A considerable amount of literature cites fatigue as one of the most prevalent symptoms of patients with the experience of cancer. It is a prevalent side effect with cancer patients and survivors of cancer, and affects people of all ages. Approximately, 80 percent of patients undergoing radiotherapy/ chemotherapy experience cancer-related fatigue (CRF), making it the most prevalent side effect of cancer treatment. This type of fatigue is distinct from the fatigue people experience in the course of their daily activities (Kapoor et al., 2015; Bower, 2014). In this paper, causes of CRF, its manifestations among patients/survivors, and treatment interventions will be explored.
Pathophysiology and Causes of Fatigue
Based on current literature about cancer, no pathophysiological evidence has been adduced to substantiate the cause of CRF (Wang & Woodruff, 2015). However, several predisposing factors have been identified as having a close link between the causes and development of CRF. One such factor is cancer treatment.
Fatigue may be at elevated levels among patients before starting treatment. However, research has shown that fatigue increases during cancer treatment, including treatment with biological therapies, radiation, chemotherapy, and hormonal mechanisms. For instance, fatigue has been found to increase among patients with advanced forms of cancer during chemotherapy (Wang & Woodruff, 2015). According to Wang and Woodruff (2015), chemotherapy generates various toxicities that may contribute to the development of severe fatigue. Since severe fatigue may lead to discontinuation of treatment, chemotherapy can be a dose-limiting factor during cancer treatment. Moreover, chemotherapy lowers the level of hemoglobin in the body (Bower, 2014). Less hemoglobin in the body means that the supply of oxygen is limited. As a result, the body lacks the necessary nutrients hence the severe fatigue.
Since pathophysiological mechanisms behind the development fatigue are unclear, fatigue-related symptoms have been used to theorize about its development. Symptoms such as reduced appetite, pain, distress, drowsiness, and disturbed sleep have been used as a rationale for the development of the inflammation hypothesis on CRF. The hypothesis maintains that activation of the proinflammatory cytokine network causes fatigue among cancer patients undergoing treatment (Wang & Woodruff, 2015). Studies that have comprehensively investigated sickness and inflammatory markers in patients undergoing both radiotherapy and chemotherapy show that inflammation significantly correlates with fatigue (Bower, 2014).
Genetic factors play an influential role in the development of CRF. Investigations into the role of genetics are based on the evidence that has been found regarding the role of inflammation and pro-inflammatory cytokine in the development of fatigue among cancer patients/survivors. Results from these studies indicate that inflammation-related genes show greater association with fatigue before and after treatment (Bower, 2014).
Pre-treatment fatigue is the most consistent predictor of post-treatment fatigue among cancer patients/survivors. Patients who report higher levels of fatigue before undergoing radiotherapy or chemotherapy also report elevated levels after the enlisted treatment mechanisms have been administered(Wang & Woodruff, 2015; Bower, 2014). Regardless of the other factors involved in the development of fatigue among cancer patients, these findings suggest that either the presence of pre-treatment fatigue causes CRF or combines with other factors to induce fatigue.
Depression has also been cited as another contributing factor for the development of CRF. Fatigue is a common symptom of depression. Although the linkage between depression and fatigue is complex, fatigue is thought to result in depressed mood due to its tendency to interfere with occupational, social, and leisure activities. In the same breadth, exposures to extreme stress during childhood as a result of abuse or neglect have been associated with higher levels of fatigue among breast cancer survivors (Bower, 2014).
Manifestations of Fatigue among Cancer Patients/Cancer Survivors
Unusual tiredness is a characteristic manifestation of fatigue among cancer patients and cancer survivors. Tiredness manifests itself in exhaustion, general weakness, malaise, impatience, diminished attention, decreased motivation, and emotional lability (Kapoor et al., 2015; Wang & Woodruff, 2015). These symptoms may limit the patient or survivor from going doing their daily activities. The symptoms may affect the ability of the patient to maintain their livelihoods, creating further emotional problems for the affected individuals.
Anxiety and depression are common characteristic behaviors of people suffering from CRF. Many cancer patients experience anxiety and depression after diagnosis and during treatment. This problem is even more pronounced in patients who have been diagnosed with the incurable form of cancer. Given the enlisted conditions, these patients show difficulties in performing ordinary activities such as walking, cooking, and eating among others. Besides, social relationships and ability to work are affected significantly (Wang & Woodruff, 2015).As a consequence, their overall quality of life of the affected persons is diminished.
