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Coping with Fatigue

by Lillian Nail, PhD, RN

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Dr. Lillian Nail (pictured here) is a multiple cancer survivor and a member of a dragon boat paddling team.

Fatigue is now recognized as one of the most common side effects of cancer treatment. Prior to the 1990s, fatigue was not viewed as a side effect of treatment. But the results of studies on the experience of receiving cancer treatment, which documented high rates of fatigue (60%-100%) across different types of treatment, characterized the pattern of fatigue during and following treatment, and indicated that some people had fatigue that persisted months to years beyond the end of treatment.

These research findings changed cancer care. Hospitals and treatment centers began incorporating information about fatigue as a treatment side effect in treatment consent and in information for people starting cancer treatment to give them accurate information about the “usual” experience of treatment. Fatigue became part of routine side effect assessment, and unusually severe fatigue began to be recognized and investigated.

By 1994, two other lines of research were also yielding important information. Fatigue decreased as anemia improved in trials testing erythropoietin as a treatment for chemotherapy-induced anemia, and studies of moderately intense aerobic exercise during cancer treatment showed lower levels of fatigue with exercise. But it seemed like these research results were not getting much attention in cancer care.

I had a lot of personal experience with treatment-related fatigue by late 1994. I had recently completed chemotherapy for non-Hodgkin lymphoma, and eight years earlier I had undergone radiation treatment for breast cancer. Chairing the planning group for the Oncology Nursing Society’s Fatigue Initiative through Research and Education (FIRE) Project™ allowed me to address my frustration about the lack of solutions for managing fatigue in people with cancer. We merged the research-based knowledge with best clinical judgment and practical experience to develop resources on fatigue for patients, professionals, and the public. My current recommendations for dealing with fatigue reflect current published research, best clinical judgment, and practical experience.

When you are asked how you are feeling, be sure to include fatigue in your response if you feel tired.

Get information.
Prior to beginning a treatment, ask what proportion of people experience fatigue with the treatment, and ask for a description of the pattern of fatigue during and following treatment.

Give information.
When you are asked how you are feeling or asked about symptoms, be sure to include fatigue in your response if you feel tired. If you are not asked to provide a numeric rating like 1-10, give one anyway. Keep a diary of your ratings, and show how your fatigue level is changing. If you have trouble getting providers to pay attention to fatigue, describe the impact of fatigue on your life. State it in terms that anyone can relate to, like “I’m so tired that I have to sit down for 30 minutes after I put on my jeans.”

Get exercise.
Exercise that raises your heart rate, like walking, may help. Check with your providers about exercise restrictions and referral to a physical therapist or exercise specialist to plan your exercise program. Remember to start at your own level, and stop if you have symptoms. That may mean walking laps in your living room at first. Safety is important. You may have someone walk with you, or you might join a supervised rehabilitation program.

Use energy conservation.
Sit rather than stand, arrange your work area so tools are easy to reach, plan activity for times when your fatigue is low, delegate trips up and down the stairs to someone else, and avoid doing heavy physical or mental work when you feel most tired.

Look for correctable causes of fatigue.
Check with your provider about looking for correctable causes of fatigue, like anemia, sleep problems, dehydration, low thyroid function, depression, and other illnesses. Psychostimulant drugs may help some people. (Refer your provider to the most recent National Comprehensive Cancer Network Cancer-Related Fatigue Guidelines at for information about correctable causes and about psychostimulants.)

Know yourself.
Keep track of your personal clues that you are about to “hit the wall” so that you can ensure you have a way to get home or have an exit strategy from a social event or work commitment. Prearranged code words, agreeing on exit strategies with a spouse or business partner before an event, and preplanning rest periods are examples of ways to deal with risky situations. Some people have a list of situations and activities to avoid because they worsen their fatigue. Examples include overheated rooms, alcoholic beverages, and standing too long.

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Dr. Lillian Nail is the Rawlinson Professor of Nursing at the School of Nursing and a member of the Knight Cancer Institute at Oregon Health & Science University in Portland, OR, where she conducts research on symptom management and cancer survivorship.

This article was published in Coping® with Cancer magazine, May/June 2009.