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

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

3. 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.

4. 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.

5. Standards of Care of CRF
NCCN Clinical Practice Guidelines

6. 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

7. 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

8. Non to Mild: Active Treatment

9. Non to Mild: Post Treatment

10. Non to Mild: End of Life

11. 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

12. Primary Evaluation

13. Interventions: Active Treatment

14. Interventions: Post Treatment

15. Interventions: End of Life

16. 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

17. 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

18. 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

19. 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, …)

20. Conclusions

21. Thank you for your attention! Questions?