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What is fatigue?
Fatigue is feeling tired -- physically, mentally, and
emotionally. It means having less energy to do the things you normally
do or want to do. It can be caused by cancer, cancer treatment, and
other factors. Fatigue can last a long time and can affect your daily
routines, self-care, recreation, and relationships.
The fatigue that comes with cancer is different from the
fatigue of daily life. Everyday, normal fatigue is most often a
short-term problem that gets better with rest. Cancer-related fatigue
is worse and it causes more distress. Rest does not make it go away.
And even a little activity may make you feel exhausted. For some
people, this kind of fatigue can cause even more distress than pain,
nausea, vomiting, or depression. Cancer-related fatigue can:
- differ from one day to the next in how bad it is and how
much it bothers you
- be overwhelming and make it hard for you to feel well
- make it hard for you to be with your friends and family
- make it hard for you to do your normal activities,
including going to work
- make it harder for you to follow your cancer treatment plan
- last different lengths of time, which makes it hard to
guess how long yours will go on
Cancer patients say fatigue is the most distressing side
effect of cancer and its treatment -- it can have a major affect on a
person's quality of life.
Fatigue is very common in people with cancer
Cancer-related fatigue is the most common side effect of
cancer and cancer treatment. Research suggests that anywhere between
70% to 100% of cancer patients getting treatment have fatigue. And
about 30% to 50% of cancer survivors have said that their fatigue lasts
for months or even years after they finish treatment.
Even though fatigue is a very distressing symptom, doctors and
nurses seldom focus on it, and patients and caregivers rarely report
it. It may be hard to talk about, but fatigue is common for people with
cancer. And there are things that can be done to help if your health
care team knows you are having this problem.
Talk about your fatigue
Treating fatigue is an important part of care for you and your
family. But before anything can be done to help you, your health care
team must know about your level of fatigue, or how bad your fatigue is.
People with fatigue describe it in many ways. They may say
they feel tired, weak, exhausted, weary, worn-out, or slow. They may
say they have no energy and cannot concentrate. They also talk about
having heavy arms and legs, little drive to do anything, being unable
to sleep or sleeping too much. They may feel moody, sad, irritable, or
frustrated. Patients rarely describe their symptom as "fatigue" unless
their health care team suggests it.
Only you know if you have fatigue and how bad it is. No lab
tests or x-rays can diagnose or show your level of fatigue. The best
measure of fatigue comes from your own report of your fatigue level to
your health care team. But fatigue can be hard to describe.
You can describe your level of fatigue as none, mild,
moderate, or severe. Or you can use a scale of 0 to 10, where a 0 means
no fatigue at all, and a 10 means the worst fatigue you can imagine.
Talk to your doctor or nurse about how to describe your fatigue so they
can understand how it affects your everyday life.
How bad is your fatigue?
If you have moderate (4 to 6) to severe (7 to 10) fatigue,
your doctor may ask you to give more information about your fatigue.
You may be asked questions like:
- When did the fatigue first start?
- When did you first notice that this fatigue is different
than usual for you?
- Has it changed over time? In what way?
- Does anything make it better? Worse?
- Do you have any other problems or concerns?
- How has the fatigue affected the things you do every day or
the activities that give meaning and enjoyment to your life?
In planning how to treat your fatigue, your doctor may take
into account your cancer, the type and length of treatment, how likely
the treatment is to cause fatigue, and your response to treatment.
What causes fatigue in people with cancer?
Cancer itself can cause fatigue directly by spreading to the
bone marrow, causing anemia (uh-nee-me-uh, a low red blood cell count).
Or it can cause fatigue indirectly, by forming toxic substances in the
body that change the way normal cells work.
