Cancer-Related Fatigue: What It Is and How to Manage It
Ashish Khanna, M.D.
July 5, 2019

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Ashish Khanna, M.D., is a physical medicine and rehabilitation specialist at the Kessler Institute for Rehabilitation and part of the ReVital Cancer Rehabilitation Program. Dr. Khanna completed his residency in physical medicine and rehabilitation at the Kingsbrook Jewish Rehabilitation Institute in Brooklyn, NY, where he became interested in cancer rehabilitation early on. He completed his fellowship subspecialization in cancer rehabilitation at Medstar Georgetown University and the National Rehabilitation Hospital in Washington, DC. He specializes in the treatment of people who have pain or functional issues as a result of cancer or cancer treatments, including people who have been diagnosed with breast cancer. This includes pain, shoulder issues, fatigue, joint pain from aromatase inhibitors, and other issues. He has lectured at numerous international conferences, has published peer-reviewed research on a variety of related topics, and is the co-author of an upcoming book on cancer rehabilitation.

Listen to the podcast to hear Dr. Khanna explain:

  • how cancer-related fatigue is different from other fatigue
  • the link between inflammation and fatigue
  • why exercise is the best remedy for fatigue
  • steps you can take if you think you have cancer-related fatigue

Running time: 25:22

Show Full Transcript

Jamie DePolo: Hello everyone, welcome to the Breastcancer.org podcast! I’m Jamie DePolo, senior editor at Breastcancer.org. Today, we have Dr. Ashish Khanna, M.D., as our guest. He’s a physical medicine and rehabilitation specialist at the Kessler Institute for Rehabilitation and part of the ReVital Cancer Rehabilitation Program.

Dr. Khanna completed his residency in physical medicine and rehabilitation at the Kingsburg Jewish Rehabilitation Institute in Brooklyn, NY, where he became interested in cancer rehabilitation early on. He completed his fellowship sub-specialization in cancer rehabilitation at Medstar Georgetown University and the National Rehabilitation Hospital in Washington, DC.

He specializes in the treatment of people who have pain or functional issues as a result of cancer or cancer treatments, including people who have been diagnosed with breast cancer. This includes pain, shoulder issues, fatigue, joint pain from aromatase inhibitors, and other issues. He has lectured at numerous international conferences, has published peer-reviewed research on a variety of related topics, and is the co-author of an upcoming book on cancer rehabilitation.

Today, he joins us to talk about breast cancer-related fatigue and how it can be managed and treated. Dr. Khanna, welcome to the podcast!

Ashish Khanna: Thank you. I’m happy to be here.

Jamie DePolo: We’re excited to have you because we get a lot of questions on our discussion boards about fatigue. So that leads me to my first question. It seems that almost all breast cancer treatments — surgery, radiation, chemotherapy, hormonal therapies, targeted therapies — they all have fatigue as a side effect, and I believe that I’ve read that it’s the most common cancer side effect. Could you tell us what exactly fatigue is and how it’s different from being tired, and why do so many treatments cause it?

Ashish Khanna: Yeah, that’s a great question. Thanks again. So fatigue is, as you mentioned, the most common cancer-related sort of complaint that’s out there. Let’s start with, what is cancer-related fatigue, in general. It’s definitely not the same as regular fatigue.

All of us are familiar with regular fatigue, when we didn’t get a good night’s sleep, or in my case, just had a baby, so I’m familiar with a different type of fatigue. That’s the type of fatigue that a good cup of coffee can help with. But cancer-related fatigue is different than that. I think one of the biggest barriers I see is that people don’t really feel like cancer-related fatigue is a real thing, or that they just feel fatigued and that’s something that they ignore. But cancer-related fatigue actually is an actual diagnosis, and we do have some understanding of what causes it and what it is. So people who have that should understand that they are not alone, this is a very common thing. So hopefully, after we go through this today we’re going to talk about that, and people can feel like they’re not the only ones in the world who have this problem and that there are solutions to it. So I appreciate you bringing awareness to this topic, for sure.

So, like I said, cancer-related fatigue is different than regular fatigue. There are a lot of different definitions in the literature. Of course, when you have a lot of different definitions, it makes the research sort of… a little bit more difficult, and we can’t all agree on exactly what the diagnostic criteria for that is. I use a definition where I would call it cancer-related fatigue when it lasts greater than 2 weeks. If you feel fatigued for more than 2 weeks and you feel it every day.

One of the big differences between regular fatigue is that you feel fatigued out of proportion to exertion. So if you didn’t get a good night’s sleep you may be tired throughout the day, but you’re not more tired than you would usually be. So for example, I have one patient who feels every time they get up to turn on the light switch they feel like they walked around the block. You know, something like that. That’s out of proportion to exertion, to the amount of energy they put into a task. It is associated with distress or a loss of function, so it has to impact your life in some way. Of course, it has to be associated with a cancer diagnosis, or chemotherapy, or something like that.