Some patients experience eating disorders. This is due to the low appetitive that characterize most fatigued patients. The low appetite for food typically reduces the amount of food consumed by the cancer patients hence the decline in energy supply necessary for the normal functioning of the body (Bower, 2014).
Priority Nursing Issue Associated with Fatigue
As noted elsewhere, CRF affects the quality of life of patients. Therefore, assessing the extent of interference with the lives of patients or survivors is an issue utmost significance for nurses. Assessment needs to include the factors that contribute to the development of the condition. The findings of from these assessments could enable clinicians to redesign patients' fatigue management with the quality of life of patients/ survivors (Borneman, 2013).
Effective pathophysiological interventions for CRF have not been established (Wang & Woodruff, 2015). However, standard interventions have been proposed to mitigate the severity of the condition. Education of patients and survivors has been proposed as one of the psychosocial mechanisms that reduce CRF. This approach seeks to modify behaviors which, in turn, help patients to reduce symptoms such as anxiety, depression, and exhaustion. Education and behavioral therapies have been found to have a moderate impact in decreasing CRF (Barsevick et al., 2013; Borneman, 2013).
Literature on CRF interventions suggests that exercise records significant effect on reduction of CRF both during and after treatment. During treatment, exercise acts as a buffer against treatment-related fatigue, whereas exercise, after the patient has undergone treatment, reduces the patient's susceptibility to fatigue (Bower, 2014).These exercises may include swimming, cycling and walking among others. However, not all exercises are effective in mitigating CRF. Evidence from meta-analyses suggests that aerobic exercises register significant reductions in CRF. Aerobic exercises administered alongside training components that focus on muscle groups have been found to be more effective in reducing fatigue than administration of aerobic exercises alone (Barsevick et al., 2013). The effectiveness of physical activity notwithstanding, Bower(2014) notes that studies that focus on fatigued patients have not been done because clinical trials enlist patients depending on given eligibility criteria. Hence, the results obtained cannot be termed as effective as the studies suggest on patients with severe fatigue.
Administration of Methylphenidate and placebo are some of the conventional drugs that are used to treat CRF. In several studies featuring placebo-controlled clinical trials, Methylphenidate, a psychostimulant, has been found to result in a higher reduction of fatigue than placebo. Studies have also shown opioids may benefit cancer patients on a short-term basis. Moreover, Modafinil, a central nervous system stimulant, has been found to be effective in treating patients with severe fatigue and sleep problems (Wang & Woodruff, 2015; Bower, 2014; Barsevick et al., 2013).
Anti-depressants are used based on the belief among cancer researchers that fatigue and depression share pathophysiological characteristics. Paroxetine has been found to result in significant reduction of depression but not fatigue. Paroxetine is more effective when used alongside placebo than when it is used as a stand-alone intervention. Antidepressants such as nortriptyline and amitriptyline have also been found to reduce sleep difficulties and depression due to their sedative qualities (Wang & Woodruff, 2015).
Barsevick, A. M., Irwin, M. R., Hinds, P., Miller, A., Berger, A., Jacobsen, P., Cella, D. (2013). Recommendations for high-priority research on cancer-related fatigue in children and adults. JNCI Journal of the National Cancer Institute, 105(19), 1432-1440. doi:10.1093/jnci/djt242
Borneman, T. (2013). Assessment and management of cancer-related fatigue. Journal of Hospice & Palliative Nursing, 15(2), 77-86. doi:10.1097/njh.0b013e318286dc19
Bower, J. E. (2014). Cancer-related fatigue-mechanisms, risk factors and treatments. Nature Reviews Clinical Oncology, 11(10), 597-609. doi:10.1038/nrclinonc.2014.127
Kapoor, A., Kumar, H., Narayan, S., Singhal, M., Bagri, P., & Beniwal, S. (2015). Cancer related fatigue: A ubiquitous problem yet so under reported, under recognized and under treated. South Asian Journal of Cancer, 4(1), 21-23. doi:10.4103/2278-330x.149942
Wang, X. S., & Woodruff, J. F. (2015). Cancer-related and treatment-related fatigue. Gynecologic Oncology, 136(3), 446-452. doi:10.1016/j.ygyno.2014.10.013
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