Keywords
cancer-related fatigue - chemotherapy - physical activity - pharmacological - radiotherapy
- integrative therapies
Introduction
Cancer-related fatigue (CRF) is defined by the National Comprehensive Cancer Network
(NCCN) (2024) as the experience of physical, emotional, and/or mental exhaustion related
to cancer or its treatment. CRF does not imply for typical tiredness; rather, it is
a distressing lack of energy, disrupting daily life and not improving with usual rest
or sleep. CRF can be very prevalent among cancer patients. It is often overlooked
and underdiagnosed.[1] The weariness encountered by patients with cancer receiving chemotherapy is enduring
and may extend beyond the duration of the chemotherapy treatment, significantly affecting
several dimensions of the patients' life, including physical, psychological, professional,
and economic elements. After cancer treatment concludes, fatigue typically goes down,
but some patients may continue to experience exhaustion for months or even years.[2]
Consequently, it is important to evaluate tiredness in every individual diagnosed
with cancer and consider it a crucial symptom. Fatigue affects 50 to 90% of cancer
patients overall, with the latter percentage being associated with those receiving
aggressive anticancer chemotherapy or radiation therapy.[3] Research on tiredness is still lacking, and there are not many papers in the literature
on CRF in the Indian population, despite its high incidence and possible detrimental
impact on patients' activities and emotional health.[4] CRF has been found to be strongly correlated with cancer, its type, stage, and duration;
cancer treatment (chemotherapy, radiation therapy, immunotherapy, and surgery); and
comorbid conditions like anemia, malnourishment, cardiopulmonary disorders, liver
failure, renal diseases, neurological disorders, etc.[5]
CRF cannot be definitively diagnosed with a laboratory test; however, to receive helpful
therapies, patients should discuss their symptoms with the treating physician in detail
and on a regular basis. The patients need to be examined for symptoms associated with
CRF because they might not self-report exhaustion. There are several established scales
devised to assess the degree of fatigue such as the European Organization for Research
and Treatment of Cancer–Quality of Life Questionnaire–30 Core Questionnaire (EORTC-QLQ-C30),
Piper Fatigue Scale—Revised, Brief Fatigue Inventory, Cancer Fatigue Scale, Fatigue
Symptom Inventory, Patient-Reported Outcome Measurement Information System (PROMIS)
Fatigue Short Form and CT, and Multidimensional Fatigue Inventory-20, etc.[6] An evidence-based clinical practice guideline by the Academy of Oncologic Physical
Therapy (APTA Oncology) provided recommendation of A (“should be used in clinical
practice”) for EORTC-QLQ-C30 and few other assessments.[7]
Cancer patients receiving cytotoxic chemotherapy, radiation therapy, bone marrow transplantation,
or biological response modifier treatment are increasingly prone to fatigue. The cornerstone
of treating CRF is treating its underlying cause, which may include dietary deficiencies,
anemia, electrolyte imbalances, chemotherapy side effects, or nutritional problems.
Physical activity-based therapies, psychoeducational and mind–body interventions,
and techniques for treating sleep disorders, are some of the nonpharmacological procedures
included in the management strategies. Eliminating fatigue is not always possible,
but there are ways to help lessen or manage CRF. Some possibilities include self-care
practices such as yoga, exercise, eating well, and making time to rest can help increase
your energy level.[8]
The current study was aimed to understand the prevalence of CRF in Indian patients
and its impact on quality of life.
Materials and Methods
One hundred patients were enrolled in this prospective, observational study conducted
at SVS Medical Hospital, Mahbubnagar, Telangana, India, for a duration of 6 months.
All patients aged > 18 years and willing to consent for the study questionnaire were
included in this study. The patients with brain metastases were excluded as it might
impact their ability to complete study procedures. The data for this study were collected
from the case files of 100 enrolled patients. A structured pro forma or data collection
form was utilized to record key details from patient files. This form included demographic
information (e.g., age and gender), cancer type, stage, and treatment modalities (chemotherapy
and radiotherapy). Additional data were gathered through patient interviews and questionnaires,
which included validated tools mainly the EORTC QLQ-C30, a 30-item instrument that
evaluates multiple aspects of quality of life, and the NCCN fatigue intensity scale.[9]
[10] In the NCCN fatigue scale, “0” represents an absence of fatigue and “10” represents
worst fatigue. According to this scale, 0 to 3, 4 to 6, and 7 to 10 indicate no or
mild fatigue, moderate fatigue, and severe fatigue, respectively.[10] All collected data were entered into an electronic database for further analysis,
ensuring accuracy and completeness by cross-checking against the original case files
and reports.
Statistical Method
Categorical variables were reported as proportions and frequencies. Continuous variables
were reported as means or medians. All analyses were performed on deidentified data
using the Statistical Package for Social Science (SPSS) software version 23 and GraphPad
Prism version 9.
Results
In total, 100 patients were included, the mean (±standard deviation) age of the group
was 43.78 (±17.18) years. The age group-wise distribution is shown in [Table 1]. Among the study population, breast cancer and gastric cancer were the most common
diagnosis, representing 22 patients each. Regarding the stage of the cancer, patients
with stage III cancer had the highest number (36%), followed by stage IV (25%). There
were higher number of patients receiving radiotherapy (63%), in comparison to number
of patients receiving chemotherapy (37%).
