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Managing Cancer-Related Fatigue

Updated: Feb 13

What is cancer-related fatigue?


Did you know that 80-100% of people going through cancer treatment experience fatigue to some extent? Cancer-related fatigue (CRF) is a very common side effect of cancer and treatment, but it means much more than ‘just feeling a little bit tired’.


CRF is defined 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 function”. In reality, you may experience an overwhelming, full body, all-encompassing tiredness that is not resolved by a full night sleep.


Any type of cancer and cancer treatment can contribute to CRF. The way individuals experience CRF will vary greatly: some people may experience fatigue in the days after treatment, while for others it may continue for weeks, months or even years after finishing their treatment. In a longitudinal study of 763 breast cancer survivors, 35% were fatigued in the first 5 years after treatment, with 34% reporting fatigue between 5 to 10 years following treatment (LaVoy et al, 2016).


Cancer related fatigue
Cancer related fatigue

What causes cancer-related fatigue?


While it is known that cancer treatments, medications and cancer itself can cause chronic and persistent fatigue, research has yet to provide a definitive physiological cause for this. It does however identify that the complex relationships between the immune system, enzymes and hormones (alongside many other complex bodily processes) are likely to contribute to CRF.


Likely physiological factors that contribute to cancer related fatigue include:

  • Increased systemic inflammation.

  • Overwhelmed immune system.

  • Accumulation of cell waste and toxic substances.

  • Increased stress response.

  • Hormonal changes or imbalances.

  • Reduced or poor nutrition.

  • Increased levels of pain.

  • Reduced levels of haemoglobin (anaemia).

In addition to the above, psychological and practical factors may also contribute:

  • Reduced quality or quantity of sleep.

  • Increased feelings of anxiety, depression, worry or grief.

  • Difficulty balancing hospital appointments, work, family commitments, social life, finances, etc.


How might I experience cancer-related fatigue?


People use many CRF can impact you in many ways, affecting resilience and impacting physical and psychological function. Symptoms or experiences may include:

  • Generalized weakness or limb heaviness

  • Reduced concentration or attention

  • Reduced motivation or interest to engage in usual activities

  • Insomnia (not sleeping) or hypersomnia (always sleeping)

  • Waking up from sleep feeling unrestored or unrefreshed.

  • Marked emotional reactivity (e.g., sadness, frustration, or irritability)

  • Feeling unable to complete your normal daily activities due to lack of energy, e.g. going to work, family commitments, social commitments, etc.

  • Problems with short-term memory

  • Post-exertional fatigue lasting several hours, e.g. feeling exhausted after going shopping, doing exercise, attending a social event, etc.


How can I manage cancer-related fatigue?


First of all, if you experience persistent fatigue, it is important to speak with your GP or oncology team about this as they will likely wish to rule out reversible causes such as anaemia or infection.


If your fatigue is thought to be cancer-related, then implementing some self-management techniques is going to important for managing your symptom. If you feel you need further support with any of the below techniques, a referral to relevant allied health professions, such as a physiotherapist, occupational therapist or dietitian, will be helpful for you.


1. 3 Ps of energy conservation (pacing, prioritising, planning)


Pacing

When you have less energy day-to-day, it is important to pace yourself in order to converve energy and use it efficiently. It can feel tempting to want to rush through tasks or a to-do list, in order to get things done as quickly as possible and rest afterwards. We know however that this is not the most efficient way to use our energy and can result in something we call ‘booming and busting’ which are periods of exertion/excessive use of energy, following by lows in energy, which limit your ability to engage with other activities. It is better to manage your energy, by thinking about the activities you will be completing and considering whether there is any way you can make the task more energy efficient. Can you complete the task sitting down? Can the task be completed in smaller parts? Can someone else help you with the task? For example, you would like to cook a roast dinner for your family but you do not feel you have the energy. Instead of pushing through and feeling exhausted afterwards, think about getting a food delivery to your home instead of doing a full shop, doing some of the food preparation in sitting instead of standing, starting the preparation earlier in the day so you are spreading the tasks out and resting in between, consider buying some of the elements ready chopped or prepared, can you delegate some of the tasks to anyone else, etc.


Prioritising

It is important to be honest with yourself about what is important to you. There are endless tasks we may have or want to do each day, but we may not always have the energy for this. Sometimes we may feel like all of it is important and has to get done, but this is where making a note of what you have to do each day and then prioritising it honestly can be really helpful. You may use a High Important, High Urgency, Low Importance, Low Urgency system and aim to complete the High Importance High Urgency and Low Importance High Urgency tasks first. For example, a high importance high urgency task may be a finance task that must be completed by a close deadline, followed by low importance high urgency task such as hoovering the living room before a friend visits tomorrow. It is also important to consider how important the task really is, for example you may wish to mow the lawn because you feel conscious about how neighbours may perceive your long grass! Mowing two lawns may require too much energy and there is no-one around to help you this particular day, but you don’t wish to leave it any longer. You may decide to mow the front law which can be seen by others and leave the back lawn another week instead! Prioritisation is only about what matters to you. This is very personal, as what is a priority to one person, may not be for another person.


