The fatigue of cancer
CMAJ 1998;159:921
Dr. Jane Poulson, in her inspiring article on coping with the chemotherapy-related fatigue of cancer, "Dead tired" (CMAJ 1998;158[13]:1748-50 [full text]), offered a challenge to palliative care physicians to seek out the pathophysiology and treatment of this "pervasive and depressing symptom." As part of a larger study involving the Edmonton Symptom Assessment System (ESAS), we reviewed what literature was available on the measurement of fatigue.
Smets and associates1 reviewed fatigue in cancer patients in 1993, noting that 70% of patients report a sense of fatigue during chemotherapy or radiotherapy and that, for certain diagnoses, 30% to 40% of patients continue to lack energy for years after the treatment is finished. In 1997 Vogelzang and colleagues2 reported on a telephone survey of 419 cancer patients and their oncologists. Whereas 78% of the patients suffered fatigue and 32% reported significant disability because of it, only 27% of the oncologists recommended treatment for fatigue. Half of the patients did not discuss treatment of fatigue with their oncologists.
Poulson suggests that we physicians take this symptom too lightly, and I agree. In our recent, as-yet-unpublished study, we used the ESAS, which involves a series of 100-mm visual analogue scales for measuring 9 symptom domains, of which tiredness is one. For the tiredness subscale, we recorded the blinded perceptions of this symptom by the patient, the nurse and a close family member. The mean score (out of 100) of the patients was 34, of the nurses 40 and of the family members 38. Agreement, as measured by Cohen's kappa statistic, was significant between the patient and the family member (kappa = 0.47) but not between the patient and the nurse (kappa = 0.11). Although the nurses overestimated the patients' tiredness, there was poor agreement on the presence of this symptom.
We did not study physicians, but if the nurses' perceptions are anything to go by, we doctors are probably just as unskilled at recognizing this symptom (or, more likely, worse). To relieve suffering we must recognize the existence of the symptom and its effect on those afflicted. We must also accept that this recognition may be obscured by our paucity of knowledge, our presumptuous attitude or our restricted skills in this arena.
Bill Eaton, MD
St. John's, Nfld.
Graham Worrall, MD
Whitbourne, Nfld.
eatonb@morgan.ucs.mun.ca
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References
- Smets EMA, Garssen B, Schuster-Uitterhoeve ALJ, deHaes JCJM. Fatigue in cancer patients. Br J Cancer 1993;68(2):2204.
- Vogelzang NJ, Brietbart W, Cella D, Curt GA, Groopman JE, Horning SJ, et al (Fatigue Coalition). Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey. Semin Hematol 1997;34(3 Suppl 2):4-12.