Table 1
Patient characteristics
|
Characteristics
|
N = 100
|
|
Age (y), mean ± SD
|
43.78 ± 17.18
|
|
Age range (y, %)
|
|
|
≤ 20
21–30
31–40
41–50
51–60
> 60
|
2.0
27.0
17.0
16.0
17.0
21.0
|
|
Gender (%)
|
|
|
Male
Female
|
49
51
|
|
Cancer type (%)
|
|
|
Breast cancer
Gastric cancer
Lung cancer
|
22
22
12
|
|
Stages of cancer (%)
|
|
|
Stage I
Stage II
Stage III
Stage IV
|
15
24
36
25
|
|
Cause of fatigue (%)
|
|
|
Chemotherapy
Radiotherapy
|
37
63
|
|
Level of fatigue (EORTC QLQ-C30 scale, %)
|
|
|
Normal (1–30)
Mild (31–60)
Moderate (61–90)
Severe (91–120)
|
9
15
44
32
|
|
Level of fatigue (NCCN fatigue scale, %)
|
|
|
No or mild fatigue (0–3)
Moderate fatigue (4–6)
Severe fatigue (7–10)
|
9
47
44
|
Abbreviations: EORTC QLQ-C30, European Organization for Research and Treatment of
Cancer–Quality of Life Questionnaire–30 Core Questionnaire; NCCN, National Comprehensive
Cancer Network; SD, standard deviation.
In our study, as per the EORTC scale, 32 patients had severe fatigue. According to
the NCCN fatigue scale, 44 people had severe fatigue.
Discussion
The most common symptom of cancer, which affects 50 to 90% of patients, is weariness
connected to the disease, which has a serious negative influence on functional ability
and quality of life.[11] The guidelines recommend identifying contributing factors and screening for fatigue
at each treatment appointment, as well as during the initial visit when the diagnosis
of advanced illness is made.[12] While assessments like the EORTC QLQ-C30 or NCCN fatigue scale may be useful for
assessing tiredness intensity at first, a more thorough evaluation, education, and
the creation of a personalized treatment plan are often necessary for the first course
of treatment.
In our study, the majority of the patients (27%) were in the age group of 21 to 30
years. A similar study conducted in a tertiary care center in the Malwa region of
Punjab had majority of the patients (29.77%) from the age group of 41 to 50 years.[13] In our population, 63% of the patients reported being treated with radiotherapy.
Radiotherapy is reported to be associated with causing fatigue in patients with cancer.
A prospective study of Janaki et al from Bengaluru assessed the magnitude of fatigue
and its implication on the quality of life during radiotherapy. In that study of 90
patients receiving radiotherapy, 87.8% of the patients had fatigue at baseline and
this proportion increased over the course of radiotherapy. A significant reduction
in social function and global health status was also reported over various time points
during radiotherapy.[14]
Regarding the limited literature available for CRF from India, some researchers have
published various aspects of CRF. A study from All India Institute of Medical Sciences,
Delhi, India, assessed prevalence of fatigue in patients with cancer, as well as its
predictors. Among 110 patients, 97 patients documented to have severe fatigue. Positive
correlation between fatigue and quality of life was observed. Pain, physical functioning,
Eastern Cooperative Oncology Group performance status, and the level of albumin were
the predictive factors for fatigue.[15] Another study from Delhi analyzed CRF in breast cancer survivors. In this study
of 65 patients, 95% patients experienced any grade CRF, with 85% patients experiencing
moderate to severe CRF. A total of 86% of the patients perceived fatigue to be due
to effect of cancer treatment. Physical exercise was the most common measure adopted
for CRF, in 49% of the patients.[16] An international study from Nagpur showed significant reduction in fatigue with
physical exercise, pranayama, and 100 g of millet protein powder.[17] Another trial from Bengaluru demonstrated the benefits of plant-based, high-protein
diet in reduction of fatigue, reduction of fat mass, and improvement in muscle mass
in patients with breast cancer undergoing chemotherapy.[18]
While minor fatigue that does not compromise quality of life can be treated with nonpharmacologic
treatments alone, patients with moderate or severe fatigue may benefit from both pharmacologic
and nonpharmacologic therapies.[8] Exercise, cognitive-behavioral therapies, and may be sleep treatment are among the
nonpharmacologic approaches that have demonstrated promise. While pharmacologic therapies
have been employed to address CRF, findings from a meta-analysis conducted by Mustian
et al indicate that these approaches are not as successful in treating CRF as nonpharmacologic
(such as exercise and psychological) therapies.[19] Psychostimulants have the ability to quickly counterbalance the fatigue-related
sensations of low energy, diminished mental capacity, or lethargy, and they hold promise
for the management of CRF.[8]
There are few limitations associated with our study, which includes shorter duration
of 6 months and a small sample size. Additionally, there was also a scope of extension
to learn the patterns that could improve quality of life in patients.
Conclusion
In conclusion, our study adds to the limited literature for CRF in Indian patients
with cancer. Our study indicates that among the Indian patients with CRF, higher proportion
of patients has moderate or severe level of fatigue. Appropriate assessment and management
of CRF should be considered in the patients for overall management.
