Cancer-related Fatigue | Evaluation (2)

Cancer and Fatigue : evaluation of fatigue

After the initial assessment with uni dimensional tool, a detailed assessment is necessary to evaluate and treat the fatigue.

Multi-dimensional scales:

These scales or tools are best suited for research purposes as they evaluate various aspects of fatigue.

Here's a few factors which should be evaluated in the initial assessment before using the tools:

• hemoglobin levels
• other medications
• pain intensity
• fever/infection
• psychological distress
• depression
• anxiety
• malnutrition or deficiencies

The patient's information should be updated on the evaluation sheet. The name, age and sex should be noted.
Having access to patient's treatment information is extremely important.
The following should be NOTED :

• Diagnosis- type and stage of cancer
• Current treatment- chemo/radio , drugs and dosage
• Relevant past treatment history( if any)
• Surgical history
• Hemoglobin levels

Then, further detailed evaluation can be made asking the following questions:

1. Do you experience fatigue or tiredness?

2. If yes, could you describe the pattern of fatigue, like when does it begin, how bad does it get, what relieves it, etc ?

3. How are you getting along with the treatment?

4. Are your sleeping habits and resting patterns changed? (time, duration, etc)

5. Has your appetite reduced?

6. Are you continuing your job/ work ?

Then, a complete physical examination should ideally be done mainly to assess-

•  muscle wasting
•  gait
•  posture changes
•  range of motion, etc

Then, one of the following available scales can be used to assess Cancer-related Fatigue.

1. Fatigue Symptom Inventory
This is a 14 point scale which is quite efficient and simple.
http://labpages.moffitt.org/jacobsenp/Copy/FSI%20English%20Version.pdf

2. Multidimensional Fatigue Symptom Inventory
This contains 30 statements and the most suitable answer has to be marked.
http://www.cas.usf.edu/~jacobsen/MFSI-SF%20English%20Version.pdf

3. Brief Fatigue Inventory
It is a short tool consisting of 4 questions and 6 sub-questions to the 4th one.

The above mentioned scales are easily available and can be used easily by translating into suitable languages for the patients.
Many other scales are also available like-

4. Piper Fatigue Self-Report Scale

5. The Schwartz Cancer Fatigue Scale

6. Lee's Visual Analog Scale for Fatigue

7. Cancer Fatigue Scale

8. The Functional Assessment of Cancer Therapy-Fatigue

9. The Functional Assessment of Cancer Therapy-Anemia

10.The Profile of Mood States of Fatigue?Inertia Subscale

Also, there are
Fatigue Intensity Scales
Fatigue/Function measures
The Fatigue Severity Scale

After collecting the data, correct interpretation should me made and the fatigue levels should be noted.
This is done by using the outcome measure methods that every individual scale has.

These scales are useful for the patients as well because it will help them self-assess their fatigue to a certain extent .
This will also help them understand the pattern of change in their fatigue levels.

Also read
5 reasons why you should study Oncology.
Cancer and surgery.
What is Radiation oncology?
What is Cancer-related fatigue?
What is psycho-oncology?
12 causes of cancer.
Cancer in 21st century.

Cancer-related Fatigue | Evaluation (1)

 Cancer and Fatigue: evaluation of fatigue

As I mentioned earlier, fatigue is a self-perceived state which is multi-dimensional in nature. Hence, it requires to be assessed using multi-dimensional tools or scales which evaluate all possible aspects of fatigue. This will help formulate a better treatment plan for every individual.

There are many scales available and appropriate for evaluation of Cancer-related Fatigue.

Uni-dimentional scales:
These simple scales can be used in busy clinical set-ups and also for quick follow-ups.
These scales do not evaluate every aspect of fatigue. However, they are used widely in clinical practice.

