Scott Webb (Host): Cancer patients face many challenges, and for those cancer patients in palliative care, cancer related fatigue is common. My guest today specializes in palliative care, and she's here to explain cancer related fatigue and how she helps patients. I'm Scott Webb and I'm joined today by Dr. April Yasunaga. 

Doctor, it's nice to have you here today. We're, uh, essentially going to focus on cancer related fatigue and what that means in palliative care patients. But before we get there, I thought maybe just a little baseline, briefly, what is palliative care? What does that mean?

(Judith) April Yasunaga, MD: The generally accepted kind of understanding is it's specialized medical care for people living with serious illness, often defined as serious life limiting illness. So focusing on providing relief from symptoms and stress of the illness. One of the main goals is improving quality of life, and we often think of that as both for the patient and or whatever they define as family.

 I think one of the important aspects of it is it's kind of an interdisciplinary team. So doctors and nurses, social workers, chaplains, and other specialists are all part of that to really look for providing that additional support for patients going through with serious and life limiting illness.

Host: Right. And of course cancer is, you know, maybe at the top of the list, I don't know. But certainly, something that folks deal with, a reason they go to palliative care, things that they deal with. So I want to have you talk about this. I, I haven't done this topic before. What does that mean, cancer related fatigue? Maybe you can take us through this.

(Judith) April Yasunaga, MD: So fatigue kind of being that subjective sensation of physical, mental exhaustion, but usually that's relieved by rest. We all experience that. So you, you're tired at the end of the night. You go to sleep and then you wake up generally refreshed. As it relates to cancer related fatigue, a generally accepted definition you'll see in the literature is fatigue that is disproportionate to kind of that baseline fatigue and is not relieved by rest. One of the definitions that I think is more helpful, is kind of considering it as distressing, persistent, subjective sense of physical, emotional, cognitive tiredness or exhaustion that's related to cancer or cancer treatment that is not proportional to recent activities, and it interferes with your usual functioning.

 I like that definition because I think it emphasizes that this is having an impact on quality of life and is distressing and thus something we should probably focus on, or address or at least, engage in terms of the conversation.

Host: Yeah, and I'm glad we started with the definition of palliative care because as you said, one of the missions of palliative care is of course improving quality of life. So as you're saying here, even though it may be a subjective thing, what is fatiguing to one person may not be the same level of fatigue for somebody else, but nonetheless, it is fatigue and you can see how that would, you know, affect somebody's quality of life. So, let's talk about the assessment. How do you assess a patient with fatigue, you know, who's going through cancer treatment? How do you determine their fatigue level, I guess. 

(Judith) April Yasunaga, MD: I think this is kind of the important aspect of things is that it is also approaching it like you would approach any other patient from really trying to understand, how it is impacting them and are there other diseases that might be at play here. So really exploring sleep hygiene and lifestyle, the stressors that they might have. How has this change in terms of their new diagnosis and potential engagement with treatment? Is it contributed to isolation? Are they not working anymore? Are they staying in their home? So they're, you know, worried about getting an infection? And so, that loneliness aspect playing a role in coping? I think exploring, other diseases that are associated or have a clinical or often present with fatigue like anemia or thyroid disease, depression certainly. We talked a little bit about sleep or if there's underlying sleep apnea that could be contributing.

 Certainly a lot of the medications that we use to treat other symptoms for specifically pain, and particularly if we're getting into medications that have side effects that could lead to fatigue. Really exploring that medication list and other supplements if there are other substances like that might disrupt sleep, like alcohol or things like that, or caffeine at night. 

So really that first assessment is a very, I think extensive history taking with ancillary history to explore, what other potential modifiable diseases that might be contributing to that. In addition then, if you boil down to there are tools out there, validated tools to really help kind of explore how much of an impact the fatigue might be playing on their function in life.

So there's a number of them. Yeah. We don't use one in particular. One of the screening tools that we use would be like a an ESAS or an Edmonton symptom assessment. And that's usually done in our office in the palliative care setting pretty routinely. So the value of that is, especially if there's an intervention, then we can kind of use that zero to 10 score to see what kind of an impact we're having over time.

