What is Cancer Related Fatigue?

Fatigue or extreme weakness is common in patients suffering from cancer. Cancer related fatigue (CRF) causes persistent and excessive exhaustion that can interfere with a patient’s daily activities. Fatigue can often be difficult to assess, as there are no objective ways to measure it..

It is usually described as a feeling of overwhelming exhaustion that does not reduce even after rest or sleep. Some people describe it as muscle weakness and difficulty in concentrating..

CRF usually begins before the diagnosis of cancer and can worsen during the course of therapy. It may persist for a few months to several years, even after the treatment has ended..

Regular exercise, adequate nutrition, stress management, psychological support, and healthy lifestyle changes may boost energy levels and improve the patient’s ability to cope with CRF. Untreated CRF, on the other hand, may affect a person’s physical and emotional health negatively..

Fortunately, the awareness regarding CRF is growing, and research studies are uncovering treatments to reduce it..
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What Causes Cancer Related Fatigue?

CRF may occur due to several factors, such as:

• Blood cancer, including leukaemia, myeloma, lymphoma, myeloproliferative neoplasms, myelodysplastic syndromes.
• The side effects of therapies, including radiation, chemotherapy, immunotherapy, surgery, stem cell transplantation, and other medications used for the treatment of blood cancers..
  

When cancer patients start receiving treatment, most of them are already tired due to medical tests and surgery, as well as the emotional stress of dealing with the cancer diagnosis. Once the treatment begins, fatigue may become worse and lower a patient’s energy level further..

CRF may be caused by other factors such as:
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Anaemia
Anaemia or a low red blood cell count may occur in blood cancers as the cancer cells accumulate in the bone marrow. These cells start interfering with the production of normal red cells that carry oxygen to all the tissues resulting in fatigue.
Anaemia may also be worsened or caused by cancer therapies. Most cancer treatments kill cancer cells. However, they can also destroy the normal blood-forming cells in your bone marrow, thus reducing the ability of the bone marrow to form new red cells.
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Increased Inflammatory Activity
Abnormal activation of the immune cells may worsen cancer related fatigue. Natural chemicals such as “cytokines” typically released by white cells in response to infections cause inflammation in the body. Cancer and cancer treatments can disrupt cytokine levels and worsen inflammation in the tissues, thus causing fatigue..

A high level of cytokines may also disrupt the secretion of serotonin, a hormone that affects a person’s sense of well-being and regulates moods and sleep. Very high or low production of serotonin might also contribute to CRF.
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HPA (Hypothalamic, Pituitary, Adrenal) Axis Dysfunction
The effect of cancer and cancer treatments on the hypothalamus, pituitary gland, and adrenal gland can result in the release of a stress hormone, cortisol. Cortisol can influence the regulation of cardiovascular functions, blood pressure, immune functions and carbohydrate metabolism.

Cancer and cancer treatments, especially those using corticosteroids, might reduce cortisol levels released in the body and thus, cause fatigue.
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Circadian Rhythm Disruption
Cancer and cancer treatments may disrupt the circadian rhythm and hence affects the sleep-wake cycles.
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Cancer Treatments
Cancer treatments may destroy healthy cells. The body needs to use extra energy to make more cells in order to heal tissues damaged during treatment. This extra energy consumption can contribute to feeling fatigued. Additionally, cancer treatments may cause a build-up of toxins in the body which will also make the patient feel more tired.
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Predisposing Factors in Cancer Related Fatigue

Several factors may predispose a person to develop CRF. Some of them include:

• Anaemia
• Poor nutrition
• Lack of physical fitness
• Sleep disturbances
• Mood Changes
• Anxiety and depression
• Life stressors related to cancer
• Financial stress and changes in the patient’s routine resulting from cancer treatment.
• Disrupted sleep, decreased appetite, limited physical activities, and depression caused by pain.
• Co-existing health problems, including underactive thyroid, sleep apnoea, infections, neurological disorders, cardiovascular issues, and poor heart, kidney, lung, or liver functions..
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What Are the Signs & Symptoms of Cancer Related Fatigue?

Patients with CRF usually feel physically and mentally drained..

The common signs of fatigue include:

• Mood swings
• A sensation of muscle weakness or physical heaviness
• Sleeping too little or too much
• Depressed mood
• Lack of restorative sleep
• Avoidance of social activities
• Lack of motivation
• Difficulty in maintaining focus or concentration\.

Cancer related fatigue may also be reflected in the patient’s cognition, moods, and changes in social interactions in various ways, including:

• Depressed or anxious moods
• Negative thinking
• Lack of motivation
• Anger and irritability
• Inability to focus or concentrate
• Reduced mental alertness
• Loss of memory
• Strain in relationships
• Withdrawal from social and leisure activities.

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What is the treatment for Cancer Related Fatigue?

CRF is often caused by more than one factor. Therefore, the physical or psychological symptoms must be treated by one or a combination of the following treatments at the same time.

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Treatment of Anaemia
Treating anaemia helps to reduce weakness in patients with CRF. The treatment for anaemia may include:

• Changes in diet and eating foods rich in iron and vitamins
• Taking iron and other vitamin supplements.
• Blood transfusions to increase red cell levels faster. The transfusion of red cells may alleviate the symptoms of anaemia and ensure sufficient oxygen is supplied to all the vital organs.
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Exercise
Exercises that increase blood circulation may reduce inflammation in healthy tissues and prevent fatigue. Patients who exercise can derive benefits such as:

• Feeling less depressed
• Feeling less tired
• Sleeping better
• Having greater energy levels, strength, and stamina..

