Green Oncology: A Pharmacist’s Role in Alleviating Cancer Related Fatigue

Green Oncology is a series of articles by Amy Smith

The Patient Issue:

Cancer related fatigue (CRF) is perceived by patients as one of the most distressing symptoms of chemotherapy.  Of those receiving chemotherapy and/ or radiation therapy, 80% experience CRF.  As a subjective side effect, it is difficult for patients to quantify and for clinicians to treat.  With improving survival rates, quality of life issues are receiving more attention.  This is a great opportunity for pharmacists to make a large impact on a patient’s life.  


The Pharmacist’s Advice:

Start by discussing expectation with your patient.  Patients may need to come to terms with a change from their “pre-cancer self” and prioritize the activities they would still like to enjoy and partake.  Activities should be scheduled at times of the greatest amount of energy.  Maintaining a daily routine and documenting energy may assist in identifying timing of peak energy levels. 

When providing advice on coping with CRF, there can be several contributing factors to first consider.  To provide the greatest relief, the root cause of the fatigue should be determined and treated directly.  Anemia is a common cause of fatigue; therefore management of this underlying cause should be addressed.  Many oncology patients struggle with anxiety and depression which may contribute to fatigue.  Persistent pain can also be very taxing therefore seek optimized pain control.  As with many of us, a good meal and a nap can help solve almost any problem therefore consider addressing nutritional status and sleep quality. 

Practicing good sleep hygiene is imperative in controlling fatigue.  Patients may wish to spend a significant amount of time napping during the day however naps should be limited to less than one hour to minimize interfering with night time sleeping.  Distractions from fatigue such as games, music, reading or social interactions may be useful.  Patients should also be advised to avoid stimulants such as caffeine, TV, and exercise prior to bed.  A consistent bedtime routine and ensuring a dark and comfortable environment can aid in improving sleep quality.  If concerns regarding insomnia persist, regardless of good sleep hygiene, consider pharmacological sleep aids however consider the “hang over” effect of these agents worsening day time fatigue.

There is a substantial amount of research devoted to exercise and CRF.  An updated 2012 Cochrane review reported that aerobic exercise may improve CRF.  Further research is required to determine the optimal intensity, duration, and timing of exercise.  Although the NCCN guidelines highlight resistance training as improving fatigue, Cochrane determined that resistance training did not reach statistical significant in improving CRF.  Based on recent evidence, you can advise your patients to step away from the dumbbells and hit the treadmill.  Although at first it may seem counterintuitive to participate in an exercise program, there is a wealth of research supporting exercise in reducing fatigue. 

In cases of severe fatigue, NCCN suggests psychostimulants may be considered for CRF.  Methylphenidate (54 mg per day) or Modafinil (200mg per day) was found to be beneficial in severe fatigue however these agents were found to be comparable to placebo when utilized in mild to moderate fatigue. 


The Bottom Line:

Many oncology patients, during and post treatment, will present with CRF.  First manage any co-morbidities (such as anemia, pain, or depression) which may be contributing to symptoms of fatigue. Non-pharmacological options, such as energy conservation techniques, proper nutrition, good sleep hygiene or exercise are the corner stone of CRF treatment.