Interventions
One's approach and guidance to someone who is struggling with chronic fatigue after cancer treatment must be based on clinical experience and tailored to the individual. If the screening indicates somatic or mental conditions in need of treatment, such therapy must be provided. There is otherwise no specific treatment for chronic fatigue, but there are several interventions that can alleviate the symptom (26).
It is generally recommended that the patient should receive updated information about chronic fatigue and about contributory and remedial factors. Advice on activity pattern is often useful because many patients exaggerate their activity level on good days resulting in exhaustion for several days after, which in turn may lead to a reduction or at worst a gradual decline in physical activity over time. Advice on energy conservation by adjusting activity levels to one's perceived level of energy might also be helpful to avoid fluctuations, and possibly help to gradually increase physical capacity. For all those affected it is recommended to maintain a regular circadian rhythm and to avoid sleeping during daytime (7, 8).
Other interventions fall into three main categories: physical activity, cognitive therapy and stress-reducing therapies. A recently published meta-analysis showed that physical activity and psychological interventions improve chronic fatigue to almost the same extent. The effect was equal regarding anaerobic and aerobic exercise, while cognitive therapy was the most efficacious of the psychological interventions. All interventions had best effect in a group setting (26).
Even though chronic fatigue can be a dynamic condition, there are no data that specifically indicate how many can be expected to recover after physical training/cognitive therapy. Yoga, acupuncture and mindfulness-based approaches have also shown promising results in some studies (7, 27). Currently, however, no general recommendations can be given since these studies are few, with only a limited number of patients included and with a lack of data on the duration of the effect.
Without verifiable documentation, aspects of the case history and symptoms may nevertheless indicate the best approach for the individual patient. For someone who is physically inactive, physical activity after consulting their physician may be a good first choice. For those with a tendency to catastrophize and with dysfunctional thoughts, cognitive therapy may be the best choice, while stress-alleviating interventions may be best for those with high anxiety and stress levels.
Regular physical activity has been documented as an effective intervention (28). It has not been clarified what intensity and type of physical activity is most effective. However, in our experience an individualised programme with a gentle start and gradual progression is important, and so far the literature also supports this. Many patients want to start at a too high intensity which may result in training interruptions, or at worst exacerbation of the fatigue. For most cancer survivors with chronic fatigue, a moderately intense training programme, including brisk walking, cycling and/or swimming will be safe (7). If the patient has other post-cancer late effects (cardiac affection, polyneuropathy) or comorbid conditions, his/her training programme must be adjusted according to this.
The above meta-analysis describes physical activity as seemingly most effective during ongoing cancer treatment, while psychological interventions – or a combination of physical training and psychological interventions – may be best for cancer survivors (26).
Numerous rehabilitation programmes are available for patients with chronic fatigue. Additionally, courses on learning to cope are arranged for patients at some learning and coping centres and the Varde centres (centres for cancer patients and their families established at some hospitals by the Norwegian Cancer Society and the regional health authorities). Psychostimulants (methylphenidate and modafinil) have been used in other countries but are not offered to patients in Norway due to lack of documented effect.
All health personnel who meet cancer survivors should have knowledge about chronic fatigue and interventions that can alleviate the symptom. Even though some cancer survivors receive follow-up care from a surgeon or oncologist, it will mostly be GPs who meet cancer survivors suffering from chronic fatigue. The GP can contribute by giving the patient information about the condition and possible interventions such as energy conservation, physical activity and cognitive therapy. The GP will also have knowledge about comorbidity and risk factors for the individual patient. Moreover, the GP will be of key importance in the administration of social security agreements so that the patient can cope with his/her occupational situation. Therefore, screening and monitoring of these patients should primarily be the GP's responsibility.