Helping Patients Manage Cancer-Related Fatigue

Sap Partners | Schools of Nursing | <b>RWJBarnabas Health and Rutgers Cancer Institute of New Jersey</b>

Andrew Kass, MSN, RN, AGNP-C, AOCNP, discusses the impact fatigue can have on patients with cancer and how oncology nurses and APPs can help their patients address this common adverse event.

Most patients with cancer experience some degree of fatigue throughout treatment.

Appropriately managing that fatigue is an important component of supportive care, because fatigue can affect whether or not patients are able to meet the everyday demands of family, friends, or work responsibilities, explained Andrew Kass, MSN, RN, AGNP-C, AOCNP, an advanced practice nurse at Rutgers Cancer Institute of New Jersey.

In an interview with Oncology Nursing News®, Kass discusses the impact fatigue can have on patients with cancer, best ways to assess fatigue as an oncology nurse or advanced practice provider (APP), and best fatigue management practices for patients.

“One thing I find interesting,” he noted about fatigue. “[Is when] I looked at the core curriculum for the Oncology Nursing Society–it's the sixth edition, it's produced by ONS. I find it interesting that it’s a 546-page booklet that is an outline for nurses that are studying to be ONS certified, [and] there are 2 pages devoted to fatigue out of 546. So, it's something that we are doing research on, but it's not as ‘focused on’ as other elements.”

Oncology Nursing News®: Why is addressing fatigue so important in improving overall patient outcomes?

Kass: Fatigue affects so many aspects of a patient's quality of life. There is a direct connection between how somebody feels when they're tired, and how well they can manage their pain, how well they can heal after surgery, and even their ability to take in information. If somebody is super fatigued, it's very hard to give them proper education on self-management. If somebody is too tired, they might not eat or drink adequately, and that might affect their ability to heal. Therefore, it is important to address it. When it comes to treating cancer, 80% to 90% of patients will complain of fatigue at some point during their journey.

When patients come to the center to receive chemotherapy, fatigue and pain are part of their initial assessment and we get a number scale from 0 to 10. We ask, “What are their activities of daily living they are doing currently?” because there are performance scales that are used to determine whether it's safe to give chemotherapy to a patient. There are 2 of them—the ECOG score and the Karnofsky score—that we use for performance status. If the patient is not out of bed more than 50% of the time, they will not get chemotherapy (unless it's critical). That shows how important it is to get fatigue under control. This is because if a patient is not able to get out of bed, they will not receive their chemotherapy. If they don't get their chemotherapy, they will not get better. Therefore, it becomes super important to take care of fatigue.

What advice might you give to patients about ways to conserve their energy and manage their fatigue?

There are things that we can incorporate, such as psycho-educational interventions. We can offer anticipatory guidance about the patterns of fatigue, as well as help coach patients about self-management in terms of energy conservation and activity management—that means mapping out the day's activities and determining where they can put their energy into and where they can conserve it. They don't want to take on tasks that they can't get done in a short amount of time. They want to have periods of rest incorporated into their day.

In terms of day-to-day activities, [I encourage] things such as a chair in the shower so that they can take a break while they're showering, to ensure that they are safe while they're doing their activities of daily living. Having somebody help with groceries is great.

I also encourage patients, if they have the means, to hire somebody to help around the house with activities such as cleaning and taking care of small tasks within the house or cooking, so that the energy of the patient can be used for visiting with friends or family, or to do other things that are more impactful during the time period when they're super sick. Some people—if they have the money—tend to conserve their money, [with the mindset that] they're going to use it later for something that's really important when getting through fatigue during their treatment is going to maybe extend their life.

As a provider, how do you determine if a patient’s fatigue requires medical intervention versus self-management at home?

My background is in infusion for chemotherapy; that is where I've been for 20 years, [and] our focus all the time is lab-based. Certainly, we are looking at their complete blood count [CBC] to ensure that it is at a level that should produce energy for the patients. We are constantly checking labs, not only just the CBC, but we're looking at hormone levels, including testosterone levels, we're looking at thyroid levels, and we're balancing replacement of things that are too low for patients.

Patients, especially those who have leukemia or lymphoma, may need frequent transfusions to maintain their activities of daily living, and we also want to look at the underlying cause of the anemia. It's not only just having cancer or going through chemotherapy that produces anemia—sometimes people don't have the right “products” in their body to make the correct cells. We want to make sure patients have adequate iron [counts] so that they can make their own red cells when they need it and receive transfusions when they do. There are erythropoietin-stimulating factors, such as epoetin alfa (Procrit) that is used to help support patients with an injection in their arm that can help tell their body to rebuild red cells, which in terms will help to store more oxygen and give them more energy. However, there are some risk factors with Procrit, including increased risks of clotting if the patient has enough blood in their body. We do use that cautiously.

What are the most frequent questions that you hear from your patients about fatigue?

We are always asking them about their fatigue. It's one of the vital signs that we grab as part of when we first assess a patient; we check their blood pressure, we check their respiration levels, and we check their pain and fatigue status. We are always aware of fatigue.

Patients will also often ask us, “Does the fatigue ever go away?” or “What can I do to eat or drink to feel better?” because they want [answers].

What I try to tell patients is that they need to exercise more to have more energy. This is well-established; it is well documented. The idea [is] presumably that when I'm a healthy person, and when I feel tired, I will tend to nap for 20 minutes; I will restore energy and I'll feel much better for the rest of the day. However, people who have cancer are going through therapy. Sometimes no amount of rest will make them feel better. [However,] energy creates energy. Patients need to be taught how to exercise to tolerance and to safety for 30 minutes a day, 3 times a week—something of that extent.

Right now, we are in winter. We talk with patients [about] walking in the mall to stretch their legs and get some activity. There’s a Live Strong program that's available through the YMCA, [it’s] a free benefit for patients. It is a 12-week membership that they get where they can go to the gyms at the YMCA and have some form of safe exercise during their treatment period. Patients tend to say that they feel better. Recently, people are also talking about doing yoga to build strength, but in a very controlled and safe manner to help to feel stronger and replenish fatigue.

What we're talking about is an integrative kind of discussion. It's not just one thing that can help a patient with fatigue, you can't just give somebody epoetin alfa and hope things feel better. Transfusions certainly will help, but that's not the big picture. We need to integrate all aspects of things that can make patients feel better.

We talk about yoga. Simple things such as drinking plenty of fluids to being well hydrated to be bringing an adequate number of calories; we usually have dieticians help us with patients that are starting to lose weight. If you lose weight, if you're not drinking enough, it will cause more fatigue. So, we need to have all those aspects together to help the patient and to support them during this really stressful time for them.