1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 3k Symptoms – Fatigue Module 3k Symptoms – Fatigue EPEC – Oncology Education in Palliative and End-of-life Care – Oncology

3. Fatigue... Definition l Persistent sense of tiredness l Interferes with function l Unrelieved by rest Definition l Persistent sense of tiredness l Interferes with function l Unrelieved by rest Cella D, Peterman A, et al. Oncology, 1998.

4. ... Fatigue Epidemiology l High prevalence-varies with stage and primary l High impact l Patterns of fatigue ChemotherapyRadiotherapyEpidemiology l High prevalence-varies with stage and primary l High impact l Patterns of fatigue ChemotherapyRadiotherapy Volgelzang N, Breitbart W, et al. Semin Hematal, 1997. Cella D, Peterman A. Oncology, 1998. Stone P, Richardson A, et al. Ann Oncol, 2000. Schwartz AL, Nail LM, et al. Cancer Invest, 2000.

5. Key points 1.Pathophysiology 2.Assessment 3.Management 1.Pathophysiology 2.Assessment 3.Management

6. Pathophysiology l Multifactorial l Abnormal energy metabolism l Increased cytokine production l Contributing factors Depression Sleep disorders Muscular dysfunction l Multifactorial l Abnormal energy metabolism l Increased cytokine production l Contributing factors Depression Sleep disorders Muscular dysfunction

7. Assessment... l Subjective report l Screen with 0 – 10 rating scale 4 – 6 = moderate fatigue 7 – 10 = severe fatigue l Fatigue history l Subjective report l Screen with 0 – 10 rating scale 4 – 6 = moderate fatigue 7 – 10 = severe fatigue l Fatigue history Mock V, Atkinson, et al. NCCN, 2003.

8. ... Assessment History / physical exam l Disease status l Current medications l Associated symptoms l Malnutrition / deconditioning l Comorbidities History / physical exam l Disease status l Current medications l Associated symptoms l Malnutrition / deconditioning l Comorbidities

9. Management... Treatable etiologies l Anemia l Depression l Pain l Hypothyroidism l Hypogonadism Treatable etiologies l Anemia l Depression l Pain l Hypothyroidism l Hypogonadism

10. ... Management Non-pharmacologic therapies… l Educate – patterns of fatigue l Clarify role of underlying illness, treatment l Optimize fluid, electrolyte intake, nutrition Non-pharmacologic therapies… l Educate – patterns of fatigue l Clarify role of underlying illness, treatment l Optimize fluid, electrolyte intake, nutrition Winningham ML. Cancer, 2001.

11. ... Management …Non-pharmacologic therapies l Promote physical activity l Include other disciplines l Energy conservation strategies …Non-pharmacologic therapies l Promote physical activity l Include other disciplines l Energy conservation strategies Winningham ML. Cancer, 2001.

12. ... Management Pharmacologic l Methylphenidate l Dexamethasone, prednisone l Modafinil Pharmacologic l Methylphenidate l Dexamethasone, prednisone l Modafinil Bruera E. Cancer Treatment Rep, 1985. Bruera E, et al. JCO, 2004. Rammohan KW, et al. J Neurol Neurosurg Psychiatry, 2002.

13. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience