Managing Fatigue

 

 

Don't Statement

Click Here to download this page in PDF format.

Don’t neglect to advise patients with cancer to get physical activity and exercise during and after treatment to manage fatigue and other symptoms.
 

Rationale

Fatigue is a common symptom among both adult and pediatric patients with cancer. During treatment for cancer, fatigue is seen in 25–99% of patients (Goedendorp, Gielissen, Verhagen & Bleijenberg, 2009; Kim, Dodd, Aouizerat, Jahan & Miaskowski, 2009), and it has been reported that 38% of individuals continue to experience persistent fatigue for years after completion of treatment (Carlotto, Hogsett, Maiorini, Razulis, & Sonis, 2013). Late fatigue has a significant impact on quality of life and is associated with increased unemployment (Carlotto, Hogsett, Maiorini, Razulis, & Sonis, 2013).   

It is the natural tendency for people to try to get more sleep and rest when feeling fatigued.  Patient-oriented internet sites emphasize saving energy rather than emphasizing exercise to combat fatigue, although exercise is shown to be one of the most effective interventions to address fatigue (American Cancer Society, 2012; National Institutes of Health, 2012). Health care providers have traditionally been educated about the importance of getting rest and avoiding strenuous activity when ill. In work done to test and validate quality measures for early breast cancer patients conducted by the Oncology Nursing Society, it was found that only 9.79% of sites involved provided any exercise recommendation as an intervention for fatigue (Fessele, Yendro, & Mallory, 2014), indicating a clear need and opportunity for improvement in management of this symptom during treatment.

In contrast to these traditional views, resistance and aerobic exercise have been shown to be safe, feasible, and effective to reduce symptoms of fatigue during multiple phases of cancer care. Exercise has also been shown to have a positive effect on symptoms of anxiety and depression.

Background

Beliefs about and approaches to the role of being sick have traditionally incorporated the idea that when one is ill, one needs to get more rest and avoid exertion to promote healing. A couple of early studies aimed at fatigue management in cancer focused on energy conservation and activity management counseling to “save energy” for prioritized tasks or activities and plan rest periods to accomplish this. These had a modest positive effect (Barsevik et al., 2004; Barsevick, Whitmer, Sweeney & Nail, 2002). This practice has been incorporated into multiple palliative care guidelines and patient information websites.  Since that time there is extensive strong evidence that exercise is more beneficial for alleviation and reduction of fatigue as well as other symptoms in patients with cancer, during treatment, after treatment, and for those with advanced disease. 

Evidence

  • Exercise has been shown to significantly reduce fatigue in multiple studies (Andersen et al., 2013; Bourke et al., 2011; Buss et al., 2010; Cantarero-Villanueva et al., 2013; Carayol et al., 2013; Chang, Mu, Jou, Wong, & Chen, 2013; Cheville et al., 2010; Cheville et al., 2013; Coleman et al., 2012; Eyigor,  Karapolat,  Yesil, Uslu, & Durmaz, 2010; Hayes et al., 2013; Hoffman et al., 2013; Hoffman et al., 2014; Hsieh et al., 2008; Litterini & Fieler, 2008; Oldervoll et al., 2011; Rajotte et al., 2012, Saarto et al., 2012; Schmidt, Weisser, Jonat, Baumann, & Mundhenke, 2012; Wang, Boehmke, Wu, Dickerson, & Fisher, 2011; Wenzel et al., 2013; Yang, Tsai, Huang, & Lin, 2010; Yeh, Man Wai, Lin, & Chiang, 2011; Yeo et al., 2012).
  • Studies were done in patients with breast, colon, and prostate cancers; postoperative patients; patients undergoing stem cell transplantation; long-term cancer survivors; and individuals with advanced disease. Systematic reviews and meta-analyses confirm the efficacy of exercise for fatigue (Arnold & Taylor, 2010; Bradt, Goodill, & Dileo, 2011; Brown et al., 2011; Cramp & Byron-Daniel, 2012; Keogh & Macleod, 2011; Kuchinski, Reading, & Lash, 2009; McMillan & Newhouse, 2011; Mishra et al., 2012; Payne, Wiffen, & Martin, 2012; Puetz & Herring, 2012; van Haren et al., 2013; Velthuis, Agasi-Idenburg, Aufdemkampe, G., & Wittink, 2010; Wanchai, Armer, & Stewart, 2011).
  • Exercise is recommended in several professional guidelines for fatigue (National Comprehensive Cancer Network, 2014; NHS Scotland, 2009; Schmitz et al., 2010).
  • There is good evidence to show that exercise can reduce anxiety (Smith, Cope, Sherner & Walker, 2014) and depression (Fulcher, Kim, Smith & Sherner, 2014) among patients with cancer.