And then the other one is just to make sure that the fatigue you’re having is not explained by any sort of other diagnosis, because a lot of other things cause fatigue also. If you’re anemic, if your blood count’s low, that can cause you to be fatigued. Unfortunately, a lot of people have depression — that can make you fatigued. Hypothyroidism, right? If you need to be on thyroid medications, that can cause fatigue. So, part of my role as a physician who specializes in this type of thing is just to make sure that you don’t have something else that’s causing the fatigue because you know, really, it can be sort of a tragedy. I’ve seen this, too, where we’re treating people for cancer-related fatigue and, you know, their thyroid was not functioning as well the whole time. It’s a different type of treatment for that, of course.

Yeah, so that would be the difference. Out of those, I think that out of proportion to exertion is one of the big things that I think distinguishes it.

Jamie DePolo: Why do so many of the treatments cause fatigue? Is it just because they’re so hard on the body?

Ashish Khanna: The biggest thing that we understand to be causing fatigue, at this stage, our understanding is that inflammation is probably the number one thing that causes it. Inflammation is like your body’s response to infection or injury, and your body makes these different kinds of molecules. They’re called cytokines, and those are circulating throughout your body. And those have a lot of local effects, and they can have a lot of systemic effects as well. So we have cancer and its treatment, you have the tumor itself, you have the metastases, there’s the chemotherapy, there’s a lot of psychological stress that comes with it, the surgery, the radiation.

All these kinds of things will cause an increase in inflammation in your body, and a high level of inflammation can impact your sleep-wake cycle, so you have less “sleep efficiency,” we call it. More time awake. It takes you longer to fall asleep. That kind of thing can then influence your cortisol levels, what we call the glucocorticoid sensitivity, things like that. And your response to stress — which, of course, you have at this point — can be dulled, I guess you could say. And all those kinds of things form like a cycle, so they feed into each other. More inflammation causes decreased sleep, flattened cortisol response, that causes more inflammation, which causes you to have worse sleep. It’s sort of a cycle like that.

I was talking about how it really is a real thing. We can actually see these on brain scans, too, as well. So we see that if you draw the blood of somebody who has cancer-related fatigue, or anyone with a high inflammatory state, they’re going to have a lot of those pro-inflammatory cytokines in their blood, indicating they have a lot of inflammation going on. And then when you scan the brain you can actually see that they have a decreased brain metabolism happening at that particular time. That can last up to 1 year in the studies; it probably lasts much longer than that. But you can actually see in the part of the brain, in this one study that I’m referring to, in the inferior frontal cortex — an area where we make decisions, planning, what we call executive function, things like that — you actually see less activity in the brain happening. So it is a very real thing. It’s not something that can be written off.

I wanted to mention also how it’s the most common side effect of cancer and cancer treatment, too, since you mentioned that. It occurs, they say, in about 60-96% of patients during their treatment, so that’s the vast majority… so six to nine of every 10 people will have that problem.

Not only that, but it can persist for months or years also. There was one study showed that a third of breast cancer survivors continued to have fatigue 1 to 5 years later, and some have them even 10 years or more. So it’s not something that — a lot of people say, “Well you know, I finished my chemotherapy a month ago but I’m still feeling tired,” that kind of thing. Or even a year ago. So it’s important to remember that even after you’ve finished your treatments, you still can have these issues.

Jamie DePolo: Especially, too, with it looking like so many people, if they’ve been diagnosed with hormone-receptor-positive breast cancer, then they’re on some sort of hormonal therapy for 5 or 10 years, even, after, so that’s a long time. And I’m sure that also affects all the different cycles in the body that you’re talking about, too, that could possibly cause fatigue.

Ashish Khanna: Yeah, absolutely. That’s a great point, for sure.

Jamie DePolo: So, I’m curious. You mentioned that anemia can cause fatigue, and I know some of the breast cancer treatments can cause anemia. So, I guess what I was wondering is, can a person him- or herself figure out if they have fatigue or they’re just tired, or is it really better if they’re feeling tired a lot — like you said, for maybe 2 weeks straight — should they go to the doctor and say, “Look, I’m tired all the time. I need to figure out what’s going on”?

Ashish Khanna: Yeah, sure. I would report fatigue to your oncologist. If you feel like you’re having fatigue, then that’s something that definitely the oncologist would be the first-line to evaluate and assess you for that.

Unfortunately, a lot of the oncologists don’t ask about fatigue. Sometimes when I talk about fatigue I mention that there was an interesting study from 2000 — from the oncologist’s point of view, pain is more significant than fatigue. So the oncologists ask about pain. But when they interviewed the patients, actually fatigue is their number one complaint. So the oncologists — as all medical professionals, of course, obviously I’m guilty, we ask about, “Are you feeling any pain.” Pain, pain, pain. It’s a very common question. But nobody asks about fatigue that often, even though, like I said, from the patient perspective, fatigue has impacted their life more than pain.