For example-

• Verbal rating scale (none, mild, moderate, severe)
• Linear analog scale assessment (LASA)
• Numerical rating scale

Numerical Rating Scale

• These scales can be useful in case of children.
• If the patient claims to have a very high level of fatigue then he/she can be evaluated for other factors like psychological distress, pain, co-morbidities, anemia, nutrition deficiency, sleep, etc.
• One of these scales can also be used as the 1st step of evaluation of fatigue which should be followed by a multi dimensional scale.

Also , a few simple questions regarding fatigue can be used. For example,

• Are you/ have you been experiencing fatigue?

• If yes, how severe has it been in the past week ? (use the numerical rating scale)

• Is the fatigue interfering in you activities of daily living, your ability to concentrate, your work, etc

Also read
 5 reasons why you should study Oncology.
Cancer and surgery.
What is Radiation oncology?
What is Cancer-related fatigue?
What is psycho-oncology?
12 causes of cancer.
Cancer in 21st century.

  

Cancer-related Fatigue | Diagnosis

Diagnosing Cancer-related Fatigue (CRF)

When a patient complains of cancer fatigue symptoms, then Cancer-related Fatigue should ideally be diagnosed with multi-dimensional tools which measure more than just the intensity and severity of fatigue. It should also mention other aspects of fatigue like:

• frequency of fatigue
• interference of fatigue on daily activities
• timing and duration of fatigue, etc.

The proposed criteria for Cancer-related Fatigue (CRF) are listed below.This could be useful for health professionals who are likely to diagnose Cancer-related Fatigue. These criteria have not been validated for use as of now. But, they can be used as basic guidelines for diagnostic purposes.

ICD-10 Criteria for Cancer-related Fatigue

The following symptoms have been present every day or nearly every day during the same 2-week period in the past month.

image courtesy-jpalliativecare.com

After diagnosing, the fatigue levels have to be evaluated using uni dimensional tools or multi dimensioal tools. It is only after evaluation , that fatigue can be managed effectively.

Also read

5 reasons why you should study Oncology.

Cancer and surgery.

What is Radiation oncology?

What is Cancer-related fatigue?

What is psycho-oncology?

12 causes of cancer.

Cancer in 21st century.

Cancer-related Fatigue | Symptoms

What are the symptoms of Cancer-related fatigue?

In the previous post Causes of fatigue we came across various causes.
We can divide cancer-fatigue symptoms into two categories namely- Cancer fatigue symptoms before treatment and after.

When we talk about cancer fatigue symptoms before treatment, we are talking about unexplained and unexpected fatigue that lasts for quite some time.This fatigue is mostly not debilitating and is not a major obstacle in the daily activities, but is present to an extent that is noticeable.
However, the intensity will vary from person to person and also with various cancers and their stages.It may be totally absent in some cases.
This fatigue is present as a result of a myriad of changes going on inside the body because of cancer.

When we talk about cancer-related fatigue after the treatment has begun, like a cycle of chemotherapy, radiotherapy or a surgery for diagnosis or removal of tumor, this fatigue is present because of all the external changes mentioned above.
The causes of fatigue are mentioned in the previous article.

Now, lets talk about various symptoms of cancer fatigue and related to cancer fatigue.

Fatigue is totally a self-perceived state.It's like pain, only the person experiencing it will know it's presence, its intensity, it's character, etc.

It is not quite possible for a health professional to know the level of fatigue very accurately but there are ways of measuring fatigue using various scales which will be discussed in further articles.
Hence, the health professional will have to rely on the way patient describes his/her fatigue for making a diagnosis of Cancer-related fatigue.

image courtesy: cancernetwork.com

The patient may describe fatigue as or related to :

• feeling tired
• feeling very weak
• experiencing lack of energy
• feeling worn out
• feeling clumsy
• feeling washed out
• feeling irritable
• feeling sleepy all the time
• lack of concentration
• feeling drained
• have difficulty doing usual activities
• feeling sluggish
• feeling drowsy in the day
• feeling angry at everyone/about everything around
• feeling exhausted, etc

The health professional may describe fatigue as or related to:

• cachexia
• asthenia
• malaise
• lassitute
• weakness
• exhaustion
• exercise intolerence, etc.