References

American Cancer Society. (2012, December 10). Fatigue in people with cancer. Retrieved from http://www.cancer.org/acs/groups/cid/documents/webcontent/002842-pdf.pdf

Andersen, C., Rørth, M., Ejlertsen, B., Stage, M., Moller, T., Midtgaard, J., . . . Adamsen, L. (2013). The effects of a six-week supervised multimodal exercise intervention during chemotherapy on cancer-related fatigue. European Journal of Oncology Nursing, 17,331–339. doi:10.1016/j.ejon.2012.09.003

Arnold, M., & Taylor, N. F. (2010). Does exercise reduce cancer-related fatigue in hospitalised oncology patients? A systematic review. Onkologie, 33, 625–630. doi:10.1159/000321145

Barsevick, A. M., Dudley, W., Beck, S., Sweeney, C., Whitmer, K., & Nail, L. (2004). A randomized clinical trial of energy conservation for patients with cancer-related fatigue. Cancer, 100, 1302–1310. doi:10.1002/cncr.20111

Barsevick, A. M., Whitmer, K., Sweeney, C., & Nail, L. M. (2002). A pilot study examining energy conservation for cancer treatment-related fatigue. Cancer Nursing, 25, 333–341. doi:10.1097/00002820-200210000-00001

Bourke, L., Thompson, G., Gibson, D. J., Daley, A., Crank, H., Adam, I., . . . Saxton, J. (2011). Pragmatic lifestyle intervention in patients recovering from colon cancer: A randomized controlled pilot study. Archives of Physical Medicine and Rehabilitation, 92, 749–755. doi:10.1016/j.apmr.2010.12.020

Bradt, J., Goodill, S. W., & Dileo, C. (2011). Dance/movement therapy for improving psychological and physical outcomes in cancer patients. Cochrane Database of Systematic Reviews, 2011(10). doi:10.1002/14651858.CD007103.pub2

Brown, J. C., Huedo-Medina, T. B., Pescatello, L. S., Pescatello, S. M., Ferrer, R. A., & Johnson, B. T. (2011). Efficacy of exercise interventions in modulating cancer-related fatigue among adult cancer survivors: A meta-analysis. Cancer Epidemiology, Biomarkers & Prevention, 20,123–133. doi:10.1158/1055-9965.EPI-10-0988

Buss, T., de Waln-Gałuszko, K., Modlińska, A., Osowicka, M., Lichodziejewska-Niemierko, M., & Janiszewska, J. (2010). Kinesitherapy alleviates fatigue in terminal hospice cancer patients—An experimental, controlled study. Supportive Care in Cancer, 18, 743–749. doi:10.1007/s00520-009-0709-0

Cantarero-Villanueva, I., Fernández-Lao, C., Cuesta-Vargas, A. I., Del Moral-Avila, R., Fernández-de-las-Peñas, C., & Arroyo-Morales, M. (2013). The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 221–230. doi:10.1016/j.apmr.2012.09.008

Carayol, M., Bernard, P., Boiché, J., Riou, F., Mercier, B., Cousson-Gélie, F., … Ninot, G. (2013). Psychological effect of exercise in women with breast cancer receiving adjuvant therapy: What is the optimal dose needed? Annals of Oncology, 24, 291–300. doi:10.1093/annonc/mds342

