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New ASCO-SIO Guidelines on Fatigue in Adult Cancer Survivors


Cancer-related fatigue (CRF) is extremely common. Experienced by 30%-60% of our patient with cancer during treatment, CRF can last for months or years for 20%-30% of patients.1-3 This is no ordinary tired feeling: cancer-related fatigue is a sense of physical, mental, and emotional exhaustion that is not necessarily alleviated by rest or sleep.

Now, the American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology (SIO) have provided a comprehensive approach to managing CRF with an emphasis on integrative health, based on a review of 113 randomized clinical trials (RCTs). These guidelines are somewhat different from past sets of recommendations because they include patients who are in active treatment as well as those who have completed therapy. Here, I want to discuss these guidelines and their implications for clinical practice and offer you some actionable recommendations.

Understanding Cancer-Related Fatigue

The multifactorial nature of CRF, involving the cancer itself, treatment side effects, comorbidities, and psychological factors, makes it a complex symptom to manage. The updated ASCO-SIO guidelines take this into account with a large systematic review of 113 RCTs conducted between 2013 and 2023, providing evidence-based recommendations to address this challenge.

Key Recommendations

The guidelines highlight several integrative approaches that have shown efficacy in managing CRF both during and after cancer treatment. Below, these recommendations are categorized based on their timing relative to the cancer treatment phase.

Integrative Approaches During Cancer Treatment

  • Exercise: Regular physical activity is strongly recommended. Exercise has been consistently shown to reduce the severity of CRF. We recommend talking with your patients and helping them develop a tailored movement program that suits their individual capabilities and preferences.
  • Cognitive behavioral therapy (CBT): CBT is effective in addressing the psychological aspects of CRF. It helps patients develop coping strategies to manage fatigue and its impact on daily life.
  • Mindfulness-based programs: Practices such as mindfulness meditation and stress reduction techniques can significantly alleviate CRF. These programs help patients manage stress and improve their overall well-being. We offer resources on mindfulness practices at the Healing Works Foundation.
  • Tai chi and qigong: These mind-body exercise modalities have demonstrated benefits in reducing fatigue during cancer treatment. They combine gentle physical activity with meditation and breathing techniques. Join me for a 10-minute tai chi series.
  • American ginseng: This herbal supplement has shown promise in reducing fatigue during cancer treatment. However, it is important to review the other medications your patients are taking and their individual tolerance.

Integrative Approaches to Fatigue After Cancer Treatment

  • Exercise: Continuing regular physical activity remains crucial. Exercise not only helps patients manage CRF but also improves overall physical and emotional health.
  • CBT and mindfulness-based programs: These interventions are particularly effective for managing moderate to severe fatigue after cancer treatment. They help patients develop long-term strategies to cope with fatigue.
  • Yoga: Yoga combines physical postures, breathing exercises, and meditation, offering a holistic approach to managing CRF. It has been shown to improve both physical and mental health.
  • Acupressure and moxibustion: These traditional Chinese medicine techniques can help alleviate CRF. Acupressure involves applying pressure to specific points on the body, while moxibustion involves burning an herb near the skin to stimulate these points.

Integrative Approaches to End-of-Life Care

CBT and corticosteroids: For patients at the end of life, CBT can help manage the psychological burden of cancer-related fatigue. Corticosteroids may provide relief from physical fatigue.

Interventions to Avoid

The guidelines also identify several interventions that are not recommended for managing CRF due to insufficient evidence of efficacy or potential adverse effects. These include:

  • L-carnitine – Not enough evidence to support its use for CRF.
  • Antidepressants – Not enough evidence to support routine use for CRF. May not be effective.
  • Wakefulness agents – Medications such as modafinil or armodafinil. Evidence does not support their effectiveness.
  • Psychostimulants – Medications such as methylphenidate. Not enough evidence of benefit for CRF and possible unwanted effects.

Using the ASCO-SIO Guidelines in Your Practice

For clinicians, the updated ASCO-SIO guidelines provide a clear framework for integrative approaches to cancer-related fatigue. Here are some practical steps to help you build these recommendations into your own practice.

  • Take a Personal Health Inventory (PHI): Begin with a thorough assessment of the patient’s fatigue levels, preferences, and overall health status. The Oncology PHI can be a helpful tool for tailoring the recommendations to each patient’s needs and capabilities.
  • Put a team together: Work with a group, including exercise physiologists, psychologists, integrative medicine practitioners, and nutritionists, to provide comprehensive care.
  • Communicate: Talk with patients about the benefits of integrative approaches and encourage them to take an active part in their fatigue-management plan. They may have suggestions you haven’t considered. Provide resources and support to help them work with the recommendations.  
  • Monitor and adjust: Keep track of how your patients are doing with programs such as exercise, CBT, or mindfulness. Asking about this at each visit is just as important as checking the medications they are taking. Adjust the interventions as needed, and encourage questions.
  • Consider barriers: Recognize and address potential barriers to implementing these interventions, such as limited access to exercise facilities or psychological services. Explore community resources and support groups that can assist patients.

Conclusion

Cancer-related fatigue is now recognized as something that occurs at many stages of one’s cancer journey. It may not disappear when cancer treatment is over. The updated ASCO-SIO guidelines offer a robust framework for managing cancer-related fatigue through several integrative approaches.

By incorporating these evidence-based recommendations into clinical practice, you can help your patients who are cancer survivors have a better quality of life starting at diagnosis. Exercise, CBT, mindfulness-based programs, and other integrative methods can be effective against cancer-related fatigue, helping patients regain their energy and well-being.

Learn more about CRF and other side effects of cancer and treatment in “Healing and Cancer,” my recently released book with coauthor Alyssa McManamon, M.D. We discuss pain, sleep disturbance, and many other issues that can start during treatment and prevent your patients from recovering from cancer as completely as they otherwise might.

Resources

Finding Integrative Health Care Providers

References

1. Bower JE, Lacchetti C, Alici Y, Barton DL, Bruner D, Canin BE, Escalante CP, Ganz PA, Garland SN, Gupta S, Jim H, Ligibel JA, Loh KP, Peppone L, Tripathy D, Yennu S, Zick S, Mustian K. Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update. J Clin Oncol. 2024 May 16:JCO2400541. doi: 10.1200/JCO.24.00541. Epub ahead of print. PMID: 38754041.

2. Kang Y-E, Yoon J-H, Park N-H, 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

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