But yeah, you definitely should speak to the oncologist about that and ask them to see if they can do some kind of a fatigue workup, which would include a thyroid — it can. And a lot of patients who are undergoing cancer treatments, of course you know, they’re getting their blood drawn every other day, it feels like sometimes. They’re human pincushions. So a lot of these labs, of course, will already be done. But if we’re talking about 6 months or 1 year later, and maybe nobody has checked your blood in a couple of months or something like that.

And then screening for depression, too. An oncologist may not be able to do that, but if you’re feeling sad, don’t feel hopeful about the future, those kinds of things, you should definitely seek help for that. Because those go hand-in-hand.

Jamie DePolo: So the bottom line really is, if you’re feeling this way, definitely bring it up to your doctor even if your doctor doesn’t ask about it.

Ashish Khanna: Yeah, yes. Like I said, chances are they won’t ask about it, unfortunately.

Jamie DePolo: My next question is, which I’m sure is what everybody really, really wants to know is, how do you manage or treat fatigue? Are there medicines, are there just taking more frequent naps, are there some alternative things like yoga or diet things you can do? How do you approach that when you’re trying to make it better?

Ashish Khanna: That’s a great question. There are a lot of different treatments for fatigue. One of the big ones that we recommend would really be exercise. Exercise has the highest level of evidence in the treatment of fatigue. It’s really difficult to ask a person who is fatigued to exercise, but really, that’s one of the best interventions that we have that we know can work. I can talk about what kind of exercise I recommend to patients and things like that if you like?

Jamie DePolo: That would be great.

Ashish Khanna: Ok! Basically, exercise in general has been shown in a lot of different studies, it’s pretty well-established that patients who exercise during their treatments or afterwards have lower levels of fatigue, during and then particularly after the treatment as well. You can do exercise at home or at the gym. That’s shown to have a small but definite improvement in fatigue. One of the best ways to do it is to do a supervised aerobic exercise program. If you want to go to the local YMCA or find a LiveStrong sort of trainer who specializes in cancer, that’s one way to do it. The other way to do it that I sort of encourage is to find a physical therapist in your area. You know, insurance will cover the physical therapist, and they can design a custom exercise plan for you.

Jamie DePolo: And how important is it for someone to look for a trainer who has experience with people who’ve been diagnosed with cancer? I know there’s actually… I believe the — and I’m going to get the name of the professional organization incorrect. But the professional organization for trainers, for athletic trainers, I believe they have a cancer specialization. How important is that in your mind?

Ashish Khanna: I think if you can find one in your local area then that would be the person to go to in my opinion. I don’t work with a whole lot of trainers. I work a lot more closely with physical therapists, who also have their own oncology specialization. But any sort of professional with additional training in cancer, who understands the side effects of these types of things and understands what fatigue is and how to treat it I think would be of value. If you’re lucky enough to live in a place where you have access to those resources, I would certainly seek them out. The physical therapists can certainly, and the trainers, too, can come up with something that works for you.

Like I said, you have a hard time convincing somebody who is so easily fatigued to do exercise, but anything that you can do really helps. If you can do it, the actual guidelines would say that if you can do 150 minutes a week of moderate-intensity aerobic exercise is what you can do. And that doesn’t have to be… I’m not talking about jogging or running, even a brisk walk. Moderate exercise really would b… I tell people moderate exercise would be where you’re exercising but you’re not so out of breath. You can still hold a conversation. If you can walk briskly to the point where you can still hold a conversation, if you can do that 3 days a week for an hour or something like that, the studies show the benefit of just doing that. If you can do another 2 days a week of a strengthening exercise or something like that, that adds to it. And if you’re able to do vigorous exercise, then more power to you! That’s even better. But for a lot of the fatigue patients I tell them, “The guideline’s 150 minutes a week, so if you can, do an hour 3 days a week.”

Jamie DePolo: And is there, with exercise, because I know as you said, sometimes it can be really difficult for somebody who is so fatigued to even think about exercising? I guess I’m wondering in your experience, how long does it take before someone may start seeing the benefits of that, where they may start feeling less fatigued because they’re, say, walking an hour 4 days a week?

Ashish Khanna: In my experience, pretty soon. Yeah. I ask patients to give this a shot, and the ones who are able to do it, they do come back, when I see them 1 month or 2 weeks later, saying that they do feel a little bit better.

Jamie DePolo: OK, well that’s great. Because then, if somebody sees immediate results, I think anyway, it’s a little bit easier to do because you know you’re not going to be waiting, like, “Oh I have to do this for 6 months before I see any benefits.”

