CANCER-RELATED Fatigue. Nelson Byrne, Ph.D., C.Psych. Krista McGrath, MRT(T), HBSc.

Transcription

1 CANCER-RELATED Fatigue Nelson Byrne, Ph.D., C.Psych. Krista McGrath, MRT(T), HBSc.

2 Faculty/Presenter Disclosure Faculty: Nelson Byrne, Ph.D., C.Psych. and Krista McGrath, MRT(T), HBSc. with the Mississauga Halton/Central West Regional Cancer Program: Primary Care Oncology Day Relationship with Commercial Interests: No affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.

3 Agenda Definition Prevalence Etiology Clinical presentation Pathophysiology Screening Assessment Interventions and management

4 Cancer-Related Fatigue a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning (NCCN, 2010).

5 Case Study Mrs. L. Mrs. L. is a 52-year-old woman diagnosed with T2N0 triple negative left-sided breast cancer treated with mastectomy and dose dense chemotherapy. She completed chemotherapy about a year ago. Mrs. L. and her husband emigrated from China in She lives with her husband and two young adult children. She recently returned to work full-time in an accounting office. Her return to work was gradual over a period of 8 weeks. At work she struggles with concentration and memory. She complains of some non-specific joint aches and pains, especially since completing chemotherapy. She describes feeling completely exhausted at the end of the work day and feels guilty about not being able to care for her family s needs as well as she would like. When asked to describe her current energy level relative to where it was prior to cancer, she indicates it is at about 50%. The couple reports that fatigue impacts their physical intimacy. Activities that Mrs. L. used to enjoy doing are now limited.

6 Case Study Mrs. L. (continued) Mrs. L. reports that she interprets every physical symptom she now experiences as a sign of cancer recurrence. She endorses physical symptoms of anxiety such as racing heart, shortness of breath, and muscle tension. She also describes a number of frequent worries, such as the success of her children, her mother s health, conflicts between family members, etc. Mrs. L. reports that when she goes to bed at night, these worries occupy much of her thinking, and it can take her several hours to fall asleep. On a good night, she reports getting about 4-5 hours of sleep, with interruptions. Even prior to her cancer diagnosis, Mrs. L. struggled with sleep. Mrs. L. described a previous episode of depression following the sudden death of a close relative about 15 years ago for which she was prescribed Paxil for a 10-month period.

7 Cancer-Related Fatigue Most common symptom experienced by cancer patients Has the greatest impact on everyday life Related to cancer or its treatment May occur at any time throughout treatment and continue after completion of treatment May not get better with sleep or rest

8 Prevalence 60-90% of cancer patients will experience cancer related fatigue (Cella et al, 2010) fatigue in the normal population is reported at ~6% Among cancer outpatients, 58% report that fatigue affects them somewhat or very much (Stone et al, 2000) comparable figures for pain and nausea/vomiting are 22% and 18%, respectively Varies by type and stage of cancer Cancer related fatigue may persist for years (up to 30% of cancer survivors report persistent fatigue for years after antineoplastic therapy (Portenoy, 1999))

9 Anemia Reduces the amount of oxygen available to cells resulting in fatigue Most common cause of reversible fatigue Occurs in about ½ of all cancer patients undergoing treatment Caused by several factors destruction of red blood cells from treatments iron deficiency vitamin B12 deficiency Treatment of anemia will depend on the cause

10 Chemotherapy Your patients fatigue may get worse over time while on chemotherapy They may feel more fatigued shortly after their chemotherapy treatment and before their next treatment begins they will likely begin to feel less fatigued1 Level of Fatigue One Cycle Chemo Cycles

11 Radiation Therapy Your patients fatigue will depend on many different factors related to their radiation treatments e.g., radiation dose, area being treated, and whether or not they are having chemo and radiation therapy in combination Their fatigue may get worse over the course of their treatment and will usually peak after the treatments are completed Their fatigue may last for several months after finishing radiation End of treatment Level of Fatigue Time

12 Clinical Presentation Tiredness/exhaustion, disproportionate to recent activity Impairment in important areas of life (e.g. ADL s, work, social life) Diminished concentration or attention Significant distress or negative mood related to feeling fatigued Sleep disturbance Decreased motivation or interest to engage in usual activities/disturbance in quality of life Sleep perceived as non-restorative/unrefreshing

