Defend against drain on your energy

People with cancer describe fatigue with a variety of words, such as “tired,” “exhausted,” “weak,” “worn out,” and “wiped out.” However it’s described, fatigue related to cancer is different from the fatigue felt occasionally by healthy individuals. It is usually more severe, lasts longer and is unrelieved by sleep. Managing your fatigue is an essential part of your health care, so be sure to talk to your doctor or another member of your health care team about your fatigue.

Why does fatigue occur?

Treatment-related fatigue occurs primarily because the body needs extra energy to repair the healthy tissue damaged by cancer treatment. It is important to know that fatigue is not necessarily a sign that the disease is getting worse. In addition, other side effects of treatment, such as pain, nausea and vomiting, can cause or worsen fatigue. Physical and mental fatigue may also be a side effect of medications you take for pain or other symptoms. Sometimes the interaction of two or more medications may cause fatigue; the more medications you take, the more likely it is that an interaction may cause fatigue. Another cause is anemia, a condition in which the level of red blood cells is low. (See Anemia for a more complete discussion of the condition). Fatigue can also be caused or worsened by things not related to treatment; for example, stress, other medical conditions, changes in your sleep/wake cycles, and reduced activity may contribute to fatigue. Depression can also cause fatigue, even though it may appear to be related to treatment or illness.

Who is most likely to be affected by fatigue?

Fatigue occurs in almost all people at some time during cancer treatment, regardless of the type of cancer or the type of treatment. How fatigue will affect you depends on your age, your general health, the types of treatment you receive, and your normal level of activity before treatment.

When does fatigue occur?

When fatigue occurs depends on the type of treatment. If you have surgery, the after-effects of anesthesia, the use of strong pain relievers, and limitations on activity can make you feel tired and weak for a few days to a few weeks after surgery.

If you are receiving chemotherapy, you will probably feel the most tired about two hours after treatment. Fatigue typically peaks within a few days after the beginning of a chemotherapy cycle and then gradually gets better until the next treatment cycle begins. Radiation therapy takes longer to produce fatigue; a feeling of being tired and weak usually starts a few weeks after treatment begins and gradually diminishes after treatment ends.

Fatigue may be fairly constant or may occur from time to time. Some people feel less tired once treatment has been completed, and others may feel tired for several months after treatment has ended. Long-term fatigue (one year or more) is most common among people who have received bone marrow transplantation and high-dose chemotherapy.

How is fatigue managed?

Your doctor can prescribe treatment if there is a specific cause for your fatigue. You may need to stop taking some drugs or supplements or change drugs to avoid interactions that cause fatigue. Most people think more rest will help relieve fatigue. However, the opposite is true. Increasing activity and performing regular exercise (such as walking or bike riding) are the best ways to help manage and reduce symptoms of fatigue. Try to start exercising early during treatment, as it may feel too difficult later on, when you’re more likely to be tired.

There are many other ways you can help yourself feel less tired (Table 1). If you are working during your treatment, talk to your supervisor before treatment begins about the possibility of fatigue and ways you can handle it, such as taking time off and scheduling treatments to avoid the need to work on important tasks when fatigue may be at its peak. If your fatigue is severe, your doctor or nurse may recommend that you take a psychostimulant drug for a short period of time. These drugs help improve alertness during the day and raise your energy level while also decreasing fatigue, and they can also counteract the drowsiness caused by some opioids. Psychostimulant drugs include modafinil (Provigil), armodafinil (Nuvigil), methylphenidate and dextroamphetamine.

Table 1. Ways to manage fatigue related to cancer treatment

Conserve energy
▪ Set priorities for activities and do only what is most important
▪ Schedule important activities for times of the day when you have the
  most energy
▪ Ask friends and family to help
▪ Sit down when washing or grooming
▪ Use assistive devices if necessary (canes, walker, etc.)
Balance activity and rest
▪ Pace yourself: Attend to one activity at a time and space activities
  throughout the day
▪ Participate in regular physical activity, such as walking or bike riding
▪ Take frequent rest periods or naps, but limit each nap to 45 minutes 
▪ Get eight hours of sleep each night
Engage in activities that provide relaxation or distraction from fatigue
▪ Perform deep breathing exercises
▪ Use imagery techniques
▪ Read, listen to music, play games
▪ Pray/meditate
Seek relief of other symptoms
▪ Talk to your doctor about managing symptoms that may contribute
  to fatigue such as pain, nausea and vomiting, and depression
Maintain adequate nutrition
▪ Eat a well-balanced diet to help promote healing

When should I talk to my doctor about fatigue?

You should describe your level of fatigue to your doctor at every office visit. You should also call your doctor’s office immediately if you have the sudden onset of any of the following symptoms:

  • Confusion
  • Dizziness or loss of balance
  • Extreme tiredness that forces you to stay in bed for more than 24 hours
  • Fatigue that has gotten worse or a sudden decrease in energy level
  • Feeling of breathlessness (out of breath) or of a racing heart after mild activity

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