To what extent is fatigue a factor in bone marrow failure disease patients?
There’s not a lot of data yet looking at fatigue in the diseases that aren’t cancer. However, with the help of AA&MDSIF we recently conducted a study where patients reported fatigue levels and it does seem similar to what we see in cancer-related fatigue. This is self-reported data from a diverse group of individuals. We asked about and measured fatigue. It is a prominent symptom in the group of patients we surveyed. We have submitted an abstract on this that will be a poster presentation at ASH 2015. We’re going to submit the MDS portion of this study to a global academic program in Brazil in April.
What kind of methods are there to determine how much fatigue a patient is experiencing versus what they report? How do you get patients to self-
monitor or really pay close attention to their fatigue level to accurately communicate this?
This is very important – and every patient’s experiences are different. At MD Anderson, we use a validated tool, the brief fatigue inventory. For fatigue symptoms in patients, we have to rely on self-reporting because there’s no other diagnostic measurement such as a blood test that can do this. The tools we use can be very helpful tracking the patient’s progress with fatigue as we change interventions or make additions or changes to their regimen. Patient reporting is the primary method – I often have my patients keep a ‘fatigue diary’ at home so they can figure what things they do may be adversely affecting their fatigue level, and they can better plan around those things.
Are you able to tell what the source of the fatigue is? For example, are chemotherapy, radiation and stem cell transplants all suspect, along with non-treatment sources of fatigue?
In most cases, it’s multi-factorial. We know fatigue is linked to the various treatments used and likely the disease itself, depending on the status of the disease. With survivors who no longer have the disease, there still can be residual fatigue from the treatment that occurred. Fatigue is nonspecific, and besides the disease and treatment, other symptoms like depression, anxiety and sleep dysfunction are closely associated with fatigue. These contribute to it along with other co-morbidities patients may have, such as untreated hypertension, diabetes or heart disease. In evaluating fatigue, we have to consider all of these factors. So, there can be a number of contributing factors but we can’t discern which ones are contributing more to the fatigue than another. We treat the easiest ones first and see how much we can minimize the level of fatigue the patient reports.
We do know that patients who receive intensive treatments and have had different kinds of previous treatments – radiation, chemotherapy, stem cell transplants among them – tend to have more fatigue. If a patient has a relapse, doctors have to consider their symptoms and quality of life. If they have had a number of treatments, the fatigue can be overwhelming, and this has to be stabilized or optimized before moving on to the next kind of treatment.
What non-drug therapies or interventions seem to work well helping patients manage and reduce fatigue?
The best evidence for non-pharmacologic or non-drug management is activity enhancement, such as exercise, and psychosocial interventions, which are behavioral-type therapies. These interventions are recommended based on the most evidence in the literature. For the majority of patients, we try to have them start some type of exercise program. The level of exercise depends upon the patient. An individualized approach should be taken. Their level of physical activity and other underlying patient-specific factors may contribute to the type and intensity of exercise. Psychosocial interventions have included educational activities, support groups and individual counseling, comprehensive coping methods, stress management training and personal behavioral intervention. Some examples that may be helpful to patients include taking brief naps early in the day or listening to guided imagery tapes daily.
What has the MD Anderson cancer fatigue clinic been doing recently?
We’re very busy, always evaluating more patients. We are also doing an internal study right now with the pain and symptom management group in our clinic exploring the relationship of fatigue and motivation. One of our postdocs in the symptom management group is working on this, and we’re recruiting patients from the clinic for this to find out whether there is a true relationship between motivation and fatigue. We hope to have some data in the next few months. So, we have studies being run along with the day-to- day activity at our cancer-related fatigue clinic.
What is the most important advice you can give a patient seeking to better manage their fatigue?
First of all, patients should try to self-monitor their fatigue, to get an idea of what makes it better and what makes it worse. Knowing what their usual activities are and correlating these with their fatigue level can be helpful when talking to their provider about fatigue and fatigue level changes associated with particular daily activities. When a new drug is started, or when the dose changes, patients should note the effect upon their fatigue. So, it is helpful for patients to keep a diary to determine whether they can define a pattern of fatigue or to note factors either improving or worsening their fatigue.