Carlotto, A., Hogsett, V. L., Maiorini, E. M., Razulis, J. G., & Sonis, S .T. (2013). The economic burden of toxicities associated with cancer treatment: Review of the literature and analysis of nausea and vomiting, diarrhoea, oral mucositis and fatigue. PharmacoEconomics, 31, 753–766. doi:10.1007/s40273-013-0081-2

Chang, C.-W., Mu, P.-F., Jou, S.-T., Wong, T.-T., & Chen, Y.-C. (2013). Systematic review and meta-analysis of nonpharmacological interventions for fatigue in children and adolescents with cancer. Worldviews on Evidence-Based Nursing, 10, 208–217. doi:10.1111/wvn.12007

Cheville, A. L., Girardi, J., Clark, M. M., Rummans, T. A., Pittelkow, T., Brown, P., . . . Gamble, G. (2010). Therapeutic exercise during outpatient radiation therapy for advanced cancer: Feasibility and impact on physical well-being. American Journal of Physical Medicine and Rehabilitation, 89,611–619. doi:10.1097/PHM.0b013e3181d3e782

Cheville, A. L., Kollasch, J., Vandenberg, J., Shen, T., Grothey, A., Gamble, G., & Basford, J. R. (2013). A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: A randomized controlled trial. Journal of Pain and Symptom Management, 45, 811–821. doi:10.1016/j.jpainsymman.2012.05.006

Coleman, E. A., Goodwin, J. A., Kennedy, R., Coon, S. K., Richards, K., Enderlin, C., . . . Anaissie, E. J. (2012). Effects of exercise on fatigue, sleep, and performance: A randomized trial. Oncology Nursing Forum, 39,468–477. doi:10.1188/12.ONF.468-477

Cramp, F., & Byron-Daniel, J. (2012). Exercise for the management of cancer-related fatigue in adults. Cochrane Database of Systematic Reviews, 2012(11). doi:10.1002/14651858.CD006145.pub3

Eyigor, S., Karapolat, H., Yesil, H., Uslu, R., & Durmaz, B. (2010). Effects of pilates exercises on functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer patients: A randomized controlled study. European Journal of Physical and Rehabilitation Medicine, 46, 481–487. Retrieved from http://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2010N04A0481

Fessele, K., Yendro, S., & Mallory, G. (2014). Setting the bar: Developing quality measures and education programs to define evidence-based, patient-centered, high quality care. Clinical Journal of Oncology Nursing. 14.7-11. doi: 10.1188/14.CJON.S2.7-11

Fulcher, C. D., Kim, H., Smith, P.R. & Sherner T.L. (2014) Putting evidence into practice: Evidence based interventions for depression. CJON 18. 26-37.doi: 10.1188/14.CJON.S3.26-37.

Goedendorp, M. M., Gielissen, M. F. M., Verhagen, C. A., & Bleijenberg, G. (2009). Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database of Systematic Reviews, 2009(1). doi:10.1002/14651858.CD006953.pub2

Hayes, S. C., Rye, S., DiSipio, T., Yates, P., Bashford, J., Pyke, C., . . .  Eakin, E. (2013). Exercise for health: A randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer. Breast Cancer Research and Treatment, 137,175–186. doi:10.1007/s10549-012-2331-y

Hoffman, A. J., Brintnall, R. A., Brown, J. K., von Eye, A., Jones, L. W., Alderink, G., . . .  VanOtteren, G. M. (2013). Too sick not to exercise: Using a 6-week, home-based exercise intervention for cancer-related fatigue self-management for postsurgical non-small cell lung cancer patients. Cancer Nursing, 36, 175–188. doi:10.1097/NCC.0b013e31826c7763

Hoffman, A. J., Brintnall, R. A., Brown, J. K., von Eye, A., Jones, L. W., Alderink, G., . . . VanOtteren, G. M. (2014). Virtual reality bringing a new reality to postthoracotomy lung cancer patients via a home-based exercise intervention targeting fatigue while undergoing adjuvant treatment. Cancer Nursing, 37, 23–33.  doi:10.1097/NCC.0b013e318278d52f

