Cancer breeds questions. At the U-M Comprehensive Cancer Center, we face tough questions every day - in our clinics, our laboratories, our classrooms and our community - and we know we're only as good as our latest answer. In this latest installment of "Frequently Asked Questions," we take on cancer-related fatigue. Our expert is Bernadine Cimprich, Ph.D., R.N., Associate Professor of Nursing at the U-M School of Nursing. A pioneer in the field of cancer quality of life research, Dr. Cimprich helped draft the Treatment Guidelines for Cancer-Related Fatigue published by the National Comprehensive Cancer Network (NCCN).

Q: So many cancer patients relay stories about how exhausted they feel. Is it as common as the anecdotal evidence suggests?

A: Perhaps more so. Research indicates that as many as nine in ten cancer patients experience fatigue while undergoing treatment. And it isn’t limited to the treatment phase. As many as 75 percent of cancer survivors report fatigue persisting for months or even years after treatment.

Q: What makes a cancer patient’s fatigue different from that of a healthy person?

A: It’s not like the “tiredness” we all experience – the kind that can be overcome by a good night’s sleep. Sleep often won’t help a cancer patient’s fatigue, which, according to the consensus of our panel at the NCCN, has the following characteristics:

• It’s not proportional to work or exertion – you can do little or nothing at all and feel completely spent.
• It interferes with valued daily life activities.
• It can impact virtually every aspect of life: physical, cognitive, social, emotional and sexual.
• Its intensity can be surprising – for some, it’s the most distressing aspect of cancer.

It’s a complex problem, and I believe the work of the NCCN represents a real breakthrough in increasing awareness and empowering people to address it. It’s so important for patients, their families and their caregivers to recognize that cancer-related fatigue is common.You’re not alone, and you’re not imagining it.

Q: So how should patients fight back against fatigue?

A: Through research conducted over the past decade, mainly with breast cancer patients, we’ve established several strategies. But before you can act to counter fatigue, there’s an important concept you must understand about it. Not all fatigue is alike. I think everyone is familiar with general physical fatigue, and that’s certainly a major component in the equation for the cancer patient. But there’s another kind of fatigue, called cognitive or attentional fatigue that also causes significant distress.To have success, often both need to be addressed.

Q: OK, let’s start with the physical component. If sleep won’t help, what will?

A: This is the area where the bulk of the research has taken place, although it isn’t my field of expertise.An interesting paradox has been found here:The intervention that helps is exercise. For most of us, exercise causes physical fatigue! The idea is that, among populations like cancer patients, there is a tendency to decrease activity during treatment. In the process, they become deconditioned. With deconditioning comes decreased physical functional capacity – they can’t do as much without becoming tired. It’s a vicious cycle.

The way to break the cycle is through a process of conditioning or reconditioning. Beginning when a person is diagnosed and starts treatment, an intervention should take place to maintain physical activity, as much as feasible. If the patient is not active, an effort to develop some level of physical activity should be attempted if possible, with the help of the care team.The intervention can be quite modest. What’s true of the general population holds true of this group as well – keep people moving with a regular routine according to their capacity, and the results will be more positive. The goal is to prevent the accumulation of fatigue symptoms.The research done with breast cancer patients indicates that those who started exercising at the beginning of treatment had less trouble with fatigue over the course of treatment than those who didn’t.

Q: Now tell us about cognitive fatigue.

A: That’s my area of study.When I began as a cancer nurse in 1963, one of my roles was patient education – preparing patients to care for themselves after they left the hospital. Although we took time and care to inform them, it was stunning how much difficulty people had taking in the information, and how little they retained once they got home.Twenty years later, I came to the doctoral program at U-M knowing exactly what I wanted to study. I had a theory that mental fatigue was contributing to the problems I saw with patients, and that it came from dealing with all the demands put on them when they were diagnosed.

Think about it: In a short period, a patient must make sense of this problem, figure out what to do about it and determine how it will impact his or her life. It might take me a year to decide what car to buy, yet a cancer patient must decide what to do with his or her life in just days! There is a cost for negotiating this path — and the cost is mental fatigue.

When mental fatigue sets in, it impacts a specific part of the brain called the executive attention system – the area that allows you to block out distraction, stay focused, tend to competing demands, complete tasks, etc. That’s a limited capacity system – like a bank account. After so many withdrawals, the money is gone.

Q: How does cognitive fatigue become evident?

A: Continuous use of the executive attention system will have subtle fatigue effects at first. Little tasks become more difficult and the ability to focus and concentrate gradually wanes. Initially, patience, listening and tolerance also may begin to diminish, leading to greater frustration, argumentativeness or irritability. As a patient becomes more fatigued, they may be overwhelmed with even simple tasks and feel more and more out of control.

Q: Let’s talk about intervention or treatment. In this case will sleep help?

A: Again, sleep is important but not enough.With cognition, attention is the cornerstone.When it’s compromised, everything else is too. For example, we begin to forget even important things. It’s difficult to regain cognitive capacity, so the best strategy is to prevent as much deterioration as possible.

The goal must be to restore attention, not simply to create distractions in an attempt to relax the mind. So unfortunately, activities like watching television or shopping won’t help either.

In my research with breast cancer patients, I’ve been able to demonstrate that one solution is to expose the cognitively exhausted person to natural environments. A variety of options exist, including sitting in a park, birdwatching, walking on a beach or path, gardening or simply sitting by a window with a nature view. We’ve shown that by engaging in natural restorative activities patients feel more mentally alert and more refreshed – even when measured at one year after surgery.

Q: Sounds easy.

A: It is. As little as 20 minutes of restorative activity in a natural setting three times a week can make a difference. Like physical activity, beginning this practice as early as possible is the best intervention. Research has shown that some onset of cognitive fatigue can be seen as early as the point of cancer diagnosis.

Q: Finally, any advice for patients on how to talk with their caregivers about fatigue?

A: The fatigue treatment guidelines for patients developed by the NCCN and distributed by the American Cancer Society give some very sound advice about having the conversation. First, remember that the best measure of fatigue is your own description of it to your health care team. There’s no lab test for it.To help you describe your fatigue, you might try using a scale of 0 to 10, with 0 = no fatigue and 10 = the worst you can imagine.

Also, in addition to the strategies we’ve discussed for fighting physical and mental fatigue, when tackling fatigue with your care team, remember these steps as well:

• Determine and manage any medical causes that may lie behind your fatigue – anemia, dehydration, pain, sleep disorders, nutritional deficiencies.
• Differentiate between fatigue and depression.
• Consider energy-conserving techniques such as pacing yourself, focusing on priorities, accepting help, delegating tasks and creating structure for your daily activities.
• Monitor your level of fatigue and the effectiveness of the strategies you choose to fight it and share this information with your care provider.

Read the Treatment Guidelines for Patients on Cancer-Related Fatigue and Anemia developed by the National Comprehensive Cancer Network.

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