20 items; 7-point Likert scale; measures general, mental, and physical dimensions and activity level in past 24	Smets et al., 1995 [8]
FACIT-F	40 items; 5-point, 0–4 scale; includes 13-item FACIT-F scale; also measures physical, social/family, emotional, and functional dimensions	Yellen et al., 1997 [7]
European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Fatigue Module (EORTC QLQ-FA13)	13 items; measures physical, emotional, and cognitive aspects of fatigue, fatigue interference, and its sequelae	Weis et al., 2013 [9]
Revised Piper Fatigue Scale (PFS-R)	22 items; 11-point scale; measures behavioral, affective, sensory, and cognitive dimensions of fatigue	Piper et al., 1998 [10]

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Fatigue: Assessment

Assessment of specific aspects of fatigue for in-depth evaluation:

Onset
Duration
Pattern
Change in intensity and frequency over time
Exacerbating or alleviating factors
Associated patient distress
Interference with functioning

National Cancer Institute (2021)

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Fatigue: Assessment

In-depth evaluation also include assessment of contributing factors:

Anemia
Hypothyroidism
Fluid/electrolyte imbalance
Weight/caloric intake
Sleep disturbances (insomnia, hypersomnia, sleep apnea, etc.)
Emotional disturbances (depression, anxiety), including psychiatric history/adversity during childhood
Treatment-related side-effects like Pain, Neuropathy
Review of medication effects
Assessment of social economic, spiritual factors
Co-morbidities and functional status

National Cancer Institute (2021)

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Fatigue: Evaluation of Anemia

Anemia is assessed by:

A careful history and physical examination
An evaluation of a complete blood count and red blood cell indices
An examination of the peripheral blood smear
Vitamin B₁₂or folate levels
Serum iron, transferrin, and ferritin levels
Erythropoietin level, the direct and indirect Coombs test
Examination of a bone marrow aspirate and biopsy

National Cancer Institute (2021)

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Screening for Fatigue

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Fatigue: Barriers To Management

Patient barriers:

Belief that physician would introduce subject of fatigue if important.
Concerned that reporting high levels of fatigue alter their treatment.
Fear of being perceived as complaining.

Professional barriers:

May not recognize fatigue as a problem for the patient.
Unrecognized and untreated as a symptom

only recently prevalence/incidence correlated with reduced QOL

Not aware that effective treatment/management are available

System barrier: Lack of supportive care referral, lack of emphasis on fatigue management.

National Cancer Institute (2021)
Piper et al. (2008)

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Fatigue: General Management

Patient education is central to effective management of fatigue.
Patient and family must be counselled about the known pattern of fatigue during and following treatment.
Reassure patient/family that treatment-related fatigue is not necessarily an indicator of disease progression.
A combination approach to nonpharmacologic and pharmacologic intervention may be introduced.
Consider referral to appropriate specialist or supportive care provider.
Fatigue assessment should be a continuous process throughout diagnosis/treatment/post-treatment/end-of-life care.

Berger et al. (2015)

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Fatigue: General Management

Berger et al. (2015)

Interventions should be culturally specific
Interventions should be tailored to the needs of patients and families along the illness trajectory

Be mindful of the individual circumstances and resources
Not all patients may be able to integrate options for interventions due to variances in their socio-economic circumstances

Interventions should emphasize on meaningful interactions and promote dignity of the patient.

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Nonpharmacological Management in Active Treatment

Provide patient education/counselling on:

Self-monitoring of fatigue levels
Energy conservation strategies:

Set priorities and realistic expectations
Pace
Delegate
Schedule activities at times of peak energy
Labor-saving devices like sock aids, reachers, rolling carts
Postpone nonessential activities
Limit naps to <1 hour to not interfere with nighttime sleep quality Structured daily routine
Attend to one activity at a time

Using distractions like games, music, reading, socializing

Berger et al. (2015)

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Nonpharmacological Management in Active Treatment

Maintaining optimal level of activity

Starting and maintaining exercise program as per healthcare providers instructions

with caution in patient with bone metastases, thrombocytopenia, anemia , fever or active infection, limitations secondary to metastasis or other comorbid illnesses

Referral to rehabilitation: physical therapy, occupational therapy, physical medicine
complementary therapies like massage therapies, yoga

Psychosocial Interventions: Cognitive behavioral therapies (CBT), educational therapies, supportive expressive therapies
Appropriate nutritional consultation

Source: Berger et al. (2015)

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Nonpharmacological Management in Active Treatment

Berger et al. (2015)
National Cancer Institute (2021)

CBT is a type of psychotherapy that focuses on recognizing and changing maladaptive thoughts and behaviors^{1, 2}

to reduce negative emotions and behaviors
to facilitate psychological adjustment

CBT/BT has shown to control CRF over long periods of time²
Supportive expressive therapies facilitate expression of emotion and foster support from one or more people¹

support groups, counseling
journal writing

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Pharmacologic Management During Active Treatment

Berger et al. (2015)

Pain Management (consider non-pharmacological strategies as well)
Anemia Treatment
Optimization of treatment for:

Sleep dysfunction
Nutritional deficit/imbalance

Treatment of comorbidities:

Alcohol/substance abuse
Cardiac dysfunction
Hepatic dysfunction
Renal dysfunction
Infection
Neurologic dysfunction
Endocrine dysfunction (eg, hot flashes, hypothyroidism, hypogonadism, etc)
Pulmonary dysfunction
Gastrointestinal dysfunction

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Case Study/Critical Thinking Question/What would the nurse do?

