Guidelines to Assess and Manage the Symptoms of Fatigue and Insomnia

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In 2014, ASCO developed a clinical practice guideline to provide a mechanism for physicians to screen, assess, and manage the persistent symptoms of fatigue in adult cancer survivors.1 As summarized below, the guideline calls for regular screening, assessment, laboratory evaluation, and patient education to combat the problem.

Earlier this year, the National Comprehensive Cancer Network (NCCN) released its updated clinical practice guidelines for sleep disorders.2 These recommendations are also summarized here.

ASCO on Fatigue


  • All health-care providers should routinely screen for the presence of fatigue from diagnosis onward, including after the completion of primary treatment.
  • All patients should be screened for fatigue as clinically indicated and at least annually.
  • Screening should be performed and documented using a quantitative or semiquantitative assessment.

Comprehensive and Focused ­Assessment: History and Physical

  • Perform a focused fatigue history.
  • Evaluate disease status.
  • Assess treatable contributing factors.
  • The clinical team must decide when referral to an appropriately trained professional, such as a cardiologist, endocrinologist, or mental health clinician is warranted.

Laboratory Evaluation

  • Consider performing laboratory evaluation based on the presence of other symptoms and onset and severity of fatigue.

Education and Counseling

  • All patients should be offered specific education about fatigue after treatment, including information about the difference between normal and cancer-related fatigue, persistence of fatigue after treatment, and causes and contributing factors.
  • Patients should be offered advice on general strategies that help manage fatigue, such as physical activity and cognitive behavioral therapy.
  • If treated for fatigue, patients should be observed and reevaluated on a regular basis to determine whether treatment is effective or needs to be reassessed.

NCCN on Sleep Disorders


  • Questions to ask patients at regular intervals include the following: Are you having problems falling or staying asleep? Are you experiencing excessive sleepiness? Do you snore frequently or stop breathing during sleep?

Assessment of Treatable ­Contributing Factors

  • Assessment should consider comorbidities, including alcohol and/or substance abuse; obesity; cardiac dysfunction; respiratory disorders; endocrine dysfunction; anemia; emotional distress; neurologic disorders; psychiatric disorders; medications; hot flashes; review caffeine intake; review history of cancer treatments; pain; fatigue; shift work; and current coping strategies, such as relaxation techniques, meditation.


  • Obtain details about the characteristics and course of the insomnia. Is the problem causing a decrease in daytime functioning, poor quality of life, or distress?
  • Address secondary causes, including medical, neurologic, and psychiatric issues; pain; shift work; and medications that may cause insomnia.


  • Treatment may include sleep hygiene education, cognitive behavioral therapy, and pharmacologic intervention. Refer patients to a sleep specialist for chronic or refractory symptoms. ■


1. 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.

2. National Comprehensive Cancer Network: NCCN Clinical Practice Guidelines in Oncology: Sleep disorders, version 1.2016. Available at Accessed June 14, 2016.

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