Lucy Potter, M.D. Hi, I'm Dr. Lucy Potter, instructor in General Internal Medicine at MD Anderson Cancer Center. And this is Dr. Carmen Escalante, chair of General Internal Medicine at MD Anderson Cancer Center, and this is the Cancerwise Podcast. Welcome. Thank you for being here. Cancer patients of all different types of cancers commonly experienced fatigue. Can you explain how prevalent it is and how detrimental it is to patients?  

Carmen Escalante, M.D. Of course, it is the most common symptom in our cancer patients. It is especially more prevalent in patients that have had what we describe as multi-modality therapy, meaning combinations of different kinds of therapies like chemotherapy, immunotherapy, surgery, hormonal treatment, as in many of our breast cancer patients, our stem cell transplant patients. We do know that patients that have more advanced disease tend to have more fatigue, but it is also relevant in our survivors and that in patients that have completed our treatment, it can still be as as prevalent as 30% of that population.  

Lucy Potter, M.D. I see. So, then tell me what really causes this fatigue? 

Carmen Escalante, M.D. There are many factors. Fatigue is a very nonspecific symptom. There are no imaging studies or blood tests to quantify it. When we want to quantify it, we have to use validated survey tools to give us some objective way to measure it. When we evaluate for cancer-related fatigue, we have to consider many factors. Those include the status of the cancer. And as I said, those with more advanced disease tend to have more fatigue, we have to consider whether they're in current treatment or whether they've completed all treatment. We know that those in active treatment tend to have more fatigue than those that have may have completed treatment. Although, as I said earlier, there are about 30% of patients that have completed treatment that may continue to have some level of fatigue. We have to consider the medications they're taking. There are certain medicines, like beta blockers or sedatives, that may add to the fatigue level. We have to consider their symptoms. We know that other symptoms like pain, sleep dysfunction, depression, anxiety, all those symptoms, insomnia, sleep apnea, all those things can be additive to the level of fatigue. And of course, we have to consider other co-morbidities and optimizing those, things like uncontrolled diabetes or heart disease. So, as you can probably surmise, it's usually there are multiple factors attributing to fatigue and not just one thing. 

Lucy Potter, M.D. You are the director of our cancer-related fatigue clinic. Can you tell us about how it came about and what goes on? 

Carmen Escalante, M.D. Yes, we started this clinic around 1998 and it has thrived since. It was a multi-team effort with others in symptom management and physical medicine, physical therapy. We noted that patients often had fatigue, which is our No. 1 symptom in both cancer patients that are in therapy, as well as those that may have recently completed therapy. And there was a lack of information and data sharing, and patients were very interested in this. It changed their home status, their ability to thrive even post-treatment. And so that's how it all began. 

Lucy Potter, M.D. So, I've noticed that when doctors see their patients for fatigue, the patients actually don't really want to talk about it or are hesitant to talk about it. Why is that? 

Carmen Escalante, M.D. That's absolutely true. And and many patients have have fears they consider that they don't want to be, you know, known as a complainer. They believe that this is part of the treatment, part of the package. And, you know, they have to accept it and they want, the most optimal treatment. So, there is also a fear that if they discuss it with their provider, perhaps they'll decrease the dosage and they may not get as good an end result. So, many times they don't bring it up, and we need to educate them that they should bring this up. It is a valid symptom. There are things that we can do to improve it. 

Lucy Potter, M.D. I see, I see. And then in the role of the caregiver for these patients then, how do they recognize what can they do for cancer-related fatigue? 

Carmen Escalante, M.D. Caregivers are often present when we evaluate the patient and give lots of good insights that the patient may not have realized before. They often can help what I call being a cheerleader in helping to coerce them into starting exercise, or starting another regimen that we may recommend. You know, as you're aware, patients without fatigue often it's very difficult to get them to start exercise. And then you have a patient with cancer and with fatigue, and you're asking them to start moving, and it can be challenging. So, often a caregiver is exceptionally important in helping to define their sleep patterns, to helping to get them to exercise, to making sure they're taking their medications correctly, and numerous other nutrition, making sure they're, you know, they have a healthy nutritional intake. So, the caregiver is very prominent and very important in the care of these patients I see. 

Lucy Potter, M.D. So, then after we diagnosed the fatigue, how can we manage it? 

