Being a cancer patient tends to be exhausting. And cancer-related fatigue can last long after treatment. It can take the form of depression, anxiety, sleep disturbance and pain.
A new study in JAMA Oncology finds that exercise and psychological interventions are most effective at treating cancer-related fatigue — more effective than medication. Which doesn’t mean cancer patients should start marathon training; they can start with simple activities, like walking.
I spoke with the study’s main author, Dr. Karen Mustian of the University of Rochester Medical Center. Our conversation, edited:
JR: What is cancer-related fatigue and how common is it among patients?
KM: Up to 100 percent of patients will report fatigue at some point in their treatment. Its severity ranges, and it can be moderate to severe. In many situations, these treatments that you have to receive for the disease lasts for many, many months — six months, nine months, a year or more. The fatigue can begin when you're diagnosed and you begin your treatments. It can become chronic, meaning that it kind of stays there and lingers.
Historically, we anticipated that once people were done with their treatments, that fatigue would dissipate and it would go away. We now know that while it may decrease a little bit, there's still a significant proportion of patients out there, as high as 30 percent or more, who will experience persistent fatigue. It will go on for years after their treatment ends and it will really impair their ability to resume their normal daily activities of life. And it's extremely debilitating.
Some examples: Many people actually still try to work a job when they're undergoing treatment, and it can prevent you from being able to do that. It can prevent you from being able to do your normal activities: prepare a meal, get dressed. It can impair your ability to walk around and get things done.
One of the things we worry about the most is that it can in fact impair your ability to come back and forth to the cancer center to receive your treatments. It can cause our health-care teams to sometimes think about lowering your dose or spreading your treatments out.
Have patients even stopped treatment because of its effects?
So what did your study find?
We reviewed 113 randomized clinical trials that studied the most common types of treatments that we use for cancer-related fatigue right now. That would be exercise, psychological interventions, and some pharmaceuticals. We really wanted to look at the scientific evidence and determine which of these really appears at this point to be the most effective treatment option for managing this toxicity.
What we found was that actually, exercise and psychological interventions were the most effective. They were better than any of the pharmaceuticals that we had tested to date, in the research literature. And the main findings suggested that really, we should be offering exercise and psychological interventions as first-line therapy for treating cancer-related fatigue.
What exactly does “exercise interventions” mean? Were patients put on an exercise regimen? Were they undergoing physical therapy?
Most people hear the word 'exercise' and they think of very vigorous activities, they think of long durations, like going to a class for 30 minutes or an hour, maybe going to a gym or a facility. That really wasn't what these interventions look like for the most part. Many of them involved walking. Walking more throughout the day, even if it's in short 10-minute bouts at a time.
They involved using resistance training, sometimes with weights but oftentimes also with therapeutic resistance bands. Some of them were in community facilities but a lot of them were home-based programs that people could do on their own — some very low intensity yoga, other things like that. They were really low to moderate intensity; they were not super vigorous for the most part.
And psychological interventions?
I think when most people hear that they think of one-on-one therapy with a counselor or therapist. That is not what with these interventions were. Most of them were delivered in group formats and they really focused on what we call cognitive behavioral therapy or psycho-educational therapies. Really what that means is talking with people and helping them to sort of re-frame the way that they think about fatigue and what they might do.
A great example of that would be understanding that simply sleeping or napping more is not going to be sufficient to mitigate your cancer-related fatigue. And that actually changing your thoughts that rest is the answer, and understanding that you might actually have to get up and walk a little bit, would be helpful.
What most surprised you in your findings?
The thing that surprised me the most is knowing that by and large pharmaceuticals — and many of the ones that have been studied in these trials — are still prescribed for patients who come in and say that they have cancer-related fatigue. And oftentimes the patients think that that's the answer. So when they discuss the situation with their health care team, they think that the answer is probably going to be in the form of a medication.
While it wasn't surprising to me that exercise worked for helping with fatigue, what was surprising is that it worked significantly better than any pharmaceutical agent that we have tried to study to date. And what this is showing is that we should really be thinking differently about what our first response is for patients, when they tell us that they have this debilitating fatigue.
Why do you think pharmaceuticals weren't as effective? The results are pretty dramatic.
It's very likely that we haven't found the right pharmaceutical that is addressing the right mechanistic pathway. This toxicity and the way it arises probably is a combination of the disease and the treatments that patients undergo — the chemotherapy, the radiation therapy, hormone therapies, and all the effects that they have systemically throughout the body are pretty complex. So probably if there is a pharmaceutical product, we have not found the right one yet if one exists.
But how can you get someone to start exercising during cancer treatment with fatigue? It seems like getting started is the hardest thing.
You're asking a key important question. It is about getting the information to patients, helping providers be able to talk and communicate about this, and have it rise to the top of their toolkit when they think about helping a patient manage this toxicity.
And the other part that is becoming really apparent is that even healthy people who are aren't going through cancer can use some formal support and intervening in their life to help them exercise.
Cancer patients have a lot of questions; even if they want to exercise they don't know what to do or how to do it safely. So it's about figuring out points of contact in their cancer care trajectory where someone can actually come in and have a conversation with that patient about being active and exercising, how it might help. And we're beginning to see that in cancer centers across the country, and its importance rising to the surface.
It's not just something people will intuitively do on their own and easily adopt especially not at this time period in their life. And so really formally intervening is important.
When a patient reports that the exercise was effective, what does that look like for them? How is it manifested?
It means they feel like getting up out of their bed and getting dressed. They feel like going and making their cup of tea or coffee and actually eating breakfast. If they have children or grandchildren or family members, they actually feel like engaging with them in their normal life activities. It can be those really basic things.
How would you translate your findings into advice for patients or caregivers?
One of the single most important things that you can do when you have a diagnosis of cancer is to create a plan to remain active and to be active throughout that cancer trajectory.
And while our knee-jerk reactions might be to retreat, and to rest, and for caretakers to be very protective and say, 'Let me do that for you. Don't get up don't walk over there,' actually encouraging them to be more active, asking them to get up and go for a 10-minute walk and walking with them — those kinds of things can make some of the most drastic positive impacts in the entire experience that someone would have with cancer.
Readers, your experiences?