3. Cancer – Related – Fatigue Sign o f human vulnerability Relevant in modernoncology Complex aetiology and impact Challengingfor research Multidimensionality Anaemia Fragments of discovery
4. 0% 50% 10% 20% 30% 40% 60% 70% 80% 90% 100% Percent of Citizens with Fatigue in 12 Countries v. Percent of Cancer Patients with Fatigue in 6 Studies N A C C E R Aren’t all individuals tired ? (Morrow 2007)
5. Fatigue in patients with cancer (CRF) What is it and how is it called by patients in your language?
20. Fatigue: Key Theoretical Causative Issues Energy supply and energy transformation Muscle-metabolism, muscle endurance Cytokines Metabolic, biochemical changes Symptoms, Symptom-clusters Treatment induced side effects Cognitive responses Psychosocial, spiritual issues
21. Addressing Fatigue: Overcoming Barriers The first steps of fatigue management are awareness, communication and assessment Patient barriers: - reluctant to report, is inevitable, unimportant, untreatable Patients speak about fatigue in routine practice only if subject is addressed by professionals – they belief that professionals would introduce it if important Professional barriers: Lack of fatigue documentation , reimbursement issues System barriers: Lack of supportive care referrals , specialist consult. Borneman T, Piper B et al. J Nat Canc Netw. 2007, 5 (10):1092-101
28. Cause-related treatment Fatigue as a door opener for communication Glaus A, Fatigue. In: Knipping C, Lehrbuch Palliative Care, 2006, 247-256
29. Screening or / and measuring fatigue? Simple question “How are you?” May reflect general experience of quality of life Interchangeable concepts fatigue and general quality of life? More specific open question “are you tired?” The sixth vital sign? Single scale e.g. “not unusually tired to totally exhausted” Validated fatigue questionnaire for specific fatigue-diagnosis, treatment and research Fact-F, MFI, FAQ (in German)
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32. Comprehensive Assessment first! Disease status Treatment Response to treatment Physical assessment Detailed fatigue assessment Pain, emotion. distress, sleep disturbance, anaemia, hypo-thyreoidismus (Mock 2000) Co-morbidities cardiac, pulmonary, renal, hepatic, neurologic, endocrine, infection List of medication Nutritional and metabolic status: weight, caloric intake, fluid, electrolytes; sodium, potassium, calcium, magn. Activity: changes in exercise / activity patterns Deconditioning
33. The Gang of seven (Piper 2008) Fatigue intensity, duration, (ICD 10 diagnosis) 1 Anaemia 2 Pain 3 Sleep disorder 4 Emotional distress (depression / anxiety) 5 Physical activity patterns, changes, deconditioning 6 Nutritional, metabolic status: weight, caloric- and fluid intake; electrolytes; sodium, potassium, calcium, magnesium 7 Co-morbidities cardiac, pulmonary, renal, hepatic, neurologic, endocrine, infection List of medication
34. Fatigue Intervention-Categories Physical exercise Sleep enhancement Rest and activity balance Treating other symptoms, incl. anaemia Pharmacological interventions Psychological, cognitive, spiritual interventions “Good medical and nursing care” others
35. Fatigue Interventions: Physical Exercise Myth: exercise expenses energy rather than reduces CRF Evidence: most effective fatigue intervention Aim: Decrease loss of physical performance and increase functional capacity Expected outcome: exercise may break the cycle of deconditioning (Mock 1997) Theory: Cancer or its treatment lead to decreased activity-> results in reduced physical performance -> low physical performance results in higher fatigue levels Practical advice: avoid inactivity (Schmitz KH 2010)
36. Physical Exercise Against Fatigue: Evidence NCCN 2008: overall 40-50% reduction of CRF Mock V 2005: Reduction of fatigue and better sleep Mock V 2008: Sign. higher oxygen uptake in exercisers, improved fitness and functional status Dimeo F 2008: Reduction of fatigue and increase in physical performance with resistance programme Cramp F et al. 2008: Overall beneficial (meta-analysis)
37. Pysical Exercise: Methods Encouraging all patients to maintain as normal level of activity as possible: (NCCN 2011) For pts with substantial deconditioning: Low level exercise, comfort and symptom limited exercise, Donelly C, 2008 Individually tailored ex. Programme (fitness, co-morbidities): van Weert 2008 Walking, 30 Min. 3-5 times a week (breast ca pts) Mock 2005 Bicycling (pts with BMT), Dimeo 1998 Resistive strength training (pts with prostate c.), Dimeo 2007 Dancing, Swimming Very short exercise with rest intervals in advanced disease