Fatigue is also very common with many cancer treatments, such
as chemotherapy, radiation therapy, bone marrow transplant, and
immunotherapy. Cancer treatments often kill fast-growing healthy cells,
especially the cells in the bone marrow that make blood. This causes
fatigue because red blood cells carry oxygen to fuel all the cells in
the body. Too few red blood cells (anemia) means too little energy to
meet the body's needs. Treatments can kill normal cells and cancer
cells, which leads to a build-up of cell waste. The body needs extra
energy to clean up this waste and repair damaged tissue.
Here are some questions about fatigue and your cancer
treatment that you may want to ask:
- Will the cancer treatment that I am getting cause fatigue?
- How bad will my fatigue likely get?
- Are there ways to control my fatigue or make it better?
- If my fatigue gets bad, how will you decide how to treat
it?
- What can be done if the treatment does not make my fatigue
better?
- What are the likely side effects of the treatments for
fatigue?
- What other health care professionals can help manage my
fatigue?
- Is my fatigue caused by anemia? If so, how will it be
treated?
Other things that can affect fatigue
Fatigue is different for every cancer patient. Many
treatment-related and disease-related factors have been linked to
fatigue, but doctors still don't know exactly what causes
cancer-related fatigue.
There are some other factors that often worsen fatigue, and
you should be checked for them. Managing these factors can greatly help
reduce the fatigue.
- anemia
- pain
- emotional distress (including depression and anxiety)
- sleep problems
- medicines you are taking that could make your symptoms
worse
- other medical problems (such as infection, low thyroid
function, or heart, lung, liver, kidney, or nervous system disease)
- nutrition problems
- low level of physical activity
Anemia
A low red blood cell count is called anemia. Your red
blood cell count will be measured with a blood test called a CBC. (CBC
stands for complete blood count.) Doctors often define anemia as a
blood hemoglobin (Hb) level of less than 12 g/dL (grams per deciliter).
But many people do not feel much different until the hemoglobin level
falls below 11 g/dL. Symptoms of anemia get worse as the hemoglobin
gets lower. These symptoms can include:
- fast heart beat
- shortness of breath
- trouble breathing on exertion (such as when walking or
climbing stairs)
- dizziness
- pale skin
- fatigue
There are many different causes of anemia. Your health care
team will try to find out the cause of your anemia so they can give you
treatment that makes it better.
For more information on anemia, please see our document Anemia in People With Cancer.
Pain
Cancer pain can make you less active, decrease your appetite,
cause sleep problems, and cause depression -- all of which can lead to
fatigue. Cancer pain should not be accepted as part of cancer
treatment. There is always something that can be done to make pain
better.
For more information about treating cancer pain, talk to your
doctor or nurse. You can also learn more in our document, Pain Control: A Guide for Those
With Cancer and Their Loved Ones.
Emotional distress
People diagnosed with cancer go through many unpleasant
emotions. There are many different types of feelings, from anger to
depression, but their overall effect is distress. Distress can include
a feeling of sadness about the loss of good health or fear of what will
happen in the future. These are normal feelings. But sometimes the
distress becomes so great that it causes physical problems like
fatigue. Depression and anxiety are common types of distress that can
cause the physical symptom of fatigue.
For more information on distress, see Distress in People Wth Cancer.
Sleep problems
If you wake up often during the night, have trouble falling
asleep, or wake up early in the morning and cannot go back to sleep,
you are most likely not getting the rest you need. This change in your
sleep can lead to fatigue. Tell your doctor or nurse about your
sleeping problems. They will try to find out why you are having trouble
sleeping so they can help plan the best treatment for this problem.
Medicines
Many medicines can cause symptoms of fatigue and problems with
thinking. This includes certain over-the-counter drugs, and possibly
other supplements, as well as prescription medicines. The drugs most
likely to cause fatigue are
- pain medicines
- sleep medicines
- anti-depressants
- anti-nausea medicines
- anti-seizure medicines
- certain heart medicines
The degree of sleepiness varies from patient to patient.
Taking many drugs with many side effects may make fatigue worse, too.