Hsieh, C. C., Sprod, L. K., Hydock, D. S., Carter, S. D., Hayward, R., & Schneider, C. M. (2008). Effects of a supervised exercise intervention on recovery from treatment regimens in breast cancer survivors. Oncology Nursing Forum, 35,909–915. doi:10.1188/08.ONF.909-915

Keogh, J. W. L., & Macleod, R. D. (2011). Body composition, physical fitness, functional performance, quality of life, and fatigue benefits of exercise for prostate cancer patients: A systematic review. Journal of Pain and Symptom Management, 43,96–110. doi:10.1016/j.jpainsymman.2011.03.006

Kim, J.-E. E., Dodd, M. J., Aouizerat, B. E., Jahan, T., & Miaskowski, C. (2009). A review of the prevalence and impact of multiple symptoms in oncology patients. Journal of Pain and Symptom Management, 37, 715–736. doi:10.1016/j.jpainsymman.2008.04.018

Kuchinski, A., Reading, M., & Lash, A. A. (2009). Treatment-related fatigue and exercise in patients with cancer: A systematic review. MEDSURG Nursing, 18,174–180. Retrieved from https://www.amsn.org/professional-development/periodicals/medsurg-nursing-journal

Litterini, A. J., & Fieler, V. K. (2008). The change in fatigue, strength, and quality of life following a physical therapist prescribed exercise program for cancer survivors. Rehabilitation Oncology, 26, 11–17. Retrieved from http://www.oncologypt.org/publications/rehabilitation-oncology-journal/volumes/26/26-3-Rehabilitation-Oncology-Journal.pdf

McMillan, E. M., & Newhouse, I. J. (2011). Exercise is an effective treatment modality for reducing cancer-related fatigue and improving physical capacity in cancer patients and survivors: A meta-analysis. Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 36, 892–903. doi:10.1139/h11-082

Mishra, S. I., Scherer, R. W., Geigle, P. M., Berlanstein, D. R., Topaloglu, O., Gotay, C. C., & Snyder, C. (2012). Exercise interventions on health-related quality of life for cancer survivors. Cochrane Database of Systematic Reviews, 2012(8). doi:10.1002/14651858.CD007566.pub2

National Comprehensive Cancer Network. (2014). NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue [v.1.2014]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf

National Institutes of Health. (2012, May). Surviving cancer: Fatigue. Retrieved from http://nihseniorhealth.gov/lifeaftercancer/fatigue/01.html.

NHS Scotland. (2009). Palliative care guidelines. Retrieved from http://www.palliativecareguidelines.scot.nhs.uk/default.asp

Oldervoll, L. M., Loge, J. H., Lydersen, S., Paltiel, H., Asp, M. B., Nygaard, U. V., . . . Kaasa, S. (2011). Physical exercise for cancer patients with advanced disease: A randomized controlled trial. Oncologist, 16, 1649–1657. doi:10.1634/theoncologist.2011-0133

Payne, C., Wiffen, P. J., & Martin, S. (2012). Interventions for fatigue and weight loss in adults with advanced progressive illness. Cochrane Database of Systematic Reviews, 2012(1). doi:10.1002/14651858.CD008427.pub2

Puetz, T. W., & Herring, M. P. (2012). Differential effects of exercise on cancer-related fatigue during and following treatment: a meta-analysis. American Journal of Preventive Medicine, 43(2), e1–e24. doi:10.1016/j.amepre.2012.04.027

Rajotte, E. J., Jean, C. Y., Baker, K. S., Gregerson, L., Leiserowitz, A., & Syrjala, K. L. (2012). Community-based exercise program effectiveness and safety for cancer survivors. Journal of Cancer Survivorship, 6,219–228. doi:10.1007/s11764-011-0213-7

