1. Cancer-Related Fatigue 慈濟醫院血液腫瘤科 高瑞和醫師

2. Cancer-related fatigue is a persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning. DEFINITION OF CANCER-RELATED FATIGUE 中文：疲憊，疲累

3. Cancer-Related Fatigue Acute fatigue: physiologic response, recoverable Chronic fatigue: pathologic condition, unable to recover even after rest Affect body and mind: physical, emotional, mental 身心憔悴

4. Temporal relationship with intervention Chemotherapy peaks within days Radiation therapy peaks after weeks May persist for prolonged period Almost universal with biologic response modifiers Cancer-Related Fatigue

5. Causes of Cancer-Related Fatigue Physiologic Underlying neoplasm Antineoplastic treatment Concomitant systemic disease Sleep disorders Immobility and lack of exercise Chronic pain Psychological Anxiety, depression

6. Cancer-related pathophysiology that cause fatigue Symptoms related to energy imbalance Pain and pain treatment Anemia Cachexia Infection Paraneoplastic syndrome Metabolic disorder Stress and mood Fatigue induced by cancer therapy

7. Signs of Cancer-Related Fatigue Feeling tired, weary or exhausted even after sleeping Lacking energy to do your regular activities Having trouble concentrating, thinking clearly, or remembering Feeling negative, irritable, impatient, or unmotivated Lacking interest in normal day-to-day activities Spending less attention on personal appearance Spending more time in bed or sleeping

8. Diagnosis of Cancer-Related Fatigue Ask the patient Do you feel tired or fatigued? Does fatigue make you change your activities? Patient self-report is the best diagnostic tool

9. Prevalence of Cancer-Related Fatigue 50% at diagnosis, 75% if bone metastasis Patient with chemotherapy80-96% Patient with radiotherapy60-93% *Cox et al: In general population, 20% men and 30% women always feel tired. Fatigue-1 & Fatigue-2 studies

10. Impact on QOL Fatigue-1 study 1996 2/3 patients considered that fatigue affected their performance of normal daily activities 61% patients claimed that fatigue influenced their life more than pain

11. Impact on QOL Fatigue-2 Study 1998 Fatigue (25%) other than nausea (13%) as the main symptom after chemotherapy Loss of emotional control: 90% A feeling of isolation and solitude: 74% Dejection: 72% Marked effect on employment and financial status: 75% had changed employment The effects on care-giver: more working breaks (20%)

12. Stone et al Ann Oncol 2000 52% never reported fatigue to their oncologist Only 14% had received treatment or advice on how to manage fatigue 33% with fatigue declared they had not received adequate treatment 538 cancer patients Extent of The Problem

13. Oncologist’s view: pain in more clinically relevant than fatigue (61% vs 37%) Patient’s view: fatigue affects everyday life much more than pain (61% vs 19%) Extent of The Problem

14. 1.Screening 2.Primary evaluation 3.Interventions 4.Reevaluation

15. SCREENING

16.  Disease status and treatment Rule out recurrence or progression Current medications/medication changes  Review of systems  In-depth fatigue assessment Onset, pattern, duration Change over time Associated or alleviating factors Interference with function Primary Evaluation Phase Focused History:

17. How is Fatigue Assessed? 1.When did the fatigue first start? 2.When did you first realize that it is an unusual type of fatigue for you? 3.How has it progressed over the course of your treatment or since your diagnosis? 4.What help relieve your fatigue? 5.What makes your fatigue worse? 6.How has the fatigue affected your daily activities or the activities that give meaning and enjoyment to your life?

19. Pain Emotional distress: depression Sleep disturbance Anemia Nutrition assessment: weight/calori intake change fluid, electrolyte imbalance Activity level: changes in exercise or activity pattern, deconditioning Comorbidities: infection, cardiac, pulmonary, renal, hepatic, neurologic, endocrine, hypothyroidism Assessment of Treatable Contributing Factors

21. Anemia and Cancer-Related Fatigue Correlation between Hb levels (  12g/dL vs.  12g/dL) and fatigue QOL parametersP value Higher QOL scores0.003 Less fatigue0.01 Fewer symptoms of anemia0.02 Better sensation of physical well being0.003 Better sensatin of function al well being0.001 QOL: quality of life Sobreo et al. Semin Hemato 2001, 28:15-18

22. Treatment of Anemia-related Fatigue Iron, folic acid replacement Blood transfusion Erythropoietin therapy: supported by strong clinical evidence 10,000 units sc tiw or 40,000 units sc weekly

23. INTERVENTION-1 Patient/Family Education

24. Common Strategies for Management of Fatigue INTERVENTION-2

25. Non-Pharmacologic INTERVENTION-3

26. Pharmacologic INTERVENTION-4

27. Re-evaluation

28. What to look for? Feeling like you have no energy Increased sleeping Lack of desire to do normal activities Decreased attention to personal appearance Feeling tired even after sleeping Difficulty concentrating Patient Self-Care

29. Plan rest periods to conserve energy for important things Schedule necessary activities throughout the day rather than all at once Engage in light activity Get enough rest and sleep Eat a nutritious diet including plenty of liquids Remember that fatigue caused by treatment side effects is temporary and that energy will What to do? Patient Self-Care

30. Finale Fatigue is common in cancer patients which should be recognized, evaluated, monitored, documented and treated promptly at all stages of the disease, both during and after treatment.

31. 誌謝 PPTT Members 王玉祥 王全正 王宏銘 王正旭 邱昌芳 巫宏博 林炯森 林哲斌 林勝豐 吳銘芳 高瑞和 張正雄 張明志 張義芳 郭集慶 陳仁熙 陳彥仰 陳博明 曹朝榮 黃文豊 黃文聰 黃承華 黃叔牧 黃明立 葉士芃 葉光揚 馮盈勳 葉坤輝 趙大中 蕭士銓 蕭惠樺 鄭丞傑 劉青山 謝瑞坤 謝長堯 顏家瑞

32. The End