National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 1.2011.

To ensure that all cancer patients with fatigue were identified and treated promptly and effectively.  These guidelines included recommended standards of care for assessment and management of fatigue in children, adolescents, and adults with cancer.

The guidelines were evidence- and consensus-based. The guidelines were multidisciplinary, and all recommendations were category 2A unless otherwise stated.

The guidelines provided several algorithms for assessment and management based on age group, level of self-reported fatigue, and phase of treatment.

Screening

• All patients with cancer should be screened for the presence or absence of fatigue at regular intervals as a vital sign.
  • Age older than 12 years:  Screen on a 0-to-10 scale or as none, mild, moderate, or severe.
  • Age 7 to 12 years:   Use 1-to-5 scale (1 = no fatigue and 5 = worst).
  • Age 5 to 6 years:  Screen using “tired” or “not tired.”

Focused Evaluation of Fatigue

• A focused history and assessment of contributing factors should be performed when screening indicates moderate to severe fatigue.
  • Age older than 12 years:  score of 4 to 10
  • Age 7 to 12 years:  score of 3 to 5
  • Age 5 to 6 years:  “tired”
• Focused history should
  • Rule out recurrence or progression of cancer
  • Include a review of systems
  • Include an in depth fatigue history, including onset and patterns, associated/alleviating factors, and interference with function.
• Assessment of treatable contributing factors, such as
  • Other related symptoms
  • Anemia
  • Sleep disturbance
  • Medication and side effects
  • Comorbidities
  • Activity and fitness level.

Management and Interventions

• Active Treatment
  • Education and counseling regarding known patterns of fatigue and reassurance that treatment-related fatigue is not necessarily indicative of progression of disease.
  • General management strategies to include self-monitoring, energy conservation techniques, and use of distraction
  • Nonpharmacologic interventions to include activity enhancement, physically based therapies (such as massage), psychosocial interventions, nutritional consultation, and cognitive behavioral therapy for sleep
  • Pharmacologic interventions to include consider psychostimulants, treatment of anemia as indicated, and consideration of mediation for sleep
• Posttreatment
  • Education and counseling about known fatigue patterns and self-monitoring of fatigue levels
  • General management and nonpharmacological and pharmacological interventions as for active treatment above
• End of Life
  • Education and counseling about known fatigue patterns and as an expected end of life symptom
  • General strategies as per active treatment and post treatment
  • Nonpharmacologic interventions to include activity enhancement, psychosocial interventions, and nutrition consultation
  • Pharmacologic interventions as per active and post treatment

Within activity enhancement information, the guideline cites several synthesized reviews regarding the use of exercise and concludes that

• Improvement in fatigue was not noted with all diagnoses.
• It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment.
• Referral to exercise specialists or physical therapy should be triggered by
  • Patients with comorbid conditions, such as chronic obstructive pulmonary disease or cardiac disease
  • Recent major surgery
  • Specific functional or anatomical deficits
  • Substantial deconditioning.
• Exercise should be used with caution in patients with
  • Bone metastases
  • Immunosuppression or neutropenia
  • Thrombocytopenia
  • Anemia
  • Fever or active infection
  • Limitations due to other illnesses.

Because fatigue is a subjective experience, it was recommended that assessment should use patient self-reports and other sources of data.

Several barriers were identified related to effective treatment for fatigue.  Due to barriers, it was stated that screening for fatigue needs to be emphasized.  Rescreening was emphasized because fatigue may exist beyond the period of active treatment.

Factors identified as potential causative agents that should be specifically assessed were outlined.  These factors were pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, medication side effects, and other comorbidities.

It was noted that fatigue often occurs as part of a symptom cluster, often with sleep disturbance, emotional distress, or pain, so that assessment of these problems and institution of effective treatment is essential.

The importance of comprehensive assessment, including review of all current medications and noncancer comorbidities, was identified.  For example, it was noted that there can be thyroid dysfunction after radiation therapy for various cancers or use of biological and that hypogonadism can be associated with fatigue.

• The majority of studies regarding the impact of exercise on fatigue were performed in patients with limited types of cancer, and findings may not be applicable to all types of patients.  In addition, the timing and amount of exercise for various groups are not clear.  There are also few longitudinal studies examining fatigue in long-term disease-free survivors, although fatigue can be a long-term or late effect.
• Although the guideline was structured according to phase of treatment, recommended interventions did not vary according to phase of treatment.  There were minimal differences in recommended content of education and counseling.
• There was little evidence regarding effective management of fatigue in end of life care.
• There was no discussion of prevention related to fatigue.