A Clinician's Approach to Fatigue of Cancer Patients Jau-Yih Tsauo PT, PhD, Professor National Taiwan University

Outline Standards of care of cancer-related fatigue CRF screening & assessment CRF management Conclusions

ICD-10 criteria for CRF The following symptoms have been present every day or nearly every day 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. 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. Postexertional fatigue lasting several hours. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is evidence from the history, physical examination, or laboratory findings that the symptoms are a consequence of cancer or cancer therapy. The symptoms are not primarily a consequence of comorbid psychiatric disorders such as major depression, somatization disorder, somatoform disorder, or delirium.

What is Cancer-related Fatigue? CRF is related to cancer or cancer treatment which causes physical, emotional and /or cognitive tiredness or exhaustion and interferes patients’ functioning. CRF is reported at all age groups and all stages of the cancer, prior to, during and following treatment. So, CRF should be screened, assessed and managed for all the cancer patients.

Standards of Care of CRF NCCN Clinical Practice Guidelines

Screening & Assessment Age 5-6 y/o: not tired, tired Age 7-12 y/o: 1-5 scale 1-2: mild 3: moderate 4-5: severe Age >12 y/o: 0-10 scale 0-3: none to mild 4-6: moderate 7-10: severe

Non to Mild Not tired in age 5-6, scores 1-2 in age 7- 12, or scores 0-3 in age>12 Education Active treatment Post treatment End of life General strategies to manage fatigue

Non to Mild: Active Treatment

Non to Mild: Post Treatment

Non to Mild: End of Life

Moderate to Severe Tired in age 5-6, scores 3-5 in age 7-12, or scores 4-10 in age>12 Education Fatigue is not an indicator of disease progression Self-monitoring of the fatigue level Expected the end-of life symptom and the fatigue intensity may vary Primary evaluation Interventions

Primary Evaluation

Interventions: Active Treatment

Interventions: Post Treatment

Interventions: End of Life

Activity Enhancement (I) Fatigue: ** during cancer treatment following cancer treatment Aerobic capacity: 11/22: significant difference between intervention and control group 3/22: significant pre-post difference 8/22: non significant difference Quality of life: -- Anxiety: -- Depression: -- Cramp et al, 2008

Activity Enhancement (II) ↑functional capacity so↓effort in activities 15~45min/session (no more than I hour) 1-5 sessions/week 3~32 weeks, average: 12 weeks 25~80% age-predicted HRmax (220-age) walk, bicycle, ergometer, treadmill, yoga, tai-chi, multidimensional (aerobic+stretching+resistance exercise) group/individualized, supervised/home-based , mixture of supervised and home-based

Psychosocial Interventions Education: energy conservation and activity management to balance rest and activity planning, delegating, prioritizing, pacing, resting Support group Individual counseling Comprehensive coping strategy Stress management training Behavioral intervention

Sleep Therapy Stimulus control Sleep restriction Sleep hygiene go to bed when sleepy, get out of bed after 20 min of wakefulness Have a routine bedtime and rising time Sleep restriction avoidance of long or late day naps Limiting total time in bed Sleep hygiene caffeine and exercise avoidance near bedtime comfortable sleep surroundings (dark, relaxing…) soothing activities at bedtime (music, …)

Conclusions

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