Exercises, which have a mind-body component, including yoga, qigong, and tai chi, may be more effective for reducing fatigue. These exercises include physical elements such as stretching, movements, controlled breathing, and balancing as well as spiritual practices and stress management techniques such as meditation. This may help to improve the patient’s overall sense of well-being. Other physical activities such as walking, yoga, riding a stationary bicycle, water exercises, swimming, and strength training may also alleviate CRF and increase energy levels.
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Treatment of Depression
Patients diagnosed with moderate to severe depression may benefit from specialised therapies, including medications and counselling. Stress management training and support groups may help patients deal with CRF associated with depression, thus improving the quality of life...

Psychosocial interventions that relieve stress and improve psychosocial support such as counselling, coping strategies, and stress management may also help to reduce fatigue and raise energy levels...

Cognitive-behavioural strategies, including progressive muscle relaxation and relaxation breathing, can also relieve cancer related fatigue and it may also be useful for improving sleep behaviours and preventing sleep disturbances.
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Nutrition Counselling
It is common for cancer patients to develop loss of appetite, diarrhoea, nausea, and vomiting due to cancer or cancer treatments. They can seek the advice of a dietitian to ensure that they are getting adequate calories, nutrients, and fluids needed for supporting the body’s functions and staying as active as possible.
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How Can I Manage Cancer Related Fatigue?

Be Flexible
Avoid measuring yourself by your pre-diagnosis energy levels and set realistic goals. Accept that you may not be able to carry out all the activities that you want every single day. You can decide which tasks are more critical to complete and focus on accomplishing them daily. Also, when feeling too tired, allow others to help you.
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Distract Yourself
Shift your focus from CRF by listening to music, looking at beautiful pictures, reading a book, meeting friends, going for a walk, watching a movie, and enjoying time in nature.
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Stay Active
Staying physically active often helps patients to avoid fatigue. You can exercise at least 3 to 5 times a week to prevent severe fatigue. You can adjust your exercise program if you feel too tired. Light exercises, such as walking, may help you to feel relaxed and allow you to sleep better. Focus on physical activities that help to build strength gradually but do not deplete your energy levels.
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Practice Healthy Dietary Habits
Patients with cancer have a higher risk of malnutrition due to nausea, vomiting, loss of appetite, and the reduced ability of the intestine to absorb nutrients due to cancer itself or cancer treatments. This can be avoided by eating a balanced diet that provides sufficient proteins, fluids, calories, vitamins, and minerals to the body..

Here are some dietary interventions that will help you avoid CRF:

• Maintain high energy levels by eating small but frequent meals or snacking throughout the day.
• Since iron intake is also vital, consume iron-rich foods, including red meat and green leafy vegetables.
• Drink plenty of water or non-caffeinated beverages throughout the day.
• Work with a dietitian to make a plan that suits your caloric needs.
• Learn how to cook healthy snacks and meals.
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Manage Stress
Mental stress can be offset, to some extent, through exercises, mindfulness meditation, relaxation techniques, religious and spiritual practices, counselling, and socialising.
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Address Sleep Habits
Practise relaxing activities such as meditation, taking a warm shower or bath, writing in a journal, reading a book, yoga, and listening to soothing music before bedtime..

Here are some simple tips to improve sleep and reduce Cancer Related Fatigue:

• Go to sleep at the same time each night.
• Avoid daytime naps as it may interfere with your nighttime sleep. If you must take a nap, avoid sleeping for longer than thirty minutes.
• Keep your bedroom quiet, cool, and dark.
• Use comfortable sleepwear and bedding.
• Use the bedroom for sleeping only.
• Avoid playing video games, watching television, or using a computer, cell phone, and social media before bedtime as these stimulate the brain making it harder to fall asleep.
• Avoid alcohol, caffeine, or high-sugar foods before sleeping.
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Ask for Help
Don’t hesitate to ask for help with your routine tasks such as cooking, shopping, housekeeping, driving, and laundry. Take rest whenever you feel tired.
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Plan Ahead
Try to schedule your cancer treatments when it will have the least effect on your routine activities, including your job.
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Keep a Journal
Keep a journal to track your symptoms of fatigue. Make notes related to the symptoms such as:

• The severity of fatigue on a scale of 0 to 10
• The time when fatigue occurs
• How it affects your daily activities
• How long the fatigue lasts
• Treatments or activities that make you feel better or worse
• Symptoms accompanying fatigue such as pain or tiredness in the legs and eyes, difficulty in concentrating, sleepiness, irritability, shortness of breath, and impatience.

Make a note of daily activities, treatments, medications, sleeping and eating habits, emotional stressors, and weight changes in the journal. Write down the strategies that worked to reduce fatigue..

A detailed journal of your symptoms will help you when you discuss the possible causes, coping strategies, and treatments with our doctors and nurses

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FAQs

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Disclaimer:
The information on the Centre For Clinical Haematology website is intended for educational use.  It should not be considered or used as a substitute for medical advice, diagnosis or treatment from a qualified health professional.