3. Definition of Cancer-Related
Fatigue
• Cancer-related fatigue is a distressing
persistent, subjective sense of
physical, emotional and/or cognitive
tiredness or exhaustion related to
cancer or cancer treatment that is not
proportional to recent activity and
interferes with usual functioning
NCCN 2012
4. CTCAE: Fatigue
• Grade 1:
– Fatigue relieved by rest
• Grade 2:
– Fatigue not relieved by rest; limiting
instrumental ADL
• Grade 3:
– Fatigue not relieved by rest, limiting self
care ADL
6. • None to mild (0-3)
– Education + general strategies to manage
fatigue
– Ongoing re-evaluation
• Moderate to severe 4-10
– Education + primary evaluation of fatigue
(history, assessment of treatable
contributing factors)
– Active treatment, follow-up, end of life
8. Functional Status Query
• Changes in exercise or activity patterns
• Influence of deconditioning
• Can patients accomplish normal ADL?
• Can they participate in formal or
informal exercise programs?
9. Impacts of Current Medications
• Narcotics, antidepressants,
antiemetics, and antihistamines:
Contribute to excessive drowsiness
and increasing fatigue
• Certain cardiac medications: e.g., beta-
blocker: bradycardia and subsequent
fatigue
10. • General Strategies for Management of
Fatigue
– Self-monitoring of fatigue levels
– Energy conservation techniques
– Use distraction
11. Energy conservation techniques
• Set priorities
• Pace
• Delegate
• Schedule activities at times of peak energy
• Labor saving devices
• Limit naps to < 1 hr to not interfere with night-
time sleep quality
• Structured daily routine
• Attend to one activity at a time
14. • Activity enhancement
• Physically based therapies
• Psychosocial interventions
• Nutrition consultation
• Cognitive behavioral therapy for sleep
15. Activity Enhancement
(active or post-treatment)
• Maintain optimal level of activity
• Starting and maintaining an exercise
program
– Endurance + Resistance
• Red and Yellow Flags
16. Some Facts
• Cancer-related fatigue interfered with
all ADLs in the majority of patients
• Interference
– Moderate
– Higher in women, non-whites and patients
with metastatic disease
• 3-5 hours of moderate activity per week
may experience better outcomes and
have fewer side effects of therapy
17. Physical Therapy Referral
(Active Treatment)
• Patients with comorbidities (e.g.,
COPD, cardiovascular disease)
• Recent major surgery
• Specific functional or anatomical
deficits (e.g., decreased neck ROM due
to surgery for head and neck cancer)
• Substantial deconditioning
18. Exercise Prescriptions
(Active Treatment)
• Individualized
– Age, gender, type of cancer, physical
fitness level
• Begin at a low level of intensity and
duration
• Progress slowly
• Modified accordingly with the patient’s
condition changes
19. Evidence - 1
• 17 RCTs
• Improvement in fatigue
– 35%
– Weighted pooled mean effect size: -0.42 (95% CI: -
0.599 to -0.231)
• Improvement in vigor/vitality
– 30%
– Weighted pooled mean effect size: -0.69 (95% CI: -0.43
to -0.949)
• Effect: administered during therapy > after therapy
was completed
Kangas and colleagues, 2008
20. Evidence - 2
• 28 RCTs
• Overall result:
– Exercise is effective in relieving fatigue
• SMD: -0.23; 95% CI: -0.33 to -0.13
– Effective both during and after therapy
– Patient population: breast and prostate
cancer
2008 Cochrane
21. Physically-based Therapies
(Active Treatment)
• Acupuncture
–?
• Massage therapy
– One RCT and one retrospective review
– Positive effects of massage therapy on
fatigue during active therapy
22. • Nervous tissue
– MRI
– Compression of neurologic tissue, (ie,
spinal cord, nerve roots, or nerve plexus)
by tumor or unstable vertebral fractures
– Patients with vertebral metastases or
spinal cord compression
Gilchrist et al., 2009
23. Red and Yellow Flags
• Skeletal system
– Dual-energy x-ray absorptiometry
• Diagnostic test for osteopenia and osteoporosis
– Radiography or computed tomography scan
• If 25%–50% of the cortex of bone is degraded, then
partial weight bearing precautions should be
instituted. If greater than 50% bone degradation,
then touch-down or non–weight-bearing
precautions are recommended
• Multiple myeloma
Gilchrist et al., 2009
Karavatas et al., 2006
24.
25. Red and Yellow Flags
• Hematologic system functions
– Might alter during anticancer treatment
– Complete blood count (ie, hemoglobin,
hematocrit, white blood count, platelet
count)
• Diagnostic test to detect anemia, neutropenia,
and thrombocytopenia
• These values also are useful in exercise
prescription, particularly in choosing safe
mode and intensity of exercise
Gilchrist et al., 2009
26. Red and Yellow Flags
• Cardiovascular system functions
– Might be affected due to anticancer treatment
– Echocardiogram
• Assesses ventricular function, including ejection
fraction, wall movement, and cardiac output
– Treatment related cardiotoxicity
• Hodgkin’s disease treated with ABVD or BEACOPP
• Breast cancer treated with doxorubicin and
cyclophosphamide
Gilchrist et al., 2009
27. Risk factors for fatigue in post-
treatment, disease-free patients
• Many….