It is important to tell your health care team about all vitamins,
herbs, supplements, and medicines you are taking. Keeping a journal of
everything you take, along with the doses and times, and when you have
symptoms may help you find out which ones may be part of your fatigue.
Other medical problems
Many people have other medical problems or illnesses that are
not related to cancer but may add to fatigue. These illnesses should be
identified and treated. Examples of other medical problems that may be
part of fatigue are:
- heart problems, such as congestive heart failure (CHF)
- lung problems, such as emphysema or shortness of breath
- kidney problems, such as kidney failure
- brain problems, such as seizures or dementia
- infections, such as pneumonia, urinary tract infections, or
viral illnesses
- low thyroid function
Low thyroid gland function is very common in people in the
United States, and it can cause or worsen fatigue. Talk with your
doctor about getting a lab test to find out the balance of thyroid
hormones in your blood. If your thyroid is not making enough hormone,
pills can be taken to replace the thyroid hormone so that the body gets
what it needs.
Poor nutrition
The body needs protein, carbohydrates, fats, vitamins,
minerals, and water to do its work. In people with cancer, changes in
nutrition can affect fatigue. These changes include how well the body
can process nutrients and the need for more energy than usual. It can
also have to do with poor intake of food, fluids, and certain minerals.
The changes can be caused by:
- changes in metabolism (the body's ability to break down and
use food)
- the need to repair damaged cells
- uncontrolled tumor growth competing for nutrients
- poor appetite
- nausea and vomiting
- diarrhea
You may have blood tests to measure things like sodium,
potassium, calcium, and magnesium -- these are important minerals that
your body needs. You may ask to be referred to a registered dietitian
who can help you learn how to best meet your nutrition needs during
this time.
You can find more information on nutrition in our document, Nutrition for the Person With
Cancer During Treatment: A Guide for Patients and Families.
Lack of exercise
Cancer treatment along with less physical activity can make
you less able to do the things you used to do. And you may find that it
takes much more effort and more energy to do the things you need to do.
This can make fatigue worse. Physical exercise can help you build up
your energy level. If you have more energy, it can help you do your
usual activities and have less fatigue. Talk to your doctor before you
start any exercises. A careful work-up by a physical therapist can help
plan the right exercise program for you.
You can find more information in Nutrition and Physical Activity
During and After Cancer Treatment: Answers to Common Questions.
Treating fatigue
Many health professionals may be part of fatigue treatment.
Treatment may involve doctors, nurses, social workers, physical
therapists, nutritionists, and a number of others. Education and
counseling are part of the treatment and help you learn how to save
energy, reduce stress, and distract yourself from the fatigue.
Fatigue is often caused by more than one problem. Treating a
certain problem, like anemia, may make you feel better, but other
things may still need to be done. For this reason your health care team
may have you try many different things to ease your fatigue. These may
or may not include medicines.
If the cause of fatigue is known, treatment will focus on the
cause. For example, if anemia is adding to your fatigue, the anemia can
be treated. In another patient, treatment may include correcting fluid
and mineral imbalances. A program of regular exercise, managing your
stress, and finding ways to deal with anxiety and depression seem to
help most people deal with fatigue. Treating sleep problems and
correcting nutrition problems can help decrease fatigue, too.
Tips for managing fatigue
Save your energy
Saving or conserving energy is one way to make sure you have
enough energy to do what needs to be done on a daily basis. You may
need to accept the fact that you can't do everything you want to do at
your current level of energy. Each day, decide which things are the
most important to do and focus on those tasks. Do things slowly, so
that you will not use too much energy as you go. Let others help you.
This can help them feel useful and get your tasks done, too.
Distraction
Sometimes feeling tired can become so discouraging and
frustrating that it's easy to let it become the focus of your thoughts.
Try to distract yourself with other things, like listening to music,
having relaxing visits with friends or family, or reading a book. These
things can give you an escape from your fatigue without using up too
much energy.
