Prostate Care: Fatigue

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Prostate Care Fatigue

• Mei Krishnasamy
• Nursing Research Fellow

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Establishing clarity

• Cancer-related fatigue a different kind of
  tiredness

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Defining cancer-related fatigue

• A subjective, unpleasant symptom which
  incorporates feelings ranging form tiredness to
  exhaustion, creating an unrelenting condition
  which interferes with individuals ability to
  function to their normal capacity
• (Ream Richardson, 1996)

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Talking about fatigue

• Its just so heavy this tiredness, its like a
  weight coming down on you and you cant move
  (Allan, Case 11)
• Sitting about all day doing nothing.if its not
  being out of breath its the tiredness (Michael,
  Case 7)
• No energy to lift my head up (Gordon, Case 14)
• Its become like an exhaustion (April, Case 5)

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Talking about fatigue Impact on family members

• "I was already exhausted, physically and
  emotionally. It was not easy to switch gears and
  summon whatever reserves still existed inside of
  me, but I knew it was absolutely necessary to do
  so"
• (family carer of patient with AIDS - Brown
  Stetz 1999)
•  
• "I counted up one day- because she lies on here
  and I sit over there-and within 10 minutes I was
  up 15 times. Just put me pillow right, just pick
  me up, just put me down, you know, frustration
  really (husband - Thomas et al 2002)

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Cancer-related fatigue the magnitude of the
problem

• Chemotherapy
• Radiotherapy
• Surgery
• Immunotherapies and hormone therapies

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Fatigue and cancer diagnoses

• Patients with melanoma, lung, and ovarian cancer
  experience the greatest level of cancer-related
  fatigue

• Patients with breast and testicular cancer
  experience the lowest levels of fatigue

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Fatigue in prostate cancer

• Health related quality of life is a primary
  endpoint of treatment evaluation for patients
  with prostate cancer
• Fatigue is a primary concern

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The evidence (1)

• Fatigue, social functioning, sleep disturbance,
  and cognitive function identified as the most
  frequent dimensions of quality of life affected
  moderately or severely in 262 men receiving RAD
  or PRECT
• Fatigue, physical functioning, and emotional
  function identified as independent predictors of
  quality of life
• (Lilleby et al. 1999)

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The evidence (2)

• Fatigue severity shown to increase from point of
  initiation of hormone therapy in a group of 58
  men receiving Goserelin (LHRH)
• 66 of the sample reported a significant increase
  in fatigue severity from baseline to three months
  post initiation of therapy
• The increase experienced in fatigue level
  comparable to that in men receiving RAD
• (Stone et al. 2000)

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The evidence (3)

• A study of 41 men receiving radiotherapy as
  primary treatment (54), after TURP (10) and
  after PREC (36)
• A moderate worsening of fatigue noted during
  radiotherapy that returned to normal levels by 6
  weeks post radiotherapy
• (Janda et al. 200)

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The evidence (4)

• Vordermark et al 2002 chronic fatigue (median
  2 years post completion of therapy) shown to be a
  problem after radical or post-operative
  radiotherapy for 103 men with T1-T3 disease
  receiving median total dose of 66Gy
• 18 of men reported experiencing severe fatigue
• (31 radical radiotherapy
• 12 post-operative radiotherapy
• 15 of men receiving hormone therapy)

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The evidence (5)

• 26 of 206 men aged between 48-85 years between
  one month and 5 years post diagnosis identified
  lack of energy and tiredness as a moderate or
  high area of unmet care need
• (Steginga et al. 2001)

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The evidence (6)

• Men who receive androgen deprivation therapy
  experienced more fatigue, more loss of energy,
  emotional distress and lower overall QL than men
  who deferred hormone therapy
• Study of 144 men with asymptomatic,
  non-metastatic prostate cancer 79 men receiving
  androgen therapy, 65 not.
• (Herr OSullivan 2000)

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Fatigue as an overlooked and under-treated problem

• Data from the CAPSURE study of 2,252 men
  demonstrated significant differences (p0.002)
  between physician and patient assessments of
  sexual, urinary, bowel function, fatigue and bone
  pain (Litwin et al. 1998)
• Similar findings presented in studies of
  heterogeneous groups of cancer patients
• (Vogelzang et al 1997 Curt et al. 2000)

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Strategies for managing fatigue

• Pharmacological approaches
• Non-pharmacological approaches

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• Fatigue
• Social functioning
• Sleep disturbance
• Cognitive function (Lilleby et al. 1999)
• Hot flashes
• (Stone et al. 2000. Herr et al. 2000)

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Pharmacological approaches

• Psychostimulants
• - Methylphenidate
• -Pemoline
• -Dextroamphetamine
• Corticosteroids
• - Dexamethasone
• - Prednisolone

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• Anaemia Blood transfusion/ Erythropoietin
  androgen therapies
• Depression
• Pain control
• Other symptoms

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Non-pharmacological approaches

• Patient education
• Exercise associations between loss of muscle
  bulk and neuromuscular function (Stone et al.
  2000)
• Psychosocial interventions
• Sleep therapy

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Patient education (Ream Richardson 1997
Johnson et al. 1997 Berglund et al. 2003)

• Well-being and health promotion
• Problem/symptom management
• Depression
• Breathlessness
• Pain
• Sleep disruption

• Self-care strategies
• Family centred

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Exercise (Segal et al. 2003, 2001 Berglund et
al. 2003 Porock et al. 2000 Mock et al. 1997
Dimeo et al. 1997 Mac Vicar et al. 1986)

• Benefits include
• Increased energy
• Maintenance or restoration of prioritised
  physical functioning
• Enhanced mood
• Improved sleep quality
• Reduced nausea and complications of prolonged bed
  rest

• Aerobic exercise walking, treadmill,
• Low to moderate intensity
• 10-30 minutes
• 3-4 times/week

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Psychosocial interventions

• Encourage and support discussion of concerns and
  worries about prostate cancer, its treatment and
  outcome (Clark et al. 1997, Johnson et al. 1997)
• Introduce relaxation, mediation, group support
  (as appropriate)
• Cognitive behavioural strategies

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Sleep therapy

• Daytime inactivity and night-time restlessness
  associated with increased\levels and perception
  of cancer-related fatigue
• Inactivity is de-conditioning
• Balance energy conservation with prioritised
  activity
• Plan a structured approach to sleep, rest, and
  activity based\on individual needs

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Pulling it all together

• Screen
• Assess
• Plan strategy for living with cancer-related
  fatigue
• Implement
• Re-assess regularly
• Modify strategy

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Planning and co-ordinating a strategy Nursings
contribution

• Set the agenda ask about fatigue and discourage
  silence
• Identify the core facet of the individuals
  fatigue experience
• Identify interested/core members of the health
  care team

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Refer for

• Medical advice low hb, depression,
  consideration of steroids
• Dietician- nutritional evaluation and support
• Physiotherapy for exercise
• Occupational therapy for physical functioning
  skills, stress management

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• Evaluate the components of the strategy
• Re-assess fatigue duration, severity, and
  distress
• Plan, deliver, and evaluate strategies within a
  framework of family centred care