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Please note: This article is part of the Cancer Center's News Archive and is here for historical
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Cancer and Fatigue: Advances in Solving the Puzzle
-Bernadine Cimprich, Ph.D., R.N.,
Assistant Professor of Nursing
Program Director, Quality of Life Research
Fatigue, manifested as a global sense of loss of energy,
is the most frequently reported source of distress associated
with breast cancer, regardless of treatment modality (1).
Fatigue has been reported in 58% to 95% of women treated for
breast cancer. Numerous studies of symptom distress have indicated
a high prevalence of fatigue during and following adjuvant
chemotherapy for breast cancer with few observed differences
in the clinical pattern of fatigue among standard chemotherapeutic
regimens (2). Prospective studies also have consistently shown
that fatigue is a distressing symptom during radiation therapy
following breast-conserving surgery, increasing in severity
over the course of treatment (3). Increased use of multiple
treatment modalities for breast cancer, including high-dose
chemotherapeutic regimens and biotherapeutic agents, may compound
the problem of fatigue in breast cancer patients. Few prospective
studies, however, have compared possible differences in incidence
and severity of fatigue among various breast cancer treatment
modalities. Finally, fatigue often becomes a chronic, unexplained
post-treatment problem in long-term survivors of breast cancer
that persists even years after completion of treatment (4).
Impact of Fatigue
A patient's descriptive report of the sensation of fatigue,
such as being tired, weary or worn out, belies the complexity
and impact of the problem (1). Cancer-related fatigue should
not be confused with the normal, adaptive sensation of tiredness
that one experiences after a day's hard work and is relieved
by rest. Rather, the problem of fatigue is characterized by
decreased ability to do mental and physical work that persists
and worsens in a manner that is disproportionate to any work
Fatigue presents significant obstacles to effective functioning
during and following breast cancer treatment. Persistent fatigue
has been commonly associated with impairment in mental functioning
including decreased attention, impaired perception and thinking,
and reduced ability to function effectively (1). Reported
consequences of fatigue are decreased ability to manage everyday
tasks, disruption of employment, and difficulty maintaining
personal and social relationships (1). Clinical reports indicate
that severe fatigue can lead to premature withdrawal from
or curtailment of potentially curative cancer treatments;
however, no research has been done that systematically documents
the true costs of fatigue on quality of life and clinical
Issues in Therapeutic Management
Despite the significant nature of the problem of fatigue in
women treated for breast cancer, definitive therapeutic solutions
are yet to be determined, probably because there are multiple
contributing factors and the underlying mechanisms are poorly
understood (1) (see Table 1 for a summary of supportive management
strategies for fatigue). Importantly, in many instances, fatigue
is symptomatic of conditions directly related to breast cancer
or its treatment, such as anemia, dehydration, chronic pain,
depression and sleep problems. To the extent that these conditions
can be treated, fatigue can be relieved, at least in part.
One proposed mechanism of unexplained fatigue involves changes
in skeletal muscle structure and function related to disease
and treatment. The tendency that commonly accompanies cancer
treatment to reduce physical activity can lead to decreased
muscle strength and endurance. Early signs of such muscle
disuse are manifested in patient reports of poor activity
tolerance and fatigue. Recent studies of the effects of moderate
physical exercise in patients undergoing radiation treatment
for breast cancer have shown promising results with demonstrated
benefits of improved physical functional status and reduced
sensation of fatigue (5).
