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APOS PSYCHOSOCIAL
POCKET GUIDE

A quick reference resource for psychosocial professionals

The information contained in this guide does not constitute medical advice and is not intended to replace a healthcare provider’s independent medical judgment regarding the treatment or management of individual patients.

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Home 5 Table of Contents 5 Psychological Disorders, Psychosocial Concerns, & Evidence-Based Interventions 5 Fatigue

Fatigue

Author(s): Ashley Nelson, PhD, Lynne Padgett, PhD
Editor(s): Beth Gardini Dixon, PsyD, Sharla Wells-DiGregorio, PhD

Introduction 

  • Fatigue is a natural and generally adaptive response to physical or psychological exertion or stress. In contrast, cancer-related fatigue (CRF) is qualitatively distinct and does not improve with behavioral coping efforts (e.g., rest) often effective in resolving adaptive fatigue.
  • Definition: The National Comprehensive Cancer Network has defined CRF as “a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”
  • Prevalence: CRF is highly prevalent across the cancer-care continuum (11-99%); it is the most commonly reported treatment-related side effect among patients with cancer and may persist for months or years after treatment completion.
  • Significance: CRF is one of the most distressing symptoms experienced by patients with cancer and often profoundly limits engagement in everyday and valued life activities. Moreover, fatigue has been linked to a myriad of adverse outcomes, including impaired mood and increased hopelessness, self-reported cognitive problems, diminished social adjustment and engagement, unemployment status and economic hardship.

Guidelines

Multiple evidence-based guidelines are available.

NCCN Guidelines for Cancer-Related Fatigue V.2.20241

https://www.nccn.org/home

ASCO

Screening, Assessment, and Management of Fatigue in Adult Survivors of Cancer: An American Society of Clinical Oncology Clinical Practice Guideline2

http://jco.ascopubs.org/content/32/17/1840.full

Guidelines to Assess and Manage the Symptoms of Fatigue & Insomnia3

https://ascopost.com/issues/june-25-2016/guidelines-to-assess-and-manage-the-symptoms-of-fatigue-and-insomnia/

Shared components across guidelines include the following:

  • All patients in active treatment and survivors should be screened for fatigue as a vital sign at the initial visit and regular intervals.
  • All patients, caregivers, and families should be offered education about cancer-related fatigue and self-management.
  • Management of medical, psychosocial, and behavioral contributors.
  • Referral to appropriate professionals for pharmacologic and non-pharmacologic interventions as needed.

Screening

  • Routine fatigue screening is supported by evidence of considerable heterogeneity in the onset and course of CRF as well as inconsistencies in the disclosure or recognition of fatigue.
  • Patient-reported screening should be conducted at regular intervals across the cancer-care continuum (i.e., at initial visit, at regular intervals during and following treatment, and as clinically indicated) or when patients or caregivers report challenges with mood, sleep, cognition, or ability to participate in important activities such as work, social participation, exercise, or other daily activities.
  • For adults: screen for presence and severity of fatigue using a single-item 0-10 scale.
    • None to Mild (0-3), Moderate (4-6), Severe (7-10)
  • A positive fatigue screen (Moderate to Severe) should be followed up with an assessment of risk factors and a comprehensive evaluation.

Risk Factors

A biopsychosocial model of predisposing, precipitating, and perpetuating factors involved in the onset and maintenance of CRF is useful in the evaluation of fatigue.

 

Model Description Example characteristics
Predisposing factors Characteristics that increase an individual’s vulnerability to developing fatigue female gender; younger age; unemployed work status
Precipitating factors Triggers leading to the onset of clinically significant fatigue episodes disease processes or tumor progression; cancer treatment; comorbid medical or psychological conditions or states; pain; stress; metabolic or hormonal issues; medications
Perpetuating factors Characteristics that contribute to the maintenance or exacerbation of fatigue symptoms over time circadian rhythm dysregulation; overactive or sedentary activity profiles; social withdrawal; maladaptive thinking styles; emotional and cognitive load

Evaluation & Diagnosis

  • Comprehensive assessment following a positive screen is essential to identify treatable factors (e.g., medications, nutritional issues, deconditioning).
  • An interdisciplinary team-approach to the evaluation of fatigue is recommended to optimize treatment tailored to the multifactorial contributors specific to individual patients.
  • Medical work up by oncology to identify and treat underlying medical causes is an appropriate first step. With medical clearance, referrals to specialists or supportive care providers may include survivorship programs, palliative care, integrative oncology, psychology, psychiatry, physical therapy, occupational therapy, physical medicine.
  • Wherever possible standardized, multidimensional inventories with validated scoring should be utilized.