• Pretreatment fatigue, depression,
anxiety, comorbidities, cytokines, etc.
28. Activity Enhancement
(Post Treatment)
• Post-treatment, disease-free
• Patients to survivors transition
• Regular exercise
– Improving strength, energy, and fitness
– Decreased anxiety and depression
– Improve body image
– Increase tolerance for physical activity
29. Physical Therapy Referral
(Post Treatment)
• Specific issues that should trigger a
referral of PT if the patient
– Is significantly deconditioned, weak
– Have relevant late effects of treatment
(such as cardiopulmonary limitations)
30. Evidence
• 44 Studies, 3,254 cancer survivors
– Exercise reduced fatigue
– Moderate-intensity, resistance exercise
– Older cancer survivors
Brown and colleagues, 2011
31. Interventions for Patients at the
End of Life
• In palliative care unit: 100% reported
fatigue
• General Strategies for Management of
Fatigue
– Energy conservation
– Use distraction
32. Energy conservation techniques
(end-of-life)
• Set priorities
• Pace
• Delegate
• Schedule activities at times of peak energy
• Labor saving devices and assistive devices
• Eliminate nonessential activities
• Structured daily routine
• Attend to one activity at a time
• Conserve energy for valued activities
33. Activity Enhancement
(end-of-life)
• Optimize level of activity with careful
consideration of the following
constraints:
– Bone metastases
– Thrombocytopenia
– Anemia
– Fever or active infection
– Assessment of safety issues (risk of falls,
stability)
34. Evidence
• Pilot
• Small sample size
• But promising results
– Better activity level
– Increased QoL
– Less anxiety
Porock and colleagues, 2000
35. Activities
(End of Life)
• Walking
• Arm exercises with resistance
• Marching in place
• Dancing
37. Definition of Pain
• Pain is defined by the International
Association for the Study of Pain
(IASP) as an unpleasant
multidimensional, sensory and
emotional experience associated with
actual or potential tissue damage, or
described in relation to such damage
Merskey and Bugduk 1994; NCCN 2012
38. • Screen for pain
– Pain present or not
– Anticipated painful events and procedures
39. If pain present
• Quantify pain intensity and characterize
quality
• Severe uncontrolled pain is a medical
emergency and should be responded to
promptly
40. Pain Intensity Rating
• Minimum assessment
– In the past 24 hours: Current pain, Worst
pain, Usual pain, Least pain
• Comprehensive assessment
– Worst pain in past week, pain at rest pain
with movement
41. Numerical Rating Scale
• Numerical rating scale (0 to 10: no pain
to worst pain you can imagine)
– Verbal
– Written
• Categorical scale:
– None (0); Mild (1-3); Moderate (4-6); Severe
(7-10)
42. Top: Faces Pain Scale (Bieri et al., 1990), scored 0 to 6
Bottom: Faces Pain Scale-Revised, scored 0-2-4-6-8-10 (or 0-1-2-3-4-5).
Instructions: “These faces show how much something can hurt. This face
[point to left-most face] shows no pain. The faces show more and more pain
[point to each from left to right] up to this one [point to right-most face] - it
shows very much pain. Point to the face that shows how much you hurt
[right now]. Hicks et al., 2001
43. Comprehensive Pain
Assessment
• In order to identify
– Etiology
– Pathophysiology
– Specific cancer pain syndrome
– Determine patient goals for comfort,
function
44. Red Flag
• Pain related to an oncologic emergency
– Bone fracture or impending fracture of
weight bearing bone
– Brain metastases
– Epidural metastases
– Leptomeningeal metastases
– Pain related to infection
– Obstructed or perforated viscus
46. Classification of pain management
strategies in cancer patients
• By cause
– tumor-induced pain, iatrogenic pain, unspecific pain
• By quality
– nociceptive pain, neuropathic pain
• By duration
– acute pain, chronic pain, breakthrough pain
• By severity
– weak, moderate, strong
• By site of origin
– visceral pain, bone pain, soft tissue pain
• By psychosocial status
47. Cancer-induces pain:
mechanisms
• Cancer tissue infiltrating nerves
• Cancer tissue blocking or destroying
nerves
• Peritumoural edema compressing nerves
• Cancer tissue secreting substances that
irritate the nerves or lower the pain
threshold
• Pathologic fractures inducing functional
instability Mechanisms
48. Anticancer treatment-induced
pain
• Pain syndromes due to loss of organs
• Post radiation pain syndromes
• Chemotherapy-induced polyneuropathy
50. Classification by site of origin
• Periosteal and/or bone pain
– dull, boring, deep, but may also be sharp and lancinating. lt
is usually easy to locate and tends worsen during motion.
