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Editorial: Fatigue, the Most Common Problem within People Afflicted with Cancer: Challenge for Health Care Professionals - Widening Our Perspectives on Existential Issues

Issue: Vol.8, No.4 - October 2009

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Article Type: Editorial

Cancer-related fatigue is an almost worldwide disorder among cancer patients and has been identified as an essential problem. Causes for cancer-related fatigue have many origins; for example the illness itself, the side effects of most all therapy, mode changes, depression and other bio-psychosocial factors. Fatigue has a much more intense effect on patients with cancer than any other psychological or physical consequence of the disorder or its therapy. A numerous of studies argue for cancer-related fatigue but it is still often ignored, under-recognized and under-treated even if medical discipline has been presenting stable progress in cancer therapy itself. Fatigue is multidimensional in its appearance and influence. Fatigue can be suffered by patients as a very frustrating state of chronic energy reduction, leading to loss of production, which may diminish self-esteem. Some individuals with cancer develop fatigue, whereas others do not. Stress-induced illness is commonly seen as blameless, whereas labeling an illness as psychogenic may raise doubts about both the reality of the illness and even the character of the sufferer. Anxiety has been seen as a correlate of fatigue and anxiety is considered to be a promoting source of fatigue. Some studies present findings that fatigue associated with untreatable cancer is a lived physical experience of approaching death.

Even if it is possible for depression and fatigue to co-exist, health care professionals ought to try to distinguish between them in order to guide management. Patients with fatigue tell inability to finish some activities due to a lack of energy, while grief and depression are associated with a patient explanation that is more global, for instance being unable to do "anything." Two factors of cancer-related fatigue have been well documented. First, the physical factor is described as exhaustion or muscle weakness. The muscle weakness, causing the inability to perform activities of daily living, can be defined as asthenia. Second, the psychological factor is described as decreased capacity for activity of mental exertion causes problems in solving problems and focusing /concentrating on intellectual activities. Fatigue can be considered as being a general term covering a range of phenomena that are often, but not necessary, associated with exertion. The meaning of the term is therefore both intuitively obvious, based on one's own experience, but also indefinable.

A clear definition of fatigue is difficult to derive from the literature because many disciplines such as medicine, nursing, physiology, psychology, and ergonomics have investigated this problem with as many different perspectives.

According to National Comprehensive Cancer Network, the definition of cancer-related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. Looking at a definition proposed for nursing usage: fatigue is a subjective, unpleasant symptom, which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition, which interferes with individuals` ability to function to their normal capacity. Fatigue is a subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Despite recognition of its subjective nature, the majority of research undertaken has set out to objectify and quantify the fatigue experience.

Several instruments have been developed to measure fatigue and there is a critical review of fatigue instruments to provide clinicians information on which to base decisions of alternatives. There is also fatigue issues included in several quality of life instruments. One problem with fatigue is that a clear definition of fatigue is difficult to derive from the literature. The question then must be are we measuring the same issue? Is there an agreement between the researcher's definition of fatigue of what it is or is not and the cancer patients responding to the instruments? Are there some variables that we have been missing? Could this be the reason why studies sometimes present contradictory results? and leaving us with confusion on what to focus on. There is still work to be undertaken in understanding the phenomenon of fatigue and how to measure this. Is it possible to measure? What aspects of fatigue are to be measured? An understanding of the wider experience of fatigue is required.

Evidence is now emerging from qualitative studies that point out the considerable impact of fatigue on individuals' self esteem, role function, quality of life, adjustment to a cancer diagnosis and experiences of suffering leading to existential issues.

Fatigue is reported to affect more than the half of the cancer patients and have a considerable impact on quality of life; as a common and distressing symptom. Although the majority of healthcare professionals in different studies tell that they prescribe therapy for more than half of patients, approximately 10-15 % of patients report getting such treatment. Could this be due to the cancer patients experience affected emotions such as feelings of anxiety, fear and distress regarding the present situation but also the unpredictable future and were prescribed therapy for physical activities? The effect of exercise has been focused on fatigue in several studies, thinking on fatigue as a physical symptom.

Looking at symptom clusters across time there is a psycho-neurological cluster being quite stable over time according to the following symptoms/problems; depressed mood, cognitive disturbance, fatigue, insomnia and pain. The significant predictors are age and baseline physical performance status. It seems as psychological factors have a great impact on fatigue. Fatigue is a poorly understood and defined phenomena and we do not know how existential issues in cancer patients are coming forth; via anxiety, changed mood, sadness, apathy energy loss or fatigue.

CONCLUSION
Cancer fatigue is an almost worldwide disorder among cancer patients and has been identified as an essential problem. A clear definition of fatigue is difficult to derive from the literature; hence two factors of cancer-related fatigue have been well documented. First, the physical factor is described as exhaustion or muscle weakness. The muscle weakness is causing the inability to perform activities of daily living. Second, the psychological factor is described as decreased capacity for activity of mental exertion causes problems in solving problems and focusing /concentrating on intellectual activities. Clinicians, health care professionals as well as researchers ought to try to distinguish between them in order to guide management. They should examine other predictors or variables to understand what fatigue is caused by. It could be that fatigue has its reason in changed mood, depressed mood, anxiety or perhaps just existential issues. If the patient is pre-occupied with existential issues there is no energy left to physical, mental and social activities. The capacity of all the existing instruments of fatigue to represent differences in the fatigue experience is lacking as well as the understanding of the influence of age, gender and social and cultural factors. There are a lot of works left in working for a more informed understanding of the experiences of fatigue.

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Dr. Carina Berterv, RN, RNT, PhD
Associate Professor
Department of Medical and Health Sciences
Division of Nursing Science
Faculty of Health Sciences
Linkvping University, SE-581 85
Linkvping, Sweden

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