Carmen Escalante, M.D. Well, there are numerous treatment interventions that we kind of go to the No. 1 treatment intervention that has the best data, and it has had studies in numerous different cancer types is exercise. And it sounds contradictory because the patient is telling me they're tired and they hear, "You need to start moving. You need to start exercising." And they're thinking, "How can that make any sense to me?" And and so I try to put it in the patient perspective that this is the best data we have, that in the studies, fatigue improved and quality of life improved. And we know that exercise is part of healthy living. And so packaging it that not only can we manage, improve the management of the fatigue, you you you're living healthier. You may be able to improve your weight control, to help with depression and anxiety, to decrease cardiovascular risk. So, there are a lot of pluses into exercising besides just management of fatigue. In addition to exercise, they're behavioral aspects. And there are two groups in the behavioral interventions. There's prioritization and there's energy conservation. Prioritization, and I explain this to the patient, means reviewing your daily or weekly activities and defining which ones have the most impact on your daily life, and prioritizing those. Determining which ones do you have to do, which ones can you delegate? Whether it's professionally or personally and and prioritizing those. I also remind the patient that many of them know the time of day that's best for them, when they have the most energy. That's when they want to do their harder task. They want to save the easier stuff when they have lesser energy, and that's the things that they personally have to do. As you may know, on your list or my list, there's often a lot of things, and some of those things don't matter if you do them today, tomorrow or next week, or perhaps never. And so, you know, highlighting the things that are most meaningful. In addition, I often remind them that many times, kind of human nature, we try to front load the beginning of our week and we want to coast the end of the week. That does not work well with cancer-related fatigue. And unfortunately, when they do that, they realize the last part of the week they're so exhausted they can't enjoy it. So, reminding them to sit down once a week, whether it's using an electronic calendar or paper calendar, and tracking out all their activities and scheduling them throughout the week. Reminding them as well if they have a special event because we all have routine events. But then, of course, we have special activities that come in and out and those special events, especially if they're later in the day, not to frontload the beginning of the day and and to to schedule throughout the week. The the next part of the behavioral intervention is energy conservation. And what I mean by that is saving energy for the things that you value more. For example, some of my patients either have hobbies or tasks that require standing. Well, standing for long periods of time can be very tiring. Can they modify that? Can they sit on a stool or stool with wheels, for example, cooking or chopping vegetables or washing dishes or some hobbies like painting? Maybe they can modify that and sit and save that energy for something else, whether that is going to lunch with friends or exercising or another activity. Another example may be gardening. Many of my patients enjoy gardening, but getting up and down from the ground can be very tiring. Can they modify that to a raised garden, or perhaps sitting at a table and potting plants so they can still participate but modifying it and saving that other energy they would have used and attributing it to something else? Using a terry robe to wipe off after showering or bathing so they don't have to bend as much with a bath towel, would be examples. And and then so that would be the behavioral interventions including both what we've talked about prioritization and energy conservation. The third group of interventions is drugs. And those do not have the data that we previously talked about. I kind of save that those for when nothing else is working. So, the drug group that has most been studied is stimulants or wakening drugs. The wakening drugs are often used in sleep medicine, things like modafinil and armodafinil. They have even less data than the, the other stimulants. The stimulant that has most often been studied is methylphenidate. The trade name is Ritalin. None of these drugs are FDA approved for cancer-related fatigue. So, if we use them, we have to use them off-label. When we study them, we have to use a placebo arm because there can be a placebo effect. But for some patients, when nothing else is working, or in my experience, especially with cognitive fatigue, it can be very helpful because remember, especially in the stimulants, most of these drugs are approved for attention deficit disorders. I also remind my patients that they're controlled substances. So, I have to be fingerprinted, they're similar to narcotics to send them out, and there are no refills. So, we have a process in the clinic for refills, but those would include the interventions that we commonly use in cancer-related fatigue. 

Lucy Potter, M.D. Wow. Those are a lot of things that we can use. That's wonderful that there's such a big program and there's such a multimodality way to treat a multimodality issue factor that comes from it. 

Carmen Escalante, M.D. And obviously, if there are defined things like treatment effects, hypothyroidism or anemia, if we can modify those, then, of course, those are treated as well. But the other interventions I just defined are specifically for cancer-related fatigue. 

Lucy Potter, M.D. Oh I see. Okay. And in fact, you were talking about previously that cancer-related fatigue can affect both patients who are actively undergoing treatment, as well as those who have completed treatment. Are there any programs at MD Anderson that help with such treatments after cancer treatment is completed? 

Carmen Escalante, M.D. Yes. There's a very nice 12-week program called Active Living After Cancer that is available for our patients. And it includes exercise and other types of nutrition education and other types of educational activity that overlap with the things we often do in for cancer-related fatigue patients. So, we we make our patients aware that this program is available. And, for some, they do enroll and find some very positive benefits. 

Lucy Potter, M.D. That's amazing that MD Anderson has been able to treat patients with this fatigue both during and after completion. It's like always taking care of the patient. 