A 57-year-old man presents with signs of fatigue. A complete health history, physical exam and laboratory test results showed the patient is anemic. What would the nurse expect in treatment management of this patient? (Select all that apply)

Provide Iron supplement and Vit B₁₂ supplement
Identify the cause of anemia
Provide education and counseling on preventing exercises
Assess fatigue level

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Fatigue Management of Cancer Patient Post-Treatment

Screening patient for CRP should continue post-treatment during follow-up visits.
Can benefit with general fatigue management strategies including energy conservation and distraction.
Specific intervention recommended to manage fatigue during cancer treatment are also recommended post-treatment

includes pharmacological and nonpharmacological management of pain, anemia and emotional distress if indicated

Berger et al. (2015)

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Fatigue Management at the End of Life

General fatigue management strategies including energy conservation and distraction apply to end-of-life patients with few specific considerations.
Symptoms management needs to be a major focus of end of life care

fatigue can result in substantial regret, sadness, sense of loss due to deterioration of one’s health

Committed palliative care is critical when aggressive cancer therapy is given to patients with a low likelihood of long-term survival

Berger et al. (2015)

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Fatigue Management at the End of Life

Factors with greater likelihood of association with fatigue at end of life include:

Anemia
Medication adverse effects and polypharmacy
malnutrition
Cognitive impairment
adverse effects of recent treatments

Evaluation and correction of these factors could reduce fatigue severity
Psychosocial intervention may focus on:

sustaining sense of meaning and dignity
gaining acceptance of the limitations imposed by fatigue

Berger et al. (2015)

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Fatigue Management at the End of Life

Berger et al. (2015)

Use of corticosteroids (prednisone and dexamethasone) can be considered for short-term relief of fatigue.
Eating and nutrition should be tailored to the patient’s comfort and should not be forced as nutritional decline is expected.

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Nurse’s Role in Fatigue Management of Cancer Patient

Berger et al. (2015)
National Cancer Institute (2021)

Patient education/counseling is a vital role of nurses in management of CRF in cancer patients

inform fatigue as common side-effect, not an indicator of worsening of cancer/its treatment
Encourage self-monitoring of fatigue levels
Nonpharmacological strategies to mitigate CRF
How to safely take medications/supplements prescribed to reduce CRF

Be knowledgeable and competent about available evidenced-based tools and strategies for CRF assessment and management

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Nurse’s Role in Fatigue Management of Cancer Patient

Berger et al. (2015)
National Cancer Institute (2021)

Regularly assess and identify CRF level in patient.
Assist patient to identify, plan and perform appropriate level of daily activities necessary.

Assist patient in performing those activities where needed.

Assist referrals to physical therapies, occupational therapist, dietician according to the needs of the patients where possible.
Assist patient/families in identifying community resources to help manage CRF.

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What would the nurse do?

Which of the following is the most important role of the nurse in CRF management in cancer patient?

Providing the patient with a prescribed rest schedule.
Providing patient/family education and counselling on CFR management.
Teach the patient to take medication for rest with meals.
Instruct the family to schedule periods of rest after all activities.

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Reference:

Berger, A.M, Moone,y K., Alvarez-Perez, A., Breitbart, W.S., Carpenter, K.M., Cella, D., Cleeland, C., Dotan, E., Eisenberger, M.A., Escalante, C.P., Jacobsen, P.B., Jankowski, C., LeBlanc, T., Ligibel, J.A., Loggers, E.T., et al. (2015). Cancer- Related Fatigue Version 2. Journal of National Comprehensive Cancer Network, 13 (8). Accessed from: https://doi.org/10.6004/jnccn.2015.0122

National Cancer Institute (January, 2021). Fatigue (PDQ®)–Health Professional Version. Accessed from: https://www.cancer.gov/about-cancer/treatment/side-effects/fatigue/fatigue-hp-pdq#_99_toc

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Reference:

Piper, B. F., Borneman, T., Sun, V. C., Koczywas, M., Uman, G., Ferrell, B., & James, R. L. (2008). Cancer-related fatigue: role of oncology nurses in translating National Comprehensive Cancer Network assessment guidelines into practice. Clinical journal of oncology nursing, 12(5 Suppl), 37–47. https://doi.org/10.1188/08.CJON.S2.37-47 Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776587/

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