Cognitive Behavior Therapy
Cognitive behavior therapy (CBT) has long been used to treat a variety of psychophysiological problems, with therapy focusing on the thoughts (cognitions) and functional behaviors relevant to the presenting problems. In a randomized clinical trial, 98 mixed-type cancer survivors (intervention group = 50, wait-list control = 48) experiencing severe fatigue not attributable to a specific somatic cause were provided individual CBT.[Level of evidence: I] The CBT focused on each participant's unique pattern of the following six possible factors that might serve to perpetuate their post-cancer treatment fatigue:
- Insufficient coping with the experience of cancer.
- Fear of disease recurrence.
- Dysfunctional cognitions regarding fatigue.
- Dysregulation of sleep.
- Dysregulation of activity.
- Low social support/negative social interactions.
The number of therapy sessions varied according to the number of perpetuating factors (range: 5-26 1-hour sessions; mean: 12.5 sessions); results showed a clinically significant decrease in fatigue severity and functional impairment.
Activity and Rest
Health professionals can work with patients with cancer to develop an activity/rest program based on an assessment of the patient's fatigue patterns that allows the best use of the individual's energy. Any changes in daily routine require additional energy expenditure. Individuals with cancer should be advised about setting priorities and maintaining a reasonable schedule. Health professionals may assist patients by providing information on support services that are available to help with daily activities and responsibilities. An occupational therapy consultation can be of assistance in evaluating energy conservation methods. Sleep hygiene, including avoidance of lying in bed at times other than sleep, shortening naps to no more than 1 hour, avoiding distracting noise (e.g., television, radio) during sleep hours, and other measures may improve sleep and activity cycles.
Much of the management of chronic fatigue in people with cancer involves promoting adaptation and adjustment to the condition. The possibility that fatigue may be a chronic disability should be discussed. Although fatigue is frequently an expected, temporary side effect of treatment, the problem may persist if other factors continue to be present.
An important goal of management is to facilitate self-care for the person with cancer. Since fatigue is documented as the most commonly reported symptom in individuals receiving outpatient chemotherapy (81% of cancer patients report fatigue), a shift in responsibility for control of side effects from the health care professional to the individual is important. It is imperative that individuals with cancer are educated about fatigue before it occurs and are taught about self-care strategies necessary to manage fatigue.
Specific techniques for the management of fatigue include the following:
- Differentiation of fatigue from depression.
- Assessment for presence of correctable correlates or causes of fatigue (e.g., dehydration, electrolyte imbalance, dyspnea, anemia).
- Evaluation of patterns of rest and activity during the day as well as over time.
- Determination of the level of attentional fatigue and encouragement of the planned use of attention-restoring activities (e.g., walking, gardening, bird watching).
- Providing anticipatory guidance regarding the likelihood of experiencing fatigue, and the fatigue patterns associated with particular treatments.
- Encouragement of activity/planned exercise programs within individual limitations; making goals realistic by keeping in mind the state of disease and treatment regimens.
- Education of individuals and families about fatigue related to cancer and its treatment.
- Helping people with cancer and their families identify fatigue-promoting activities and develop specific strategies to modify these activities.
- Suggesting individualized environmental or activity changes that may offset fatigue.
- Maintaining adequate hydration and nutrition.
- Recommending physical therapy referral for people with specific neuromusculoskeletal deficits.
- Recommending respiratory therapy referral for people with dyspnea that is a contributing factor to fatigue.
- Scheduling important daily activities during times of least fatigue and eliminating nonessential, stress-producing activities.
- Addressing the negative impact of psychologic and social stressors and how to avoid or modify them.
- Evaluating the efficacy of fatigue interventions on a regular and systematic basis.