Lets see how we can  diagnose cancer-related fatigue using proposed criteria for Cancer -related fatigue as a diagnostic tool.

Also read
5 reasons why you should study oncology.
Cancer and people.
What is Cancer-related fatigue?
What causes fatigue?
How to evaluate Cancer-related Fatigue using multi-dimensional tools?

Cancer-related Fatigue | Causes

What are the causes of Cancer-related Fatigue?

In the previous article Cancer and fatigue, an introduction we saw what is cancer-related fatigue, and how it differs from healthy fatigue.To understand Cancer-related fatigue, we need to better understand the underlying causes and various other factors which can be and have been associated with it.
Fatigue, like pain, is a subjective feeling and its intensity varies from person to person.Hence, this makes it difficult, if not impossible, to measure its intensity and know its characteristics objectively.
The causes and factors mentioned here will strongly vary, and will depend upon variables like:

• Type of cancer
• Stage of cancer
• Treatment protocol
• Other medications
• Other underlying diseases
•  Level of activity before and after the disease
• Fitness level before the disease, etc

The causes of fatigue can be as following :

1. Cancer:
The disease itself is known to cause fatigue in individuals with advanced stage who are not taking any treatment for the same. A very well known symptom of cancer is rapid unexplained weight- loss. This could be the primary reason for constant fatigue as it leads to development of anorexia, cachexia or asthenia. This leads to over all physical de-conditioning of the person. The tumor when growing, may lead to hormonal imbalance too.Depending on the type of cancer and the invasion of tumor to other parts/ metastasis, there can also be involvement of lungs, heart and neuro-muscular components.All these changes in the body can lead to development of fatigue, which is mild in character.

2. Cancer treatment:
The major treatment modalities include Surgery, Chemotherapy , Radiotherapy, Biotherapy, etc.
Surgery-
This is done for diagnosis or treatment purpose.The postoperative fatigue exists even in non-cancer patients who have undergone a surgery.
Characteristics-This type of fatigue however diminishes with time but may be reinforced by fatigue due to other treatment modalities.

Chemotherapy-

This is a major contributor for generating fatigue. All the chemotherapy agents contain either the products of cell death or cell damage, and it does not spare even the healthy cells of the body, hence affecting the healthy tissues and organs too.
Characteristics-Fatigue is seen to be at its peak during the chemotherapy cycle and gradually reduces after the cycle, but never disappears totally.

Radiotherapy-

Fatigue is the most common side effect of radiation therapy.
Characteristics-This may seem to be increasing after the treatment is finished and remains for quite sometime.

Biotherapy-These agents are directly associated with cytokines, which is a known contributor towards fatigue.The intensity of fatigue varies with the dosage of the bio-therapeutic agents.

3. Psychological stress/ Depression:
The diagnosis itself can be very distressing for any individual who was leading a very normal life prior to that.This will definitely cause a lot of changes in a person's life all of a sudden which is very difficult to cope up with.Undergoing all the tests, procedures and treatments also takes its toll on the body and mind of a person.All this leads to a vicious cycle of depression and stress which results into its physical manifestation as fatigue.This is again very relative and subjective.Individuals who deal with the diagnosis in a better manner might experience lesser fatigue than the ones who can't.

4. Anemia:

Anemia is nothing but reduced Hemoglobin in the red blood cells, which is a carrier of oxygen.Anemia can be caused by Cancer and its treatments too. Anemia is a single most prevalent contributor to symptoms in cancer patients.Prevalence of anemia is high and it is closely associated with fatigue.

5. Nutrition deficiency:
In healthy individuals, fatigue occurs if the energy requirements of the body are more than the available energy sources within the body.
In individuals with cancer, there can be various causes of  nutrition deficiency like
Decreased energy intake due to nausea, vomiting, etc
Increased demand for energy due to growth of tumor.

