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Cancer-associated fatigue

Definition
Cancer-associated fatigue is a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion associated with cancer and/or cancer treatment, which is non-proportional to recent activity and interferes with usual functioning.
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Pathophysiology
Cancer-associated fatigue is multifactorial and involves medical factors (comorbidities, medications, nutritional disorders), psychosocial factors (mood disturbance), behavioral factors (physical deconditioning), and biological factors (anemia, cytokine dysregulation, hypothalamic-pituitary-adrenal axis dysregulation, 5-HT neurotransmitter dysregulation, and alterations in ATP and muscle metabolism).
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Disease course
Cancer-associated fatigue and exhaustion is often accompanied by pain, mood changes, sleep disturbances, lack of appetite, decreased activity, and reduced QoL and performance.
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Prognosis and risk of recurrence
Cancer-associated fatigue is associated with increased all-cause mortality in patients with solid tumors.
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Key sources
The following summarized guidelines for the evaluation and management of cancer-associated fatigue are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2022), the Canadian Association of Psychosocial Oncology (CAPO 2017), and the American Society of Clinical Oncology (ASCO 2014).
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Guidelines

1.Screening and diagnosis

Indications for screening
Obtain routine screening for the presence of fatigue in patients with cancer from the point of diagnosis onward, including after completion of primary treatment.
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Screen all patients for fatigue as clinically indicated and at least annually.
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  • Choice of screening tool

2.Diagnostic investigations

Clinical assessment
As per APTA 2022 guidelines:
Use the following tools for the assessment of cancer-associated fatigue in patients with cancer:
functional Assessment of Chronic Illness Therapy-Fatigue
revised Piper Fatigue Scale
patient Reported Outcome Measurement Information System Fatigue-Short Forms v1.0-Fatigue (4a, 6a, 7a, 7b, 8a, 13a)
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Consider using the following tools for the assessment of cancer-associated fatigue in patients with cancer:
brief Fatigue Inventory
cancer Fatigue Scale
multidimensional Fatigue Inventory 20
fatigue Symptom Inventory
patient Reported Outcome Measurement Information System Bank v1.0-Fatigue Computerized Adaptive Testing
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  • Laboratory evaluation

3.Medical management

General principles: as per CAPO 2017 guidelines, treat contributing factors and/or refer for further specialist evaluation.
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  • Pharmacological agents

  • Assessment of treatment response

4.Nonpharmacologic interventions

Physical activity
As per CAPO 2017 guidelines:
Advise engaging in moderate-intensity physical activity for at least 30 minutes on ≥ 5 days of the week in all patients.
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Recognize that all types of physical activity at lower intensity (such as walking and yoga) may contribute to decreasing fatigue during and after active cancer treatment.
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  • Psychosocial interventions

  • Alternative treatments

  • Dietary supplements

5.Patient education

General counseling: as per CAPO 2017 guidelines, provide routine patient education about fatigue self-management in all patients.
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6.Follow-up and surveillance

Indications for specialist referral
As per CAPO 2017 guidelines:
Promote access to multicomponent, group psychoeducation programs targeted at targeted to self-management techniues.
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Offer referral to experts or fatigue clinics experienced in CBT targeted to fatigue in patients and survivors with chronic cancer-related fatigue.
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