Cancer and Chemotherapy Fatigue

"What a difference it would have made if my fatigue had been acknowledged! .... What a comfort there would have been ... in knowing that my exhaustion was being monitored." Maureen Gilbert. A Survivor's Journey: One Woman's Experience with Cancer-Related Fatigue The Oncologist, 2003

July 25, 2005 Fatigue is a silent, invisible side effect of cancer and cancer treatments, especially a side effect of chemotherapy.In men taking chemotherapy for prostate cancer, clinical studies have shown that fatigue is a common side effect of docetaxel (Taxotere) and other drugs.

Chemo today is used at various stages of the cancer journey. Some men with high-risk prostate cancer take chemo before or soon after surgery or radiotherapy. Others take it only if they experience recurrence and hormonal therapies fail.

Age and so-called "performance status," or energy level, may affect the individual patient's reaction to chemo. Drug combinations and doses selected for safe, tolerable and effective treatments vary. A regime that suits some patients may need to be modified for you.

Some men want to continue to work full or part-time while taking chemo and are able to do so. Others are unable to work or are already on disability leave or are retired. Whether working or not, a man may still experience some degree of chemotherapy and/or cancer related fatigue.

Tiredness and lack of energy, according the National Cancer Institute, is the most common symptom reported by cancer patients. Patients describe this fatigue as different from tiredness brought on by heavy exercise or regular work. Rest does not always relieve it, light exercise may help.

A recent study found that one major barrier to effective management of fatigue in cancer patients is "a lack of awareness that fatigue is the most prevalent symptom."

With chemotherapy fatigue, you may need extra rest on some days following treatments. Some meds taken before and along with chemotherapy, such as Decadron (dexamethasone) may cause a temporary energy high, followed by a post-chemo slump.

In between treatments, jot a daily record of how you feel (say, on a scale of 1-10), and share this with your doctor and nurse. This record may help you schedule special events.

Light to moderate exercise may relieve fatigue.

Some people feel lifted by hobbies and social activities like listening to music, books on tape or radio, chat with family and friends, time with a pet animal, watching birds, smelling the roses, relaxing with a video.

Ask for help with chores and tasks as needed.

The National Cancer Institute suggests:

  • Plan your day so that you have time to rest.
  • Take short naps or breaks, rather than one long rest period.
  • Save your energy for the most important things.
  • Try easier or shorter versions of activities you enjoy.
  • Take short walks or do light exercise if possible. You may find this helps with fatigue.
  • Talk to your health care provider about ways to save your energy and treat your fatigue.
  • Try activities such as meditation, prayer, yoga, guided imagery, visualization, etc. You may find that these help with fatigue.
  • Eat as well as you can and drink plenty of fluids. Eat small amounts at a time, if that is helpful.
  • Join a support group. Sharing your feelings with others can ease the burden of fatigue. You can learn how others deal with their fatigue.
  • Limit the amount of caffeine and alcohol you drink.
  • Allow others to do some things for you that you usually do.
  • Keep a diary of how you feel each day. This will help you plan your daily activities.
  • Report any changes in energy level to your doctor or nurse. (NCI, Chemotherapy and You)

While anemia can add to fatigue, it is not the same condition. Indeed a recent study of the association between anemia and fatigue in patients with advanced cancer receiving palliative care questions the connection.

"Treatment of anemia such as erythropoietin has been reported to decrease fatigue in these patients," Tina Munch, Eduardo Bruera and colleagues say. "We reviewed medical charts of 177 consecutive outpatients seen by our palliative
care specialists. Information of fatigue intensity and hemoglobin level was collected." They found no connection between anemia and fatigue. This is how they arrived at this conclusion:

They divided the patients into 2 groups: those with a hemoglobin level 12 g/dL or less, and those with a level of 10 g/dL or more. They found no significant difference -- in all the patients, the median fatigue score was 6 out of 10. A "significant association" existed "only between the hemoglobin level and the albumin level. Hemoglobin level did not show a significant correlation with fatigue although there was a trend." Three factors remained significant: depression, albumin level, and sensation. "Our findings suggest," the authors conclude, "that anemia is not one of the major contributors to fatigue in patients with cancer receiving palliative care."

Reading this article carefully may disclose that what is described is a high plateau of fatigue in patients with advanced cancer in palliative care beyond which they cannot feel anymore fatigued than they already are. The authors write:

Our main hypothesis in this study was that the association between fatigue and anemia is low in patients with advanced cancer undergoing palliative care. Whereas there is a growing body of evidence that anemia is an important etiologic factor for fatigue in patients with early-stage cancer, it may not be as important a factor in patients with cancer undergoing palliative care. Our group has frequently observed that there does not seem to be an association between the severity of fatigue and the level of hemoglobin in the latter group of patients.

More than half of these patients had quite high hemoglobin (above 10) yet fatigue was their most severe symptom. Of note, this study apparently makes no distinction between normal hemoglobin levels in men and women. We know that for a man "above 10" or even 12 does not feel normal.

From this study an important point emerges: among previously treated cancer patients who have ceased active treatment and entered palliative care, even those who maintain virtually normal levels of red blood cells feel that fatigue is their worst symptom.

The fact remains that many cancer patients are measurably anemic, whether from hormonal suppression, during or following chemotherapy, or from advancing disease. The secondary aplastic anemia that may result from chemotherapy can interfere with active treatment plans and even become life-threatening. If your red counts drop below a certain level, a blood transfusion or medication (erythropoietin, brand names Epogen and Procrit) may treat the condition, although some advanced patients may not feel the benefit subjectively. Ask your doctor about this.

Some patients report benefit from stimulant drugs such as Ritalin (methylphenidate) or Provigil (modafinil). Provigil was not designed for cancer patients, it is used mainly to treat people with narcolepsy. It has some troublesome side effects. In a clinical trial, 74 of the 934 patients (8%) who received PROVIGIL dropped out compared to 3% of patients that received placebo. The most frequent reasons for stopping Provigil were headache, nausea, anxiety, dizziness, insomnia, chest pain and nervousness.

You or your friends and family might like to look at an online issue of the journal The Oncologist devoted to cancer-related fatigue, dated 2003. If you have the energy to scan the content you'll see one article that makes a strong plea for ACKNOWLEDGEMENT of fatigue. It's worse if you feel isolated in fatigue, this writer says:

"What a difference it would have made if my fatigue had been acknowledged! What validation I would have had. I knew that gloom was a byproduct of fatigue and not—in my case, at least—the other way around, so 'treating' the gloom would have been pointless. What a comfort there would have been, however, in knowing that my exhaustion was being monitored, was being taken seriously....

I am totally convinced that an acknowledgment of my fatigue would have alleviated many of its excesses. I was doing my utmost--a healthy diet, meditation, counseling, as much exercise as I could manage, and lots more besides--to cope with my fatigue. I needed to know that my exhaustion wasn’t the result of a want of imagination or some other lack in me or my attitude.....

I didn't need to hear of 'sleep hygiene' with its pejorative implications. Nor did I need pills or potions to block out the experience. I knew I needed to feel it all fully, if I were to grow through it, to turn it to my advantage. I knew I had healing resources within myself if I could just push through the fatigue to access them. What I needed was to be held safely in that place."

Maureen Gilbert. A Survivor's Journey: One Woman's Experience with Cancer-Related Fatigue The Oncologist, 2003

This page reported by J. Strax, last updated December 16, 2005

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