6. Other medications:

Medications other than chemotherapeutic agents like
 Opioids, given to deal cancer pain can be a major contributor due to its sedative properties.
Tricyclic antidepressants, analgesics,antiemetics,antihistamines,beta blockers,etc also may lead to perception of fatigue.

7. Poor sleep hygiene:
Disturbance in the sleep-wake cycle is a common finding.For eg, increased day-time sleep and reduced night-time sleep. This leads to a very non-restorative kind of sleep, and hence leads to higher perception of fatigue.

8. Pain:
A constant experience of pain must be very tiring. Pain is very much directly related to fatigue.

Other factors:
There can be many other factors which lead to cancer- related fatigue like-
underlying infection
dehydration
inactivity
cognitive impairments,etc.

See Cancer Fatigue Symptoms for more information.

Also read
What are the symptoms of Cancer-related fatigue?
How to diagnose Cancer-related Fatigue?
How to evaluate fatigue?
How to evaluate fatigue using multi-dimensional tools?
Causes of Cancer

5 reasons why you should study Oncology.

What is Cancer-related Fatigue?

Cancer-related Fatigue : an introduction

    Fatigue is one of the major issues in survival of many cancer patients and yet has been given very little attention. Fatigue is the most common side effect of cancer as a disease and its treatments  in the form of chemotherapy, radiotherapy or selective biological response medication,etc.
    This introductory article will address the issue of fatigue and answer the preliminary questions like 'what is fatigue', 'is there a difference between healthy fatigue and fatigue experienced by cancer patients', etc.

•   What is fatigue?

Fatigue is the feeling of tiredness or weariness experienced by a person. It does not have a huge impact on the functional ability of a healthy person. This is because the fatigue experienced by healthy individuals is generally due to physical exertion like working more than usual or taking a gym class after a long day's work.After which, the body signals that it's tired or fatigued, and after adequate rest, there remains no sign of it whatsoever. But, the exhaustion or fatigue that develops due to malignant tissues in cancer and the action of the therapeutic agents used against it is unique in intensity and character.

•    Is there a difference between healthy fatigue and fatigue that cancer patients experience?

Yes, there is.Healthy fatigue is described as acute or short term fatigue generated because of exertion, that is relieved by sleep and rest .Whereas the fatigue that cancer patients experience is not generated because of exertion  and is never completely relieved by sleep or rest. Cancer related fatigue is generally seen with associated problems like anemia, respiratory obstruction, hormonal imbalance, depression, and poor quality of life, etc.

Healthy fatigue is in proportion to the extent of physical exertion, but cancer related fatigue is disproportionate to the same.
For example, a healthy individual will experience fatigue after a long day's work and there's no sign of it the next morning. Whereas, a cancer patient will experience fatigue even without any sort of activity done, this fatigue might stay throughout the day, and may remain the same even after sleep.

• What is cancer treatment related fatigue/cancer-related fatigue?

This fatigue is developed because of cancer and its treatments.It may  be observed in patients with advanced cancer who are not under any medication for cancer.This fatigue is seen during the chemotherapy regime and after the radiotherapy cycle is completed.And also after surgeries. This is generated because of the drugs and their side effects on the body.

Cancer treatment related fatigue can be categorized as chronic fatigue because it is present over a long period of time and interferes with the normal functioning and results into poor quality of life .This may improve after therapy or treatment is completed but a certain level of fatigue persists for months or years following the treatment making this a significant issue in survivorship. The fatigue generated due to cancer and its treatments together is known as 'Cancer-related fatigue' or( CRF). This was recently accepted as a diagnosis in the International Classification of Diseases 10th Revision-Clinical Modification.

Causes of fatigue are discussed in the next post Causes of Cancer-related fatigue.

Also read
Cancer-related Fatigue symptoms
How to diagnose Cancer-related fatigue?
How to evaluate Cancer-related fatigue using simple tools?
How to evaluate fatigue using multi-dimensional tools?
What are the causes of Cancer?