13 (Hypothetical) Pathophysiology Physiological factors Increased production of cytokines Dysregulation of cortisol by HPA axis Serotonin dysregulation caused by proinflammatory cytokines Psychosocial factors Depression Stress and anxiety Insomnia Circadian rhythm disruption

14 Screening Routine screening should happen from diagnosis forward Screen with a valid and reliable tool that includes reportable scores (dimensions) that are clinically meaningful and have established cut-offs e.g., Screening for Distress Tool, which includes Edmonton Symptom Assessment System (ESAS) and Canadian Problem Checklist (CPC)

15 Assessment Rule out other causes not disease related Shared responsibility History of fatigue Contributing risk factors Physical exam Review of symptoms Self-assessment of contributing causes

16 Interventions and Management OF CANCER-RELATED FATIGUE

17 Interventions and Management Interventions for all patients, all ESAS scores Interventions for moderate and severe fatigue: Address treatable contributing factors Non-pharmacologic interventions Pharmacologic interventions

18 Interventions for all patients Education and counseling Differences between normal and cancer related fatigue Causes and consequences of fatigue Treatment related patterns of fatigue Avoid inactivity during and post treatment Use energy wisely planning, prioritizing, pacing, position

19 Interventions for all patients Education and counseling Sleep hygiene Distraction techniques Use of a fatigue journal to track severity and self-management strategies Signs of worsening fatigue to report to HCP

20 Consider contributing factors for moderate or severe fatigue Treatment complications e.g., anemia, infection, fever Medication side-effects e.g., opiates, antiemetics, antihistamines, antidepressants, etc. Endocrine, cardiac, pulmonary factors e.g., hypothyroidism, adrenal insufficiency

21 Consider contributing factors for moderate or severe fatigue Nutritional deficiencies Fluid and electrolyte imbalances Emotional distress Sleep disturbance Other ESAS-rated symptoms: pain, nausea, depression

22 Non-pharmacologic interventions for moderate or severe fatigue Moderate physical activity during and after treatment 30 mins per day, 5 days per week Unless contraindicated or previously sedentary Psychosocial interventions Psycho-educational programs (group or individual) Anticipatory guidance re: fatigue patterns Coping skills training Self-management and problem solving to manage fatigue Cognitive Behavioural Therapy from trained therapist Supportive expressive therapies

23 Non-pharmacologic interventions for moderate or severe fatigue Nutritional consultation Optimize sleep quality (CBTi) Attention restoring therapy Stress reduction strategies Progressive muscle relaxation, yoga, mindfulness, guided imagery, massage Acupuncture may be effective

24 Pharmacologic interventions for moderate or severe fatigue Methylphenidate Dexamethasone, prednisone Modafinil Amantadine

25 Pharmacologic interventions for moderate or severe fatigue Pharmacologic interventions should be used cautiously and should not be used until treatment and disease-specific morbidities have been characterized and ruled out Optimal dosing and schedules have not been established for use of pharmacologic interventions in cancer patients

26 Case Study Mrs. L. Mrs. L. is a 52-year-old woman diagnosed with T2N0 triple negative left-sided breast cancer treated with mastectomy and dose dense chemotherapy. She completed chemotherapy about a year ago. Mrs. L. and her husband emigrated from China in She lives with her husband and two young adult children. She recently returned to work full-time in an accounting office. Her return to work was gradual over a period of 8 weeks. At work she struggles with concentration and memory. She complains of some non-specific joint aches and pains, especially since completing chemotherapy. She describes feeling completely exhausted at the end of the work day and feels guilty about not being able to care for her family s needs as well as she would like. When asked to describe her current energy level relative to where it was prior to cancer, she indicates it is at about 50%. The couple reports that fatigue impacts their physical intimacy. Activities that Mrs. L. used to enjoy doing are now limited.

27 Case Study Mrs. L. (continued) Mrs. L. reports that she interprets every physical symptom she now experiences as a sign of cancer recurrence. She endorses physical symptoms of anxiety such as racing heart, shortness of breath, and muscle tension. She also describes a number of frequent worries, such as the success of her children, her mother s health, conflicts between family members, etc. Mrs. L. reports that when she goes to bed at night, these worries occupy much of her thinking, and it can take her several hours to fall asleep. On a good night, she reports getting about 4-5 hours of sleep, with interruptions. Even prior to her cancer diagnosis, Mrs. L. struggled with sleep. Mrs. L. described a previous episode of depression following the sudden death of a close relative about 15 years ago for which she was prescribed Paxil for a 10-month period.

28 QUESTIONS? 29