The burden of fatigue has now overtaken nausea and pain as the most distressing symptom during chemotherapy. It has been described as tiredness, exhaustion, depression, feeling unwell, loss of motivation and limitation of mental state. Over 75% of patients complain of fatigue and in up to a third this can be severe, considerably impacting their quality of life and ability to care for themselves and others. Fatigue and tiredness can have a negative impact on cancer management by impairing nutritional state, reducing compliance or preventing the required dose being administered.

Clinician awareness of fatigue has improved but not so long ago studies showed that clinicians underestimated the importance of fatigue in their patients. For example, Dr Vogelzang from Philadelphia reported that about a third of consultants felt that fatigue was the most important symptom for their patients whilst nearly 70% of the same patients described it as the worst side effect of chemotherapy.

Fatigue can also persist post treatments, A recent study in women who had completed adjuvant chemotherapy for breast cancer eloquently demonstrated the extent of this problem in a group of women, many of whom had children to look after or get back to work. Over half reported significant fatigue at 6 months and 20% at a year had not recovered.  Other causes of fatigue need to be excluded, many other which, particularly an under active thyroid, can be easily treated. The biggest drug related culprit in men with prostate can is Zoladex, which reduces the male hormone, testosterone and this can persist for several months post treatment. In women tamoxifen and other hormones such as the aromatase inhibitors (arimidex, exemestane & femara) can all cause fatigue.  

Fatigue is common with the following cancer treatments:

• post surgery

• chemotherapy

• radiotherapy

• hormone therapy  (tamoxifen, zoladex, aromatase inhibitors)

• biological therapies

Other medical causes of fatigue:

• anaemia

• pain

• poor sleep hygiene

• pain killers, antidepressants, anti-sickness

• organ failure and salt imbalance

• depression or anxiety

• thyroid deficiency

• alcohol or drug abuse

• travelling (car sickness)

Treating fatigue

The first steps in treating cancer related fatigue should be directed to correcting these other possible causes, particularly anaemia which responds well to simple medications. With these other issues excluded lifestyle strategies, particularly exercise, are the next line of attack. If anaemia is present, it is important to find the underlying cause and treat it as this increases the oxygen carrying capacity of the body and oxygen is important for a number of reasons:

• it improves energy levels

• it reduces fatigue

• it improves the general condition of the bodies organs particularly liver and kidney whose functions are imperative to cope with the bombardment of chemicals general given at this time 

• oxygen is also required for radiotherapy and probably chemotherapy to work effectively

In one trial of patients with head & neck cancers those with a lower haemoglobin before radiotherapy had a significantly worse outcome than those with a higher haemoglobin even though neither were not classes as clinically anaemic. Lack of oxygen at the edges of tumour also a stimulus for new blood vessels formation which eventually feeds the tumour and forms a pathway for them to spread around the body. This process is called angiogenesis and is the subject of current intense medical research.

What can you do to help?

There are several other strategies which have been shown to help treatment related fatigue. Not sleeping adequately at night is a major issue for many tired patients. Pain or getting up to pass water is factors which can be helped with medical intervention but often there are no specific causes. Following a sleep hygiene program (see appendix) has been shown in trials to help many people. Over the years other coping lifestyle strategies have been reported to helpful for many fatigue suffers and these are summarised in the table below:

Fatigue coping tactics:

Eat a healthy, balanced diet. Foods which give you sustained energy such as carbohydrates (bread, potatoes) are important.  Avoid refined sugar in foods producing peaks and troughs in glucose levels.

Rest - Periods of rest or cat naps are beneficial taken throughout the day between activities

Exercise - Regular aerobic exercise has been shown to prevent worsening of fatigue and psychological stress in patients receiving chemotherapy and biological therapies. In the studies which showed this, the definition of aerobic is exercise in which a negative oxygen balance does not occur or put another way it is not too strenuously that it uses up more oxygen in the blood stream than can be replaced by breathing, albeit at a faster pace – this generally would include walking, gentle running, dancing, cycling, rowing etc. Other recent studies have suggested that transitory periods of anaerobic exercise are particularly helpful. In practical terms this means pushing the exercise rate briefly to a higher level of oxygen consumption which the lungs can replace at that instance. On stopping, breathlessness continues until the oxygen deficit is restored – this is quite normal and the body is completely used to it. We’ve all sat on a bus panting for a few minutes after we have had to run for it! Anaerobic exercise has the advantage of opening up the lungs by taking deep breaths, keeping them flexible, compliant and generally in an all round better condition. It also stimulates the body’s natural erythropoietin hormone (epo) which gives the bone marrow a signal to make more blood. A recent trial, for example, involving women receiving radiotherapy from Michigan showed that those who participated in exercise 20 - 45 minutes 3 – 5 times a week had a significantly greater haemoglobin (red blood cells) and lower fatigue that their more sedentary counterparts. 

Distraction tactics - Listening to stimulating tapes or music. A drive for a change of scenery or a visit to friends or family are examples of diversionary activities. Try to keep a comfortable temperature and avoid being too hot or cold.

Sleep hygiene - Try to get the most of of a nights sleep. See advice on sleep hygiene for some tips.

Task management - You cannot now do everything yourself. Organise family and other carers including social workers to help you with daily activities especially the heavy one.

Further general information Your doctors and specialist nurses are in an ideal position to give you relevant information on your disease and treatment as they know your individual circumstances. Cancerbackup has a help line (0808 800 1234) and a prize winning video available in English, Italian, Urdu, Bengali, Gujarati & Hindi explaining Radiotherapy & Chemotherapy. Cancernet.co.uk has over 500 pages describing cancer, its management, practical tips and tool which patients, their carers and their doctors have found helpful during the cancer journey.