• Pain of soft tissue and muscles
– often permanent and is usually dull, boring, continuous and
diffuse in terms of location. It occurs independently of
motion.
• Visceral pain
– mainly due to infiltration, ulceration or compression in the
gastrointestinal, respiratory or urogenital tract. Visceral pain
is typically dull, deep, hard to localize, and may be colicky.
56. Physical therapy in pain
management for patients with
cancer
• Higher awareness of motion patterns
• Relaxation of painfully tense muscles
• Relaxation of fibrotic subcutaneous tissue
• Patient is taught behaviors calculated to
relieve pain
• Patient learns relaxation techniques
• Patient learns postures designed to
reduce pain
57. Postural re-education
• For patients who have altered posture or movement secondary
to pain
– Breast cancer
• Correct protective posture
– Head and neck
• Shoulder dysfunction
58. Physical Modalities
• Bed, bath, and walking supports
• Positioning instruction
• Energy conservation, pacing of activities
• Massage
• Heat and/or ice
• TENS
• Acupuncture or acupressure
• Ultrasonic stimulation
59. Massage and warm baths
• Mechanisms:
– Resolve painful tension
– Rebound vasodilation
– Mentally soothing and relaxing effects on the
limbic system
• Most beneficial to patients with high levels of
psychological distress
• Contraindications:
– Tumor regions, thrombocytopenia, high BP,
severe heart failure, etc.
(Soden et al., 2004)
60. Massage and soft tissue
mobilization
• Scar mobilization/massage, myofascial
techniques and connective tissue
massage
(Hunter, 1994; Mannheim, 2001).
63. Ice
• Mechanisms:
– Reducing inflammation, swelling,
decelerates neurotransmission, etc.
– Less risk while applying to patients with
cancer
• Contraindication:
– Patients with peripheral arterial occlusive
disease (PAOD) history
64. Hydrotherapy
• Mechanisms:
– Mechanical + thermal stimulation
– Beneficial effects on muscle, circulation,
and immune system
• Contraindications:
65. Electrotherapy
• TENS
– for treatment induced pain
– No formal guideline
– Conventional TENS
– Applied on painful area or an adjacent
dermatome
– Intensity: “strong but comfortable”
– Duration: several minutes up to several hours
• Contraindications:
66. Therapeutic exercise
• Start cautiously, build up gradually and
be within the patient’s tolerance levels
• Graded and purposeful activity
71. Definition of Dyspnea
• A subjective experience of breathing
discomfort that consists of qualitatively
distinct sensations that vary in
intensity
American Thoracic Society 1999
72. Causes of dyspnea in patients
with cancer
• Disease related • Airway obstruction
– Malignant pleural • Hypoxemia
effusion • Psychogenic
• Treatment related dyspnea
– RT related • Cardiovascular
pneumonitis failure
• Comorbidities • Neurologic disorder
– Example: COPD • Anemia
73. CTCAE: Dyspnea
• Grade 1
– Shortness of breath with moderate exertion
• Grade 2
– Shortness of breath with minimal exertion; limiting
instrumental ADL
• Grade 3
– Shortness of breath at rest; limiting self care ADL
• Grade 4
– Life-threatening
– consequences; urgent intervention indicated
• Grade 5
– Death
75. Treat underlying
causes/comorbid conditions
• Radiation/Chemotherapy
• Therapeutic procedure for cardiac,
pleural, or abdominal fluid
• Bronchoscopic therapy
• Bronchodilators, diuretics, steroids,
antibiotics, or transfusions
76. Relieve symptoms
• O2 for hypoxia
• Educational, psychosocial, and emotional
support for the patient and family
• Nonpharmacologic therapies
• Morphine
• Benzodiazepines
• Temporary ventilator (CPAP, BiPAP)
– Non-invasive in nature
77. Non-pharmacological measures
to relieve dyspnea
• Positioning
– Forward lean sitting
• Elbows resting on knees or a table when seated,
or on a suitable surface, for example a
windowsill or wall, when standing
– Advise on passively fixing the shoulder
girdle for optimizing ventilatory muscle
efficiency and relief of breathlessness
• Hands/thumbs resting in/on pockets, belt loops,
waistband, or across the shoulder handbag
strap when ambulating
78. Non-pharmacological measures
to relieve dyspnea
• Breathing techniques
– Breathing control
– Diaphragmatic
– Pursed lip
– Exhalation on effort (“blow as you go!”)
– Paced breathing
• Paced with activity
79. Non-pharmacological measures
to relieve dyspnea
• Non-invasive ventilation
• Oxygen therapy
• Airway clearance techniques
– Active cycle of breathing techniques
– Positive expiratory pressure (PEP)
80. Non-pharmacological measures
to relieve dyspnea
• Energy conservation techniques:
Reduction in the energy expenditure
• Combined of techniques
– Using a WC and portable O2 during
hygiene/toileting/outing
82. Oncology Rehabilitation
• To help patients stay physically strong
so they can tolerate conventional
cancer treatment and continue to
participate in everyday activities
• Continue services
before after
treatment treatment
during
treatment
