Screening and supportive care
Another finding is that these patients did not seek supportive care. In fact, only 10% patients sought help from a psychologist, 8% went for acupuncture, and 7% pursued homeopathy. The researchers thought many patients might not be aware that these types of therapy were available to them, or out-of-pocket costs may have been prohibitive for some patients. However, more patients with severe emotional fatigue took advantage of psychological services (17%) compared with those who had less severe emotional fatigue (8%), although Dr Di Meglio did not think enough patients went that route.
In their paper, the ESMO Guidelines Committee stated that screening all patients with cancer for fatigue at the time of diagnosis is important, and if clinically indicated, at regular intervals during treatment and after. The clinician should use brief and validated tools for severity screening. If a result indicates moderate to severe fatigue, the patient should be given a comprehensive diagnostic assessment because they may have comorbid and/or contributing conditions that are treatable. If cancer-related fatigue remains untreated, the consequences on patients can be both social and financial, and increase in severity over the long term.1,2
Role of Patient Education
Dr Di Meglio believes oncology nurses can play a vital role in educating patients about strategies to mitigate cancer-related fatigue (email communication, A Di Meglio, June 2020). Raising awareness about this problem is indeed crucial for its optimal management. Survivors should be encouraged to avoid inactivity, even when they are experiencing severe fatigue. Rest and limitation of physically demanding tasks are indeed often mistakenly reported by patients and providers as strategies to relieve cancer-related fatigue.
The strongest and most consistent evidence available supports that initiating and maintaining adequate levels of physical activity can reduce cancer-related fatigue. It is important to encourage and empower patients to engage in any kind of exercise (starting from moderate aerobic exercise such as fast walking, cycling, or swimming). Patients should find a pace and intensity which suits them best, then increase their activity until they meet exercise recommendations (150 minutes of moderate-intensity activity per week or 75 minutes of vigorous-intensity activity per week or an equivalent combination).3
Exercise as low impact as walking is generally safe for most cancer survivors, advised Dr Di Meglio. The American College of Sports Medicine recommends that cancer survivors begin this type of program after consulting with their physicians but any formal exercise testing, such as a stress test, may not be necessary.3 Nurses may also suggest that patients with severe fatigue that interferes with function should be referred to a physical therapist or exercise specialist to facilitate following exercise recommendations suggested by American Society of Clinical Oncology (ASCO) guidelines.4
“Even if it seems counter-intuitive, it is exercise, not rest that will help patients to overcome the symptom,” concluded Dr Di Meglio.
1. Fabi A, Bhargava R, Fatigoni S, et al; ESMO Guidelines Committee. Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment [published online March 12, 2020]. Ann Oncol. doi: 10.1016/j.annonc.2020.02.016
2. Di Meglio A, Charles C, Martin E, et al. Use of physical activity (PA) and supportive care (SC) among patients (pts) with early breast cancer (BC) reporting cancer-related fatigue (CRF). Ann Oncol. 2020;31(supp 2):abstr 1830.
3. Schmitz KH, Coureya KS, Matthews C, et al; American College of Sports Medicine. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409-1426.
4. Bower JE, Bak K, Berger A, et al. Screening, assessment, and management of fatigue in adult survivors of cancer: an American Society of Clinical Oncology Clinical Practice Guideline adaptation. J Clin Oncol. 2014;32(17):1840-1850.