Saarto, T., Penttinen, H. M., Sievänen, H., Kellokumpu-Lehtinen, P. L., Hakamies-Blomqvist, L., Nikander, R., . . . Luoma, M. L. (2012). Effectiveness of a 12-month exercise program on physical performance and quality of life of breast cancer survivors. Anticancer Research, 32,3875–3884. Retrieved from http://ar.iiarjournals.org/content/32/9/3875.long

Schmidt, T., Weisser, B., Jonat, W., Baumann, F. T., & Mundhenke, C. (2012). Gentle strength training in rehabilitation of breast cancer patients compared to conventional therapy. Anticancer Research, 32,3229–3233. Retrieved from http://ar.iiarjournals.org/content/32/8/3229.long

Schmitz, K. H., Courneya, K. S., Matthews, C., Demark-Wahnefried, W., Galvão, D. A., Pinto, B. M., . . . American College of Sports Medicine. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise, 42, 1409–1426. doi:10.1249/MSS.0b013e3181e0c112

Smith, P., Cope, D., Sherner, T.L. & Walker, D.K. (2014) Update on research based interventions for anxiety in patients with cancer.  CJON 18. 5-16.doi: 10.1188/14.CJON.S3.5-16

van Haren, I. E., Timmerman, H., Potting, C. M., Blijlevens, N. M., Staal, J. B., & Nijhuis-van der Sanden, M. W. (2013). Physical exercise for patients undergoing hematopoietic stem cell transplantation: Systematic review and meta-analyses of randomized controlled trials. Physical Therapy, 93, 514–528.  doi:10.2522/ptj.20120181

Velthuis, M. J., Agasi-Idenburg, S. C., Aufdemkampe, G., & Wittink, H. M. (2010). The effect of physical exercise on cancer-related fatigue during cancer treatment: A meta-analysis of randomised controlled trials. Clinical Oncology (Royal College of Radiologists (Great Britain)), 22, 208–221. doi:10.1016/j.clon.2009.12.005

Wanchai, A., Armer, J. M., & Stewart, B. R. (2011). Nonpharmacologic supportive strategies to promote quality of life in patients experiencing cancer-related fatigue: A systematic review. Clinical Journal of Oncology Nursing, 15, 203–214. doi:10.1188/11.CJON.203-214

Wang, Y.-J., Boehmke, M., Wu, Y.-W., Dickerson, S. S., & Fisher, N. (2011). Effects of a 6-week walking program on Taiwanese women newly diagnosed with early-stage breast cancer. Cancer Nursing, 34(2), E1–E13. doi:10.1097/NCC.0b013e3181e4588d

Wenzel, J. A., Griffith, K. A., Shang, J., Thompson, C. B., Hedlin, H., Stewart, K. J., . . . Mock, V. (2013). Impact of a home-based walking intervention on outcomes of sleep quality, emotional distress, and fatigue in patients undergoing treatment for solid tumors. Oncologist, 18, 476–484. doi:10.1634/theoncologist.2012-0278

Yang, C .Y., Tsai, J. C., Huang, Y. C., & Lin, C. C. (2010). Effects of a home-based walking program on perceived symptom and mood status in postoperative breast cancer women receiving adjuvant chemotherapy. Journal of Advanced Nursing, 67,158–168. doi:10.1111/j.1365-2648.2010.05492.x

Yeh, C. H., Man Wai, J. P., Lin, U.-S., & Chiang, Y.-C. (2011). A pilot study to examine the feasibility and effects of a home-based aerobic program on reducing fatigue in children with acute lymphoblastic leukemia. Cancer Nursing, 34, 3–12. doi:10.1097/NCC.0b013e3181e4553c

Yeo, T. P., Burrell, S. A., Sauter, P. K., Kennedy, E. P., Lavu, H., Leiby, B. E., & Yeo, C. J. (2012). A progressive postresection walking program significantly improves fatigue and health-related quality of life in pancreas and periampullary cancer patients. Journal of the American College of Surgeons, 214,463–475. doi:10.1016/j.jamcollsurg.2011.12.017.