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 This is an original JCO publication from 2014. Please visit the JCO website to access the full article.


Screening, Assessment and Management of Fatigue in Adult Survivors of Cancer:  An American Society of Clinical Oncology Clinical Practice Guideline Adaptation 


 Authors

Julienne E. Bower, Kate Bak, Ann Berger, William Breitbart, Carmelita P. Escalante, Patricia A. Ganz, Hester Hill Schnipper, Christina Lacchetti, Jennifer A. Ligibel, Gary H. Lyman, Mohammed  S. Ogaily, William F. Pirl, and Paul B. Jacobsen   

THE BOTTOM LINE


Guideline Question

What are the 1) screening, 2) assessment, and 3) treatment approaches to the management of adult cancer survivors who are experiencing symptoms of fatigue after completion of primary treatment?

 

Target Population

This practice guideline pertains to cancer survivors diagnosed at age 18 years and older, who have completed primary cancer treatment with curative intent and are in clinical remission off therapy, as well as patients who are disease-free and have transitioned to maintenance or adjuvant therapy (e.g., breast cancer patients on hormonal therapy, chronic myelogenous leukemia patients on tyrosine kinase inhibitors).

 

Target Audience

This guidance is intended to inform health care professionals (e.g., medical, surgical, and radiation oncologists, primary care providers, nurses and others involved in the delivery of care for survivors) as well as patients, family members, and caregivers of patients who have survived cancer. 

 

Recommendations

Contributing Factors

  • Address all medical and treatable contributing factors first (e.g., pain, depression, anxiety, emotional distress, sleep disturbance, nutritional deficit, activity level, anemia, medication side-effects, and comorbidities).

Physical Activity

  • Initiating/maintaining adequate levels of physical activity may reduce cancer-related fatigue in post-treatment patients.
  • Actively encourage all patients to engage in a moderate level of physical activity after cancer treatment (e.g., 150 minutes of moderate aerobic exercise such as fast walking, cycling, or swimming) per week with an additional 2 to 3 strength training  (such as weight lifting) sessions per week, unless contraindicated. 
  • Walking programs are generally safe for most cancer survivors; the American College of Sports Medicine recommends that cancer survivors can begin this type of program after consulting with their doctors but without any formal exercise testing (such as a stress test).
  • Survivors at higher risk of injury (e.g., those living with neuropathy, cardiomyopathy, or other long-term effects of therapy) and patients with severe fatigue interfering with function should be referred to a physical therapist or exercise specialist. Breast cancer survivors with lymphedema should also consider meeting with an exercise specialist before initiating upper body strength-training exercise.

Psychosocial Interventions

  • Cognitive behavioral therapy/behavioral therapy may reduce cancer related fatigue in cancer survivors.
  • Psycho-educational therapies/educational therapies may reduce cancer related fatigue in cancer survivors.
  • Survivors should be referred to psychosocial service providers who specialize in cancer and are trained to deliver empirically-based interventions.  Psychosocial resources that address fatigue may also be available through the National Cancer Institute and other organizations.

Mind-Body Interventions

  • There is some evidence that mindfulness-based approaches, yoga, and acupuncture may relieve fatigue in cancer survivors.
  • Additional research, particularly in the post-treatment population, is needed for biofield therapies (touch therapy), massage, music therapy, relaxation, reiki, and qigong.
  • Survivors should be referred to practitioners who specialize in cancer and who use protocols that have been empirically validated in cancer survivors. 

Pharmacological Interventions

  • Evidence suggests that psychostimulants (e.g., methylphenidate) and other wakefulness agents (e.g., modafinil) can be effectively used to manage fatigue in patients with advanced disease or those on active treatment.  However there is very limited evidence of their effectiveness in reducing fatigue in patients following active treatment who are currently disease-free. 
  • Small pilot studies have evaluated the impact of supplements, such as ginseng, vitamin D, and others for cancer-related fatigue. However, there is no consistent evidence of their effectiveness.  



SUMMARY OF RECOMMENDATIONS

SCREENING, ASSESSMENT, AND MANAGEMENT OF FATIGUE IN ADULT SURVIVORS OF CANCER

SUMMARY OF RECOMMENDATIONS TABLE*

 Clinical Question: What are the optimal screening, assessment, and treatment approaches in the management of adult cancer survivors who are experiencing symptoms of fatigue after completion of primary treatment? 