Planning

Making use of a diary is always important, for documenting your activity and fatigue levels to help identify treads that you can use to your advantage. This can also help with a feeling on control over your energy. You may be someone who plans your day each morning or you may like to plan your whole week in advance, particularly if you have hospital appointments and other commitments to consider. It can help to schedule in important tasks and commitments for the week, then review this each morning to re-prioritise and ensure the plan still works for you considering your energy that day. This can also help to reduce decision fatigue throughout the day, if you have not thought ahead. It can also help your support system to know what you are planning to do and how they can support you. There are apps available to help, such as Becca, VineHealth, Untire and OWise.


2. Communication with your support network

Cancer-related fatigue is a very difficult concept to explain to someone who has not experienced it. Since we have all felt tired before, it can be easy for people to assume you are feeling tired in the same way they have experienced it.

It can help to use imagery with your support network, to help give an indication of how much energy you have each day which can help them to understand your experience better.


You may wish to use the idea of a glass of water, e.g. in the morning this may feel half full and with each task completed, you lose a splash of water in the cup – without pacing and taking breaks between tasks, the glass will become empty and you will have nothing left to give that day.


Other imagery may include a phone battery, for example, “I’m feeling 40% charged today, I will likely need to stop and recharge” or a simple traffic light system “I am on green today so can help you with these tasks” or “I am on red today, I may need to focus on myself”.


3. Diet

I will start by saying I am not a dietitian, however optimising all lifestyle choices including diet is essential during and after cancer treatment. Protein are important building blocks during cancer treatment, to support: healthy connective tissue, enzymes, hormones, red blood cells, transporting nutrients, immunity, building and maintaining muscle. Without muscle mass and strength, daily activities and function will be more difficult and use more energy. A referral to a specialist dietitian can be requested through your oncology team or information can be found through trusted resources online (please get in touch for signposting!).


4. Sleep Hygiene

While we have mentioned that CRF is not directly correlated with sleep, it remains important to optimise sleep hygiene to give the body time to rest and recover. Sleep hygiene involves reducing stimulating activity in the hour or so before bed, including eating, technology, loud noises, bright lights and so on. It can help to use all your senses to evoke relaxation before bed, calming lights, relaxing music or quiet, soothing smells, comfortable fabrics – giving yourself complete permission in that moment to switch off with nowhere to be and no responsibilities. The same applies to any naps taken during the day. There is often mixed feelings about sleeping during the day, especially if this is not something you have done before. You may feel like you shouldn’t be sleeping or that you have things to do. Deciding that you will dedicate a specific time, e.g. one hour, to taking a nap and applying sleep hygiene rules will help you to feel more energised, compared to resisting the urge to sleep and dozing on the sofa, in the daylight surrounded by stimulation, over a longer period without any good quality rest.


5. Talking Therapy

Talking to a dedicated professional about your experience of CRF can be invaluable. It is a complex and misunderstood system, which can impact the way you feel about yourself and the world around you. Seeking the right support for your emotional and mental health is essential. In addition to this, since we know that stress, anxiety, worry, depression and poor sleep can all contribute to CRF, working through these feelings may in turn, help with your fatigue management.


6. Exercise!

As a physiotherapist, I am going to say I have left the best until last. Exercise is one of the most important elements of fatigue management and is more effective than medication in managing cancer related fatigue.


Research has found exercise can reduce cancer related fatigue by 40-50%. The relationship between exercise and fatigue remains unclear, but we know the following:

  • Exercise helps to support the immune system and reduce systemic inflammation, which we know can cause fatigue.

  • Exercise helps to reduce anxiety/depression/stress, which we know can further contribute to fatigue.

  • Exercise helps to prevent sarcopenia, a common side effect of cancer and treatment. Sarcopenia is a loss of muscle mass and strength, which likely contributes to the physical experience of fatigue.

  • Exercise helps to optimise oxygen consumption; low oxygen consumption combined with decreased muscle strength makes the relative intensity of daily living activities closer to the anaerobic threshold (the point at which your body requires additional oxygen that cannot be supplied by your muscle stores, to complete the required task or exercise).


The exercise recommendation for during and after cancer treatment is 150 minutes of moderate exercise each week (the same as the general population!). For many people during cancer treatment, particularly experience CRF, this can feel far too much!

Start by tracking your activity for one week, e.g. your step count. From here, aim to start increasing your activity by around 10% each week. For example, if you walked 4,000 steps in your first week, aim to walk around 4,400 steps the next week, then 4,840 steps, then 5,324 steps and so on! You may not be able to increase your activity each week depending on your symptoms but use this as a guide. Set small goals and be sure to celebrate them when you achieve them!


For further support or advice with exercising with cancer-related fatigue, please do not hesitate to contact me at hannah@strongerthan.co.uk, visit my website www.strongerthan.co.uk or find me on Social Media @strongerthanphysio.



References

  • LaVoy EC, Fagundes CP, Dantzer R. Exercise, inflammation, and fatigue in cancer survivors. Exerc Immunol Rev. 2016;22:82-93. PMID: 26853557; PMCID: PMC4755327.

  • Chen, X., Li, J., Chen, C. et al. Effects of exercise interventions on cancer-related fatigue and quality of life among cancer patients: a meta-analysis. BMC Nurs 22, 200 (2023). https://doi.org/10.1186/s12912-023-01363-0



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