Studies seeking to explain mechanisms associated with or causing fatigue are increasing; however, the underlying causes of fatigue remain largely unknown. Thus, identifying and predicting which patients may be at risk for developing fatigue, and tailoring interventions accordingly, are difficult. Whether fatigue experienced by patients with cancer can be classified into specific clinically significant subtypes would be useful to determine. These clinical subtypes might improve understanding of underlying mechanisms and help tailor treatment accordingly. This article refers to fatigue associated with cancer or its treatment as cancer-related fatigue (CRF). Given this broad designation, meant to encompass the array of causal mechanisms and treatment options, the authors recommend that meaningful clinical subtypes be articulated and differentiated. This article therefore reviews CRF definitions and proposes a nonexhaustive set of clinical subtypes that are intended to help sharpen thinking about causality and, ultimately, treatment recommendations.
Barbara F. Piper and David Cella
Tami Borneman, Barbara F. Piper, Virginia Chih-Yi Sun, Marianna Koczywas, Gwen Uman and Betty Ferrell
Fatigue, despite being the most common and distressing symptom in cancer, is often unrelieved because of numerous patient, provider, and system barriers. The overall purpose of this 5-year prospective clinical trial is to translate the NCCN Cancer-Related Fatigue Clinical Practice Guidelines in Oncology and NCCN Adult Cancer Pain Clinical Practice Guidelines in Oncology into practice and develop a translational interventional model that can be replicated across settings. This article focuses on one NCCN member institution's experience related to the first phase of the NCCN Cancer-Related Fatigue Guidelines implementation, describing usual care compared with evidence-based guidelines. Phase 1 of this 3-phased clinical trial compared the usual care of fatigue with that administered according to the NCCN guidelines. Eligibility criteria included age 18 years or older; English-speaking; diagnosed with breast, lung, colon, or prostate cancer; and fatigue and/or pain ratings of 4 or more on a 0 to 10 screening scale. Research nurses screened all available subjects in a cancer center medical oncology clinic to identify those meeting these criteria. Instruments included the Piper Fatigue Scale, a Fatigue Barriers Scale, a Fatigue Knowledge Scale, and a Fatigue Chart Audit Tool. Descriptive and inferential statistics were used in data analysis. At baseline, 45 patients had fatigue only (≥ 4) and 24 had both fatigue and pain (≥ 4). This combined sample (N = 69) was predominantly Caucasian (65%), female (63%), an average of 60 years old, diagnosed with stage 3 or 4 breast cancer, and undergoing treatment (82%). The most common barriers noted were patients' belief that physicians would introduce the subject of fatigue if it was important (patient barrier); lack of fatigue documentation (professional barrier); and lack of supportive care referrals (system barrier). Findings showed several patient, professional, and system barriers that distinguish usual care from that recommended by the NCCN Cancer-Related Fatigue Guidelines. Phase 2, the intervention model, is designed to decrease these barriers and improve patient outcomes over time, and is in progress.