Host: Right. Yeah. And you mentioned it's an interdisciplinary team, and it does sound like it could be both physical and mental fatigue. So good that there's a sort of a team working with patients and families. What about the interventions? How do you help folks who are, you know, whether it's on the scale or not, how do you help folks that are experiencing fatigue? 

(Judith) April Yasunaga, MD: Yeah, so some of the most validated interventions really fall in that non-pharmacologic space. One of the things that has been shown in the literature to be most helpful is actually exercise, which may seem kind of somewhat counterintuitive. We have somebody that's tired to, to kind of encourage them to exercise.

 But that's been one, and it could be aerobic or anaerobic exercise seems to help to be beneficial in terms of moving that needle on these scores. So, you know, trying to find maybe a plan or an opportunity for that. I think we need to acknowledge that that it's time consuming and we have to acknowledge that sometimes these patients have had a huge change in their routine and really asking them to do more that takes up their time. We need to find that balance or what they're willing to do. And then the other kind of non-pharmacological intervention that's been shown to be very helpful is psychological supports, whether that be in cognitive behavioral therapy or something along those lines.

And then combining those two, exercise and cognitive behavioral therapy probably, you know, has been shown to even just be more helpful. 

Host: Right. Yeah. Sort of uh treating the mind, the body, the soul, kind of, you know, one stop shopping right?

(Judith) April Yasunaga, MD: Yeah. Yeah.

Host: Yeah, that's great. Uh, it's been really educational today. Like I said, you know, yeah, I know what the words mean. Cancer related fatigue, but just really, you know, kind of understanding, what folks are experiencing, who are in palliative care, who are going through cancer treatment and the fatigue, be it, you know, mental, psychological, physical, all the above. Just give you a chance of your final thoughts, takeaways. What do you want folks to know about this topic cancer related fatigue in palliative care? 

(Judith) April Yasunaga, MD: I think the things to take away that in my view would be really kind of that assessment piece and really trying to explore if there are additional things that are contributing to the fatigue that we could help with. Sleep hygiene. And then, if there's anemia or thyroid disease or vitamin deficiencies, really exploring the mental health in terms of depression and anxiety and being sure that we add those resources when they're available. The exercise and psychological support being a part of that quote unquote prescription for helping patients that are are facing this. There are medications that can be implemented, that we you know, as a physician often will look to what opportunities there are pharmacologically to help support patients.

 Some of them just have been shown over time to be not as helpful as we were hoping. We'll often think of methylphenidate as an opportunity, which is a stimulant for cancer related fatigue. There's been a recent meta-analysis, that really kind of showed mixed results, that it was really no better than placebo.

But fortunately, you know, side effect profile, they were shown to be relatively safe. So, in general, definitely not something you'd, look to first, but there may be special populations that you would consider that as an intervention in addition to your exercise and psychological support and therapies.

(Judith) April Yasunaga, MD: Bupropion is another one that has been kind of studied and looked at, so often used for depression and has had some benefit as it relates to cancer related fatigue. These are often small studies. Sometimes we'll think about steroids, so particularly, like dexamethasone, some of the meta-analysis looking at that has also shown no difference than placebo. But I think, again, when patients are coming with a lot of symptoms, it's about symptom clusters. So if there's other symptoms at play that maybe you think about corticosteroids, there might be an opportunity there.

So those are some of the ones that I think are commonly thought of as pharmacological interventions and may have a role if you think about patients in conjunction with other symptoms that they're coming in with.

Host: Right. Yeah. It really sounds like it's not one size fits all. It's very patient centered, as you mentioned. It's interdisciplinary, treating the mind and the body, as I said, maybe the soul as well along the way here. So, good stuff today. Thank you so much. 

(Judith) April Yasunaga, MD: Thank you.

Host: For more information and to get connected with one of our providers, please visit carle.org. And that wraps up this episode of Expert Insights with the Carle Foundation Hospital. I'm Scott Webb. Stay well.