Carmen Escalante, M.D. Yeah. And of course it's important that we aggressively treat these patients. We're having better treatment outcomes for cancer that many diseases, if not cured, are in a chronic state of treatment. And so we want our patients to have the best quality of life as they either finish treatment or continue to go on through treatment in a in a more chronic situation. 

Lucy Potter, M.D. And speaking of chronic treatments in situations with all the advances, there's some current new research that's going on with fatigue as well. Can you tell me about it? 

Carmen Escalante, M.D. Well, you know, there's a new treatment modality that has risen especially. It started in melanoma, but now is really across the board and other solid much more in other solid tumors, and that's immunotherapy. And, Lucy, I know that you are involved in some work with cancer-related fatigue and immunotherapy. So, can you tell our audience about your current project? 

Lucy Potter, M.D. Yeah, for sure. So actually there are, I believe, 13 medications that have been approved by the FDA so far for immunotherapy for treatment of all sorts of cancers, more than 40 types, in fact. And, in fact, the last one was just approved in 2024. So, we're looking at right now, it's, these drugs are so new. They have had - obviously, with any cancer treatment, they've had side effects. And we want to see what these side effects are. And in the process of this, of course, as you previously stated, cancer-related fatigue is the most common side effect. So, we want to see the prevalence, what's been going on. What happens in all of these immunotherapy drugs. And basically, what does the literature show out there that we want to see in this fatigue? And ultimately, how can we improve it? 

Carmen Escalante, M.D. So, how are you doing this research? Can you can you tell us what you're doing, you and your colleagues? 

Lucy Potter, M.D. Yeah. Of course. So, right now it's through an international association of basically around 15 researchers from literally multiple countries around the world. We're perusing and looking through the entire literature of medical articles and studies that have been done since the inception of basically the first immunotherapy that was ever approved. And we're looking at the different studies that have been produced, their results, what they've shown in fatigue, not only from both basically groups and scales, from what the interventions that the researchers find, but also especially from the perspective of the patient, him or herself, what they find through the surveys that they fill out, such as, as previously discussed, also relating to depression, anxiety, sleepiness, even apathy, and of course, fatigue. And so, we want to see ultimately, in all these factors, what is going on, what can we do to ultimately improve our fatigue in our patients, and therefore, Making Cancer History®. 

Carmen Escalante, M.D. That's excellent, because there's so little known about fatigue and other symptoms with especially the newest immunotherapy drugs. And for us to be able to undertake this and get some, some baseline data so we know what to expect and how we may be able to better manage it. 

Lucy Potter, M.D. So, Dr. Escalante, do you have any final messages for our patients who are experiencing fatigue then? 

Carmen Escalante, M.D. Yes. They're not alone. This, sometimes, patients feel like their cancer's coming back or it's progressing if they have fatigue. It's normal. And most times, those aren't the case. And there are things that we've talked about earlier that we can manage it with, that we can improve it. We can't guarantee that it will make it all go away, but we certainly can have a more manageable level where they can do more and be, and take advantage of their lifestyle and their family's and all the other things that they want to participate in that because of fatigue, perhaps they have not been able to, but it's not an easy road and it takes patience. For example, with exercise, you have to do it consistently. We recommend a minimum of 150 minutes a week, and many of our patients, you can't just start exercise at that level. You have to pace yourself because if you don't, you'll hurt yourself and then you have to start over. Unfortunately, with exercise, you cannot pick up where you left off. So, I tell them it could take 6 to 12 months sometimes, depending on the functional status of the patient And so, you know, considering all these aspects, and again, it takes two months of consistent exercise to see a result in fatigue. But it is manageable. And I've had many patients, especially complex patients that have had a lot of therapy, such as our stem cell transplant patients, that do exceptionally well and improve a lot and see a difference. And I think when you decrease levels from a severe level of fatigue to a moderate or moderate to a mild, you see a big difference and you're able to to challenge yourself to do more. So, my final thought is get in there, see us, or see our literature. We have a lot of literature in patient education as well as what we've discussed today, but there are avenues to manage fatigue better. And it's okay. It's normal. We expect this. 

Lucy Potter, M.D. Well, thank you so much for being here today. Thank you so much for discussing this with us. Thank you so much for helping support our cancer patients and treating them for not only during their treatment process, but also even years afterward. 

Carmen Escalante, M.D. It is my pleasure. I find so much reward in seeing our patients improve and getting the most out of life. And thank you for being such a great co-host. Thank you. 

Lucy Potter, M.D. For more information or to request an appointment at MD Anderson, please call 1-877-632-6789 or visit MDAnderson.org. And thanks for listening to the Cancerwise Podcast from MD Anderson Cancer Center.