Recommendations: Screening

All health care providers should routinely screen for the presence of fatigue from the point of diagnosis onward, including following completion of primary treatment.

All patients should be screened for fatigue as clinically indicated and at least annually.

Screening should be performed and documented using a quantitative or semi-quantitative assessment.

Recommendations: Comprehensive and Focused Assessment

History and Physical

1) Perform a focused fatigue history

2) Evaluate disease status

3) Assess treatable contributing factors

As a shared responsibility, the clinical team must decide when referral to an appropriately trained professional (e.g., cardiologist, endocrinologist, mental health professional, internist, etc.) is needed.

Laboratory Evaluation

Consider performing laboratory evaluation based on presence of other symptoms, onset, and severity of fatigue.

Recommendations: Treatment and Care Options

Education and Counseling  

All patients should be offered specific education about fatigue following treatment (e.g. information about the difference between normal and cancer- related fatigue, persistence of fatigue post treatment, and causes and contributing factors).   

Patients should be offered advice on general strategies that help manage fatigue.

If treated for fatigue, patients should be followed and re-evaluated on a regular basis to determine whether treatment is effective or needs to be reassessed.

Contributing Factors

Address all medical and treatable contributing factors first (e.g., pain, depression, anxiety, emotional distress, sleeps disturbance, nutritional deficit, activity level, anemia, medication side-effects, and comorbidities). 

Physical Activity

Initiating/maintaining adequate levels of physical activity can reduce cancer-related fatigue in post-treatment survivors. 

Actively encourage all patients to engage in a moderate level of physical activity after cancer treatment (e.g., 150 minutes of moderate aerobic exercise such as fast walking, cycling, or swimming) per week with an additional 2 to 3 strength training  (such as weight lifting) sessions per week, unless contraindicated. 

Walking programs are generally safe for most cancer survivors; the American College of Sports Medicine recommends that cancer survivors can begin this type of program after consulting with their doctors but without any formal exercise testing (such as a stress test).

Survivors at higher risk of injury (e.g., those living with neuropathy, cardiomyopathy, or other long-term effects of therapy) and patients with severe fatigue interfering with function should be referred to a physical therapist or exercise specialist. Breast cancer survivors with lymphedema should also consider meeting with an exercise specialist before initiating upper body strength-training exercise. 

Psychosocial Interventions

Cognitive behavioral therapy/behavioral therapy can reduce cancer related fatigue in post-treatment survivors.

Psycho-educational therapies/educational therapies can reduce cancer related fatigue in post-treatment survivors.

Survivors should be referred to psychosocial service providers who specialize in cancer and are trained to deliver empirically-based interventions.  Psychosocial resources that address fatigue may also be available through the National Cancer Institute and other organizations.

Mind-Body Interventions

There is some evidence that mindfulness-based approaches, yoga, and acupuncture can reduce fatigue in cancer survivors.

Additional research, particularly in the post-treatment population, is needed for biofield therapies (touch therapy), massage, music therapy, relaxation, reiki, and qigong.

Survivors should be referred to practitioners who specialize in cancer and who use protocols that have been empirically validated in cancer survivors. 

Pharmacological Interventions

Evidence suggests that psychostimulants (e.g., methylphenidate) and other wakefulness agents (e.g., modafinil) can be effectively used to manage fatigue in patients with advanced disease or those on active treatment.  However there is very limited evidence of their effectiveness in reducing fatigue in patients following active treatment who are currently disease-free. 

Small pilot studies have evaluated the impact of supplements, such as ginseng, vitamin D, and others for cancer-related fatigue. However, there is no consistent evidence of their effectiveness.

* ASCO Guideline Adaptation of Pan-Canadian guideline on Screening, Assessment and Care of Cancer-Related Fatigue in Adults with Cancer, the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Cancer-Related Fatigue, and the NCCN Guidelines® for Survivorship.

 


 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. ("ASCO") to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action. The use of words like "must," "must not," "should," and "should not" indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary. ASCO provides this information on an "as is" basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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