Some of my patients, who are getting or after chemo treatment completion, complain of feeling severe exhaustion. One patient reported of feeling good in the morning. But she would get severe fatigue by the time she takes the morning shower. NCCN defined this Cancer-Related-Fatigues (CRF) as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and that interferes with usual functioning.
CRF seems to be common. 60% to 90% of cancer patients report fatigue with the highest rate of CRF occurring in patients undergoing chemotherapy. Although symptoms may improve after treatment, they can persist for months to years after the completion of therapy. We don’t know the cause of CRF but recent research supports a role for dysregulation in inflammation and hypothalamic-pituitary-adrenal function.
The recommended CRF treatment is to treat possible comorbid medical conditions, including anemia, pain, depression, insomnia and hypothyroidism. However, the relationship between these symptoms is complex, and it is not clear whether treating comorbid symptoms will actually improve fatigue. For example, trials of nonpharmacologic interventions for insomnia that demonstrated improvement in sleep failed to show benefit for fatigue. Nonetheless, it is still important that other primary symptoms are addressed, such as depression.
No medications have been successful in treating CRF. Psychostimulants, such as methylphenidate, dexamphetamine and modafinil, have not been clearly shown to improve CRF in clinical trials
Antidepressants have also been investigated for the treatment of CRF but showed no clear value in treating CRF. A randomized trial, studying paroxetine versus placebo in patients with cancer undergoing chemotherapy, found no influence on levels of CRF. Open label, pilot trials of bupropion in CRF appear promising, but need further validation. A large, randomized, controlled clinical trial compared donepezil (acetylcholinesterase inhibitor used to treat dementia ) with placebo, reporting no difference in levels of CRF between groups.
Studies on spplements such asL-carnitine, and coenzyme Q10 have been completed and showed no value. Data from the ginseng trial is under analysis. Guarana is a plant from the Amazon basin used in the United States in energy drinks and weight loss products showed some promises based on a randomized, controlled trial by Brazilian investigators.
Interestingly, exercise may save the day. Meta-analyses evaluating the effect of a variety of exercise programs on CRF found that physical exercise helped reduce CRF. Effect sizes ranged from 0.18 to 0.37, with the larger effect size in patients who completed treatment. Common sense strategies such as education about fatigue, teaching self-care or coping techniques, and energy conservation or activity management seem to be effective.
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