A new update to the ASCO guideline on managing cancer-related fatigue recommends that health care providers urge their patients to exercise, as well as use cognitive-behavioral therapy and mindfulness-based programs to help prevent and treat this prevalent symptom.1 It is estimated that between 30% and 60% of patients contend with moderate to severe fatigue while undergoing cancer treatment.2-4
“Fatigue is well recognized now as one of the most common and distressing side effects of cancer treatment,” said Julienne E. Bower, PhD, of the University of California, Los Angeles, and guideline Co-Chair. “During the treatment process, it’s an expected side effect and varies based on the [individuals] and their level of fatigue coming into their cancer experience but also the type of treatment received.”'
Julienne E. Bower, PhD
Patients may experience more fatigue while undergoing chemotherapy compared with other approaches, but even surgery can trigger it, she added. Even after treatment is over, it is estimated that 20% to 30% of patients continue to experience elevated cancer-related fatigue for months or even years.2-4
Updated Approach
These updated recommendations have a different foundation from those issued in 2014, which modified existing cancer fatigue–related guidelines used by other organizations.5
The 2024 Expert Panel reviewed the literature from 2013 to 2023 and selected 113 randomized controlled trials in which fatigue was either the primary or secondary outcome of a phase III trial or a primary outcome of a phase II trial.
The Expert Panel when creating the guideline update also considered that approaches have changed since 2014, and cancer-related fatigue may linger well after the patient’s primary treatment has been completed, Dr. Bower noted. The Panel weighed the fact that numerous patients now undergo extended treatments with newer targeted approaches and immunotherapy. This more expansive guideline includes recommendations for dealing with fatigue beginning at the initial diagnostic phase, through treatment and after treatment, and continuing for some until the end of life.
Current Recommendations
“Exercising continues to be a strong recommendation to help with fatigue,” Dr. Bower said. This is beneficial in helping to keep those undergoing treatment from facing the increase in fatigue they might experience otherwise. “What we found is the benefits for fatigue were seen with a variety of exercise interventions, including those that combined aerobic and resistance training and resistance-only interventions,” Dr. Bower said.
The Panel, however, could not determine which type of exercise is most beneficial, how much those battling fatigue should undertake, or for how long to continue the plan, given the diversity of exercise types, methods, and schedules tested. “We were not able to say, ‘You need to do at least 30 minutes a day, four times a week,’” Dr. Bower said. Instead, the evidence shows that a range of different approaches may be helpful in battling fatigue.
Another approach the guideline recommends is to use cognitive-behavioral therapy for managing cancer-related fatigue during both treatment and the post-treatment period. “This is not to say we’re giving people cognitive-behavioral therapy because fatigue is all in your head,” Dr. Bower said. The idea of cognitive-behavioral therapy here is to provide patients with coping strategies and more adaptive ways of thinking about fatigue and other symptoms that will lead to more positive behaviors, she noted. Cognitive-behavioral therapy may be particularly helpful for people with persistent post-treatment fatigue.
The new guideline also supports the use of mind-body therapies including mindfulness-based and movement-based interventions, such as tai chi or qigong, to help alleviate fatigue during and after treatment. This area of research has grown considerably since publication of the earlier guideline, and the evidence now strongly supports the use of these approaches. For tai chi, the Panel recommends doing this three to five times per week, at low to moderate intensity, for 20 to 60 minutes.
One thing the guideline advises against is prescribing wakefulness agents, psychostimulants, or antidepressants to alleviate cancer-related fatigue. The Panel concluded that the current literature does not support the routine use of these medications for fatigue.
Dr. Bower noted that one challenge in advising patients to use approaches such as mindfulness, tai chi, or cognitive-behavioral therapy could be in enabling them to find providers in the community who are trained to provide evidence-based therapies. However, she is hopeful that with further study, virtual programs may prove effective in combating fatigue and allow for easier access.
Dr. Bower expects the guideline to continue to evolve. Although the current recommendations are evidence-based, more studies on certain approaches would help to strengthen them. In addition, as the field learns more about the mechanisms that drive fatigue and the approaches that work best for different patients, more targeted and personalized therapies can be developed. The Expert Panel expects that, with time, additional research will be conducted to more specifically guide patients on the best strategies to combat their cancer-related fatigue.
REFERENCES
1. Bower JE, Lacchetti C, Alici Y, et al: Management of fatigue in adult survivors of cancer: ASCO–Society for Integrative Oncology guideline update. J Clin Oncol. May 16, 2024 (early release online).
2. Kang YE, Yoon JH, Park NH, et al: Prevalence of cancer-related fatigue based on severity: A systematic review and meta-analysis. Sci Rep 13:12815, 2023.
3. Bower JE: The role of neuro-immune interactions in cancer-related fatigue: Biobehavioral risk factors and mechanisms. Cancer 125:353-364, 2019.
4. Al Maqbali M, Al Sinani M, Al Naamani Z, et al: Prevalence of fatigue in patients with cancer: A systematic review and meta-analysis. J Pain Symptom Manage 61:167-189.e14, 2021.
5. Bower JE, Bak K, Berger A, et al: Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical Oncology clinical practice guideline adaptation. J Clin Oncol 32:1840-1850, 2014.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, May 16, 2024. All rights reserved.
