Cancer-Related Fatigue: NCCN Guidelines and Treatments

The first section of this blog focused on several facets of cancer-related fatigue (CRF): an overview, definition, prevalence, etiology, and the impact on patients’ lives. This portion of the blog will provide information on NCCN Guidelines and various treatments for CRF.

ARE THERE ESTABLISHED GUIDELINES FOR HELPING PATIENTS WITH CRF?

Fortunately, the NCCN has released evidence-based guidelines for addressing CRF². The guidelines are quite comprehensive and state that cancer patients should be screened and treated for CRF from diagnosis onward. Also, patients and their families should be educated about CRF, including the information that CRF may persist after treatment has ended. In addition, the standards recommend the utilization of CRF as a quality improvement outcome measure. Finally, the standards call for reimbursement for managing CRF as part of medical contracts with insurance companies.

IS THERE A “GOLD STANDARD” FOR MANAGING CRF?

Unfortunately, there is no magic bullet for dealing with CRF. As with many disease-related symptoms, a first step should be addressing possible co-occurring symptoms, such as sleep disturbances, distress, or pain. Next, strategies should be provided to “manage” CRF. The NCCN Guidelines include an excellent list of management strategies, beginning with monitoring levels of fatigue and prioritizing activities, adjusting expectations, enlisting social support, limiting naps, and encouraging acceptance of the current situation².

WHAT ARE SOME SPECIFIC INTERVENTIONS FOR CRF?

Interventions fall into two broad categories: pharmacological and non-pharmacological, which includes a range of options, ranging from psychological and psychosocial interventions, referrals to rehabilitation, and exercise.

WOULDN’T TREATING CRF WITH DRUGS BE AN EASY SOLUTION?

Yes, prescribing drugs for CRF would be expedient, but scientific evidence supporting pharmacologic management of CRF is lacking. Drugs used to treat CRF have included psychostimulants, bupropion, dexamethasone, and growth factors. Hemopoietic growth factors have been shown to cause safety issues which outweigh the possible benefits⁷. Although small studies have demonstrated some patients with severe CRF may benefit from the use of psychostimulants, currently the evidence supporting the widespread use of drugs to treat CRF is lacking⁸.

SO WHAT OTHER OPTIONS ARE RECOMMENDED FOR TREATING CRF?

There are several non-pharmacologic methods for treating CRF. Strategies include addressing concerns with a multidisciplinary team, and when appropriate, making referrals to nutritionists, physical therapists, occupational therapists, etc.

The most studied intervention for treating CRF is exercise. Recent meta-analyses ^9-10 have documented that exercise interventions can offer significant benefits to a wide variety of cancer patients both during and after treatment.

Therefore, if at all possible, patients should be encouraged to establish a regular exercise routine.Patients may face barriers which make exercise difficult, and referrals to the appropriate therapists may be helpful. It is also important to assist patients in creating realistic goals for exercise so they don’t get discouraged. Advise them to “start low and go slow,” and to be specific and realistic when setting goals.

Psychosocial interventions for CRF have been shown to have small but clinically meaningful effects⁹ and include a variety of treatments, including education and counseling, Cognitive Behavioral Therapy for sleep, supportive-expressive therapy, and behavioral/relaxation therapies. Common elements in the programs include educating patients and families on CRF, prioritization of activities, energy management, and coping strategies¹¹.

References (continued)

• Minton O, Richardson A, Sharpe M, et al. Drug therapy for the management of cancer-related fatigue. Cochrane Database Syst Rev. 2010;7:CD006704.
• Minton O, Richardson A, Sharpe M, et al. Psychostimulants for the management of cancer-related fatigue: a systematic review and meta-analysis. J Pain Sympt Manag. 2011;41:761-767.
• Kangas M, Bovbjerg DH, Montgomery GH. Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychol Bull. 2008;134:700-741.
• Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012;11:CD006145.
• Goedendorp MM, Gielissen MFM, Verhagen C AHHVM, et al. Psychosocial interventions for reducing fatigue during cancer treatment in adults. Cochrane Database Syst Rev. 2009;1:CD006953.