| Target population |
- This practice guideline pertains to cancer survivors diagnosed at age ≥18 years who have completed primary cancer treatment with curative intent and are in clinical remission off therapy as well as patients who are disease free and have transitioned to maintenance or adjuvant therapy (eg, patients with breast cancer receiving hormonal therapy, patients with chronic myelogenous leukemia receiving tyrosine kinase inhibitors)
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| Target audience |
- This guidance is intended to inform health care professionals (eg, medical, surgical, and radiation oncologists, psychosocial and rehabilitation professionals, primary care providers, nurses, and others involved in the delivery of care for survivors) as well as patients, family members, and caregivers of patients who have survived cancer
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| Treatment and care options |
| Education and counseling |
- All patients should be offered specific education about fatigue after treatment (eg, information about the difference between normal and cancer-related fatigue, persistence of fatigue after treatment, and causes and contributing factors)
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- Patients should be offered advice on general strategies that help manage fatigue
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- If treated for fatigue, patients should be observed and re-evaluated on a regular basis to determine whether treatment is effective or needs to be reassessed
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| Contributing factors |
- Address all medical and treatable contributing factors first (eg, pain, depression, anxiety, emotional distress, sleep disturbance, nutritional deficit, activity level, anemia, medication adverse effects, and comorbidities)
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| Physical activity |
- Initiating/maintaining adequate levels of physical activity can reduce cancer-related fatigue in post-treatment survivors
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- Actively encourage all patients to engage in a moderate level of physical activity after cancer treatment (eg, 150 minutes of moderate aerobic exercise [such as fast walking, cycling, or swimming] per week with an additional two to three strength training [such as weight lifting] sessions per week, unless contraindicated)
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- Walking programs are generally safe for most cancer survivors; the American College of Sports Medicine recommends that cancer survivors can begin this type of program after consulting with their physicians but without any formal exercise testing (such as a stress test)
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- Survivors at higher risk of injury (eg, those living with neuropathy, cardiomyopathy, or other long-term effects of therapy) and patients with severe fatigue interfering with function should be referred to a physical therapist or exercise specialist. Breast cancer survivors with lymphedema should also consider meeting with an exercise specialist before initiating upperbody strength training.
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| Psychosocial interventions |
- Cognitive behavioral therapy/behavioral therapy can reduce cancer-related fatigue in post-treatment survivors
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- Psychoeducational therapies/educational therapies can reduce cancer-related fatigue in post-treatment survivors
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- Survivors should be referred to psychosocial service providers who specialize in cancer and are trained to deliver empirically based interventions. Psychosocial resources that address fatigue may also be available through the National Cancer Institute and other organizations.
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| Mind-body interventions |
- There is some evidence that mindfulness-based approaches, yoga, and acupuncture can reduce fatigue in cancer survivors
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- Additional research, particularly in the post-treatment population, is needed for biofield therapies (touch therapy), massage, music therapy, relaxation, reiki, and qigong
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- Survivors should be referred to practitioners who specialize in cancer and who use protocols that have been empirically validated in cancer survivors
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| Pharmacologic interventions |
- Evidence suggests that psychostimulants (eg, methylphenidate) and other wakefulness agents (eg, modafinil) can be effectively used to manage fatigue in patients with advanced disease or those receiving active treatment. However, there is limited evidence of their effectiveness in reducing fatigue in patients after active treatment who are currently disease free.
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- Small pilot studies have evaluated the impact of supplements, such as ginseng, vitamin D, and others, on cancer-related fatigue. However, there is no consistent evidence of their effectiveness.
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