 

Commonly used standardized assessments

Assessment tool Number of items Fatigue dimensions

EORTC QLQ-C30 and

EORTC QLQ-FA12

 3 and 12 severity, physical, emotional, cognitive
Fatigue Symptom Inventory (FSI) 14 severity, frequency, interference
Functional Assessment of Cancer Therapy-Fatigue (FACIT-F) 41/13 physical, social/family, emotional, functional, fatigue
Multidimensional Fatigue Inventory (MFI) 20 general, physical, reduced motivation, reduced activity, mental
Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) 30 general, physical, mental, emotional, vigor
Piper Fatigue Scale-12 (PFS-12) 12 behavior, affect, sensory, cognition
PROMIS CAT (Computer Adaptive Testing) Up to 20 fatigue, sleep disturbance, sleep impairment

Click here to view table as PDF

  • Differential diagnosis: Fatigue rarely occurs in isolation, and often co-occurs with symptoms such as pain, sleep disruption, cognitive impairment, or emotional distress, including depression. Careful and comprehensive assessment of symptoms, including information on the onset, course, and timing are valuable for guiding decisions about primary diagnosis and treatment.

Treatment

  • Ongoing monitoring and follow-up are required for successful treatment
Treatment Treatment options/modalities Specialty Referrals
General Management/Education

Encourage ongoing physical activity

Energy conservation (e.g., pacing, prioritization, delegation)

Common patterns of fatigue during/after treatment and end-of-life.

 See below.
Physical activity Continuing or initiating physical activity at optimal levels Physical medicine, physical and/or occupational therapy, exercise physiologist
Psychosocial Interventions Cognitive Behavioral Therapy (CBT)/Behavioral Therapy; CBT for Sleep/Insomnia; Supportive expressive therapies; psycho-education therapies Service providers (e.g., psychology, social work) specifically trained in psychosocial oncology whenever possible
Mind-body interventions Mindfulness, Yoga, Acupuncture, Massage Integrative oncology providers
Nutrition Consultation Dietary changes or supplementation Registered Dietician
Pharmacologic Review of medications for potential contributions or treatment of pain, distress, and anemia Appropriate professionals include physicians and advanced practice (NP/PA) include oncology, psychiatry, palliative care, and physical medicine as well as oncology-specific pharmacists for medication review

Click here to view table as PDF

Conclusion

  • Cancer-related fatigue has a waxing/waning course that can occur during and after active treatment.
  • It negatively impacts the quality of life, physical function, and ability to participate in valued life activities.
  • A multi-disciplinary approach including screening, comprehensive assessment, education and resources, as well as pharmacologic and non-pharmacologic approaches can be discussed with patients and survivors to determine the optimal treatment plan for them.

 

References & Links

  1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelinesâ) for Cancer-Related Fatigue V.2.2024. ã National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed April 3,2024. To view most recent and complete version of the guideline, go online to NCCN.org.

https://www.nccn.org/home

  1. Bower JE, Bak K, Berger A, et al: Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical Oncology clinical practice guideline adaptation. J Clin Oncol 32:1840-1850, 2014. http://jco.ascopubs.org/content/32/17/1840.full
  2. Cavallo, J: Guidelines to Assess and Manage the Symptoms of Fatigue and Insomnia. The ASCO Post. June 25, 2016. https://ascopost.com/issues/june-25-2016/guidelines-to-assess-and-manage-the-symptoms-of-fatigue-and-insomnia/. Accessed April 3, 2024
  3. ASCO algorithm https://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/fatigue-algorithm.pdf
  4. org https://www.cancercare.org/tagged/fatigue
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