38. Physical Exercise: Side Effects Barriers (Courneya 2008) Difficulties during adjuvant Chemotherapy (10-15%): Feeling sick Too tired to exercise Positive Less fatigue Improved mood, self-esteem Better sleep quality Increased overall Quality of life Helps maintaining weight Rule: Exercise no longer than 60 minutes Length: from 6 weeks to 6 months ore more
39. Psychological, Behavioural Interventions Emotional support, fundamental fatigue alleviating interv. Emotional distress in 70% of pts prevalent, association of fatigue with depression, sadness, anxiety established, emotions may change perception of fatigue Depression remains unrecognised in over 50% of patients -> Lost opportunity to alleviate fatigue Distinguish depression from fatigue: identify feelings of guilt, worthlessness, listlessness, sadness, suicidal thoughts
40. Targeted, Emotional Support: Methods 75% of patients are supported by skilled communication with primary physicians and nurses (most common and effective method of emotional support) 25% of patients need further support by specialists Tailored, indiv. counselling reduces distress, enhances self-concept and reduces fatigue (Trijsburg 1992) Cognitive behavioural therapy reduces fatigue in post-cancer patients (Gielissen 2007) Verbal and non-verbal communication with professional or non-professional counsellors; art therapy, relaxation, distraction Group support meetings Structured interventions, incl. health education Telephone Follow-Up (Yennurajalingam S et al. 2010)
41. Managing Fatigue: Other Methods Correct anaemia (11 to 13 g/dl) and control other symptoms, assess for symptom-clusters (pain, fatigue, sleep, depression) (Barsevik 2007) Sleep amelioration/therapy, rest and activity balance -Fatigue modification through optimising sleep quality -Reduce wake time by exercise (Pain 2008) -Nap-Plan : limitation to less than 1 hour (NCCN 2011) A day off from nursing ? Address nutrition, hydration, micronutrients, vitamins Glucocorticoids and progestational steroids Treating depression
42. Targeted Interventions: Psychotropic Medication Exclude potentially treatable, underlying causes first! Systematic review suggests effectiveness; Minton et al. 2008 Methylphenidate (Ritalin) small but significant improvement Antidepressant Paroxitene: no superiority over placebo; NCCN no longer recommends antidepressants as treatment; Some benefit has been observed when fatigue is a clinical sign of depression (Breitbart 2007) Modafinil(use in narcolepsy): A systematic review concludes its effectiveness in residual fatigue associated with depression (Lam 2007). No effect as long acting drug (Moraska A et al. 2010)
43. Managing Fatigue: Complimentary Methods With some effect, further research needed Attention restoring activities (Cimprich 2000); interrupt emotional drainage (e.g. art, nature) Relaxation (no difference to exercise, Dimeo) Acupuncture, Relaxation-Acupunture in survivors (Zick 2011) Yoga (lyengar) pilot tested (Bower J 2011) Light treatment (Demiralp M, in press) L-Carnitine in advanced cancer ? No convincing results
44. Managing Fatigue: Summary Awareness and Screening for persons at risk comes first Assess and treat relevant fatigue more specifically Diagnose type of fatigue (emotional, physical, cognitive) and identify targeted intervention: Exercise programme; Balancing Activity-Rest Emotional support with targeted methods Symptom management: Anaemia, Depression, Pain , sleep Psychotropic medication Support in ADL, energy conserving & complem. Methods Coping with, accepting fatigue; protection and shielding from suffering (EAPC-Approach, Radbruch 2008) Allow patients to feel tired, live in solidarity with the weak
45. Cancer Related Fatigue: Further Research Type and dose of drugs (e.g. Methylphenidate) Lack of staging system, which is the cut off for fatigue? Comparability: Heterongeneity of study populations , different contributors to fatigue Are higher levels of fatigue predictors of non-response in advanced cancer ? Do supportive interventions, such as phone calls from nurses or physicians alleviate fatigue? Complex multidimensional syndrome: which is the main contributing factor ? Targeted approach needed
46. Outlook Combined approach most likely (counselling, physical activity, correcting hormonal or metabolic abnormalities, drugs for body composition, treating inflammation, brain functions Development of personalised treatment based on identification of contributing factors to fatigue in a given patient, followed by evidence based combined therapy