Attention-restoring activities
Certain activities can help you relax, focus better, and
direct your attention under stress. These activities include things
like walking on a beach, sitting in a peaceful setting, gardening,
doing volunteer work not related to your illness, or bird watching.
Some people use meditation or guided imagery to clear their minds
without leaving home, using books, CDs, or other audio instructions.
Reduce stress
Having cancer is stressful and cancer treatment can cause even
more stress. Talk with a social worker or nurse on your health care
team about your level of stress. This can help you know if it is
"normal" stress or more worrisome anxiety or depression. Feeling tired
may be linked to feeling depressed and anxious. Support groups, mental
health counseling, stress management training, and relaxation exercises
are some ways you can improve the feelings related to fatigue and help
you overcome the tiredness you feel.
Exercise
Research has shown that there are some ways to improve your
energy and activity level that do not involve medicine. An aerobic
exercise program -- started only with your doctor's OK -- can lead to
better heart and lung function, as well as feeling better about your
life and well-being. You may need to see a physical therapist to learn
the best exercise routine for you to follow at this time. You must be
careful about any form of exercise if you have any of these:
- bone metastasis (cancer that has spread to your bones)
- a low white blood cell count
- a low platelet count
- a fever or active infection
- anemia
- unsteadiness, frailty, or other problem that might make
exercise unsafe for you
These factors can lead to more physical problems if they are
not taken into account when planning an exercise program.
Not only can the right amount and type of exercise help
fatigue, it can also help you sleep better. Another benefit of exercise
is that it may make your mood better, too.
Nutritional counseling
Many cancer patients have changes in the way they eat,
swallow, and taste during treatment. Talking with a registered
dietician may help you learn ways to manage problems like loss of
appetite, diarrhea, nausea, or vomiting. The dietician also can make
sure you are getting enough fluids and nutrients to help keep your
blood chemistry balanced.
Sleep improvement
Sleep problems are common during cancer treatment. You may
have trouble falling asleep or sleep too much. Sleep experts tell us
that having a regular time to go to bed and get up helps us keep a
healthy sleep routine. Avoiding caffeine in fluids (like coffee, tea,
or soda), or even in foods (like chocolate) can help, too. Do not
exercise too late in the evening; this may cause sleep problems. Naps
may be needed, but try to keep them short (20 to 30 minutes or less)
and early in the day so they don’t interfere with nighttime
sleep.
Medicines
There is no magic pill that can make you less tired and give
you more energy. But there are some medicines that may help you with
your fatigue. In some cases, fatigue may be bad enough that your doctor
or nurse may recommend a stimulant medicine for a short time. Examples
of this type of medicine are methylphenidate hydrochloride (Ritalin®)
or modafanil (Provigil®).
Anti-depressant drugs and steroids
have also been used to ease fatigue. If you are having problems
sleeping, your doctor or nurse may suggest a medicine to help you
sleep.
More research is needed and is being done in this area, but
there are drugs available that may give you relief if your fatigue gets
bad.
Coping with fatigue
Learning about fatigue patterns, how bad it might be, and how
long it may last are key parts of dealing with fatigue. Many times, a
family member who learns with you can help you talk to your health care
team about your fatigue.
Here is a recap of things you can do to manage and reduce your
fatigue:
- List your activities in order of how important they
are to you, so you can do the more important ones when you have the
most energy.
- Ask for help and have other people do tasks for you
when possible.
- Put things that you often use within easy reach.
- Set up and follow a structured daily routine,
keeping as normal a level of activity as possible.
- Balance rest and activity. Too much time in bed can
make you weak. Try to avoid it. Schedule activities so that you have
time for plenty of rest that does not interfere with nighttime sleep. A
few shorter rest periods are better than one long one.
- Learn ways to deal with your stress. Try to reduce
it using things like deep breathing, imagery, meditation, prayer,
talking with others, reading, listening to music, painting, or any
other things you like to do.
- Keep a record of how you feel each day. Take it
with you when you see your doctor.