Another area of study focuses on the cognitive component of
cancer-related fatigue. The brain mechanism underlying the
ability to attend has been implicated in producing fatigue
because its function requires exertion of neural inhibitory
(mental) effort to sustain focus (6). In general, this attentional
mechanism provides the mental effort needed for effective
functioning in daily life. When dealing with a life-threatening
illness such as breast cancer, multiple psychological demands
may be experienced with little respite for prolonged periods
of time, which both compromise and place exceptional strain
on normal attentional capacity. Not surprisingly, women have
consistently described the diagnosis of breast cancer as a
point of major discontinuity in their lives resulting in a
need for adjustment in every life domain. In this demanding
life situation, mental effort is needed to help a person think
clearly, make treatment decisions, problem solve, maintain
personal relationships and carry out necessary tasks such
as treatment-related activities or self-care. Mental effort
is normally limited and fatigue can easily ensue, particularly
under conditions of psychological distress commonly present
in the diagnosis and treatment of breast cancer. On a functional
level, a person experiencing such mental or "attentional"
fatigue would have difficulty performing both mental and physical
activities such as following a train of thought, acquiring
new information, making a decision, or carrying out life tasks,
such as planning a meal or balancing a checkbook.
Current Research Initiatives
Given that multiple factors may contribute to fatigue in women
treated for breast cancer, targeted interventions are required
to effectively address the source of the problem. Investigators
at the University of Michigan Cancer Center currently are
studying the problem of attentional fatigue in women newly
diagnosed with breast cancer. Preliminary data have shown
that breast cancer patients manifest attentional fatigue with
a reduced capacity to direct attention during the three months
following mastectomy or breast conservation surgery and that
such fatigue could be ameliorated by an intervention involving
regular exposure to natural restorative environments (7,8).
Participants who were randomly assigned to take part in attention-restoring
activities showed a significant improvement in attentional
fatigue parameters over time, as well as a fuller resumption
of pre-treatment employment activities (8). In addition, the
findings indicated that attentional fatigue might be differentiated
from psychological distress, such as depressed mood state
or changes in physical functional state. A randomized, longitudinal
study is being conducted to further evaluate the efficacy
of natural restorative environments for attentional and functional
restoration in 200 women newly diagnosed with breast cancer.
The study also will examine the possible detrimental effects
of attentional fatigue on physical functioning, emotional
distress and ability to carry out life roles.
Supportive Management Strategies for Fatigue
- Determine and manage any medical causes, e.g., anemia,
dehydration, pain, sleep disorder, nutritional deficiency
- Differentiate between fatigue and depression
- Educate patients and families that fatigue is frequently
an expected side effect of breast cancer treatment
- Encourage self-care strategies at the start of treatment:
- muscle strengthening and exercise programs, e.g., light
to moderate- intensity walking - attention-restoring activities,
e.g., experiences in natural settings such as walking, sitting,
watching birds, tending plants or gardening
- Teach energy-conservation techniques, e.g., pacing activities;
focusing on priorities; accepting help; delegating tasks;
creating structure in daily activities
- Monitor level of fatigue and effectiveness of selected
- Winningham ML, Nail LM, Burke MB, et al. Fatigue and
the cancer experience: The state of the knowledge. Oncol
Nurs Forum. 21: 23-36, 1994.
- Berger AM. Patterns of fatigue and activity and rest
during adjuvant breast cancer chemotherapy. Oncol Nurs Forum.
25: 51-62, 1998.
- Irvine DM, Vincent L, Graydon JE, et al. Fatigue in women
with breast cancer receiving radiation therapy. Cancer Nurs.
21: 127-135, 1998.
- Ferrell B, Dow K, Leigh S, et al. Quality of life in
long-term cancer survivors. Oncol Nurs Forum. 22: 915-922,
- Mock V, Hassey Dow K, Meares C, et al. Effects of exercise
on fatigue, physical functioning, and emotional distress
during radiation therapy for breast cancer. Oncol Nurs Forum.
24: 991-1000, 1997.
- Cimprich B. Symptom management: Loss of concentration.
Sem Oncol Nurs. 11: 279-288, 1995.
- Cimprich B. Attentional fatigue following breast cancer
surgery. Res Nurs Health. 15: 199-207, 1992.
- Cimprich B. Developing an intervention to restore attention
in cancer patients, Cancer Nurs. 16: 83-92, 1993.
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Please note: The articles listed in the Cancer Center's News Archive are here for historical
purposes. The information and links may no longer be up-to-date.