As with other self-reported symptoms such as pain, it may be necessary to encourage the patient and other family members to report symptoms of fatigue to the medical staff. Information regarding the potential for fatigue due to the underlying disease or treatments, possible options for management, and the importance of reporting these symptoms should be given to all patients at the initiation of treatment. Patients may not mention the fatigue they experience unless they are prompted by a health professional.
Several barriers hamper appropriate management of CRF. Some of these barriers were identified in phase 1 of an ongoing three-phase project related to the implementation of evidence-based (NCCN) guidelines for fatigue management. The most commonly identified barriers were the following:[21,22]
- Patient's belief that the physician would introduce the subject of fatigue if it was important (patient barrier).
- Lack of fatigue documentation (professional barrier).
- Lack of supportive care referrals (system barrier).
Although there is no universally accepted standard for the measurement of fatigue, there are a variety of instruments that have been developed to assess fatigue and related sequelae.[2,3,4,5,6][Level of evidence: II];[7,8,9,10] Fatigue is also commonly assessed in multidimensional quality-of-life instruments. Selected instruments for assessing fatigue are listed below.
- Brief Fatigue Inventory.
- The Functional Assessment of Cancer Therapy-Anemia.
- The Functional Assessment of Cancer Therapy-Fatigue.
- Piper Fatigue Self-Report Scale.
- The Schwartz Cancer Fatigue Scale.
- Fatigue Symptom Inventory.
- The Profile of Mood States Fatigue/Inertia Subscale.
- Lee's Visual Analogue Scale for Fatigue.
- Cancer Fatigue Scale.
Evaluation of Anemia
The proper evaluation of anemia in cancer patients includes a careful history and physical examination, an evaluation of the complete blood count and red blood cell indices, and examination of the peripheral blood smear. In combination, the information from these investigations is often diagnostic.
One commonly used method for classifying anemia is to categorize the anemia by the size of the red blood cell as measured by the mean corpuscular volume (MCV). Microcytic anemias are associated with an MCV of 79 fL or lower and include iron-deficiency anemia, thalassemia, and anemia of chronic disease. Macrocytic anemias are associated with an MCV higher than 101 fL and include anemias related to vitamin B12 or folate deficiency, myelodysplasia, and liver disease. Most anemias are normocytic, meaning that the MCV is in the normal range. This category includes the following:
- Myelophthisic anemia (i.e., anemia due to neoplastic replacement of the bone marrow).
- Most chemotherapy-related anemias.
- Anemia due to renal or hepatic dysfunction.
- Hemolytic anemia.
- Aplastic anemia.