- Talk to your doctor about how to manage any pain,
nausea, or depression you may have.
- Talk to your doctor about physical exercise before
you start an exercise program.
- Get fresh air, if possible.
- Unless you are given other instructions, eat a
balanced diet that includes protein (meat, milk, eggs, and beans) and
drink about 8 to 10 glasses of water a day.
The first thing to do for fatigue is talk to your doctor or
nurse about it. Let them know how bad it is so you can get the help you
need to deal with it.
Watch for signs of fatigue
Here is a list of some signs of fatigue that you and your
family can watch for. Talk to your doctor if you have any symptoms of
fatigue.
- You feel tired and it does not get better, it keeps
coming back, or it becomes severe.
- You are more tired than usual during or after an
activity.
- You are feeling tired and it is not related to an
activity.
- Your tiredness does not get better with rest or
sleep.
- You can't concentrate or focus your thoughts.
- You are unable to get out of bed for more than 24
hours.
- Your tiredness disrupts your work, social life, or
daily routine.
- You have no desire to do the things you normally
do.
- You feel negative, sad, or irritable.
Fatigue can lead to distress. It can interfere with your daily
activities and keep you from doing the things you need and want to do.
Fatigue can make you unable to take care of yourself, affect your will
to do things, and sometimes make you feel like you cannot continue your
cancer treatment. Work with your health care team to find and treat the
causes of your fatigue.
Remember: There is no one way to diagnose or treat fatigue.
The best treatment for you is most likely to be found through open
discussions with your doctor and your nurse.
Additional resources
More information from your American Cancer
Society
We have selected some related information that may also be
helpful to you. These materials may be viewed on our Web site or
ordered from our toll-free number.
The following books are available from the American Cancer
Society. Call us to ask about costs or to place your order.
National organizations and Web sites*
Along with the American Cancer Society, other sources of
information and support include:
CancerCare
Toll-free number: 1-800-813-4673
Web site: www.cancercare.org
Offers counseling by phone, and support from others with cancer online
and by phone. Cancer information also available
National Cancer
Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER)
TTY: 1-800-332-8615
Web site: www.cancer.gov
Offers a special online module about fatigue in English and Spanish at:
www.nci.nih.gov/cancerinfo/pdq/supportivecare/fatigue/patient/
Also offers information on cancer, coping, and clinical trials
OncoLink
Web site: www.oncolink.org
Information on cancer and coping with symptoms, including fatigue
*Inclusion on this list
does not imply endorsement by the
American Cancer Society.
No matter who you are, we can help. Contact us anytime, day or
night, for information and support. Call us at 1-800-227-2345 or
visit
www.cancer.org.
References
Breitbart W, Alici Y. Pharmacologic treatment options for
cancer-related fatigue: current state of clinical research. Clin J
Oncol Nurs. 2008 Oct;12(5 Suppl):27-36.
Carroll JK et al. Pharmacologic Treatment of Cancer-Related
Fatigue. The Oncologist.
2007. 12 (Supplement 1): 43.
Díaz N, Menjón S, Rolfo C, et al.
Patients' perception of cancer-related fatigue: results of a survey to
assess the impact on their everyday life. Clin Transl Oncol.
2008
Nov;10(11):753-757.
Jacobsen PB, Donovan KA, Vadaparampil ST, Small BJ. Systematic
Review and Meta-Analysis of Psychological and Activity-Based
Interventions for Cancer-Related Fatigue. Health Psychol.
2007. 26:
660–667.
National Comprehensive Cancer Network. NCCN Clinical Practice
Guidelines
in Oncology. Cancer-Related Fatigue – V.1.2009. Accessed at:
www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf on August 19,
2009.
Rao AV, Cohen HJ. Fatigue in older cancer patients: etiology,
assessment, and treatment. Semin
Oncol. 2008 Dec;35(6):633-642.
Last Medical Review: 09/01/2009
Last Revised: 09/01/2009
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