Ashish Khanna: Yeah, right, exactly. For sure. So exercise is definitely the biggest, what we say, category 1 or level 1 evidence for that.

There are other options for treatment, too. There are the pharmacologic treatments as well. Those are what we call the psychostimulants. So a lot of people have heard of something like Ritalin, which is methylphenidate, or modafinil, which is known as Provigil also. So there are some good studies showing that there can be some benefit to taking those kind of things. To be honest with you, I don’t prescribe those too often. A lot of people are already on so many medications, they’re not really interested in adding another one. But for people I would say with profound fatigue those kind of things can make a big difference. And there are some experimental kind of treatments down the pipeline, too, that can kind of block some of those inflammatory cytokines and things like that. But hopefully, we’ll have better treatments someday. Those are coming down the pike here, too.

Yeah, and then beyond that, I’ll say there are a lot of psychological interventions, too. Those are primarily designed to provide information — I’m talking about counseling now, essentially, right? Those are designed to provide information. They can reduce stress, help you improve coping, they can give you some coping strategies, give you some social support, and things like that. And studies have shown that that helps, and I’ve seen that firsthand work as well.

Lastly, a lot of patients ask me about some of what we call complementary and alternative treatments, too. I’m not sure if you were going to ask about that, too. A lot of people do. Those are things like acupuncture and tai chi.

Jamie DePolo: Yeah. That was exactly my next question. Has acupuncture or anything like that been shown to help?

Ashish Khanna: Yeah, it has. You know, the acupuncture literature has been kind of mixed on a lot of different topics. But I do recommend acupuncture. A lot of insurances don’t pay for that so it may be something you’ll have to pay out of pocket. But yeah, I do recommend those kinds of things. You can give it a shot and see if that works for you. I’ve seen it work for a number of people.

Jamie DePolo: What about diet? Does changing your diet help at all? Is there any research on that?

Ashish Khanna: I’m not aware of anything regarding diet. I think as long as people are sort of eating a balanced diet with protein and things like that, then I think that’s really the best you can do with that.

Jamie DePolo: Ok, just curious.

Ashish Khanna: Yeah. No, it’s a good question. I’m not aware of that. Somebody can correct me on that.

Jamie DePolo: Now what about, I guess I’m wondering, this seems like maybe a silly question, but what about just taking naps? Does that ever help? I know you said exercise is the number one thing, but does napping help at all or does it really just make it worse?

Ashish Khanna: That is a good question. That’s a complicated question, too. A lot of people with cancer-related fatigue — a lot of them, not all — feel more energized at some point in the day, and then they feel really tired at another time in the day, maybe like early afternoon, some patients have a bit of a crash, I guess you could say. What we’re talking about is daytime napping. I would say, and I tell people, if you need to do it then that’s fine. We try not to do that. One of the principals of what’s called sleep hygiene is to not nap too much during the day so that you can sleep well at night. But we try not to do that too much, but if you find that that helps you then that’s great. You can continue to do that.

Another hallmark of cancer-related fatigue that just came to mind, too, that I didn’t mention earlier would be that people with regular fatigue, of course, when you take a nap you wake up and you feel much better. But a lot of times, people with cancer-related fatigue don’t feel refreshed after a nap, and that’s another way that I can tell if somebody’s feeling a true cancer-related fatigue.

Jamie DePolo: Finally, to wrap up, if we can kind of put this in a nutshell. So if someone thinks they’re having cancer-related fatigue, is there a series of steps that you’d recommend they go through? Should they talk to their doctor first, or if they’re pretty sure that’s what’s going on, should they increase their exercise, or is there an order? What would you recommend?

Ashish Khanna: I would say you could probably speak to your oncologist about it, yeah, certainly, and tell them you’d like to get some kind of supervised exercise or have someone design an exercise program for you, and they can hopefully point you in the right direction. You know, I’m somebody who specializes in this sort of thing, as you mentioned in the introduction. I wish there were more of us out there. There really are not of those of us who specialize in this type of thing. Otherwise hopefully, you have an oncologist who can point you in the right direction, and I’m happy to give you some resources or something like that if you don’t always have it on the site.

But I think just to help reduce the fatigue, just to kind of to empower yourself really, the first step I would do is sort of educate the people around you, that you have fatigue, cancer-related fatigue if you want to call it that. You have fatigue. It is real, and you can educate your family and the people around you on what exactly that entails.

I think setting up a daily routine, if you can, that lets you be active when you feel your best. So I try to tell patients to spread out the tasks that they need to accomplish throughout the day. And a lot of people, like I said, they feel more active and more energetic at certain times of the day and less so, so you’ve got to try and be aware of that. If journaling or keeping a log helps then that’s great. You can mark how you feel at different hours of the day. And the idea is that you kind of just want to pace yourself.

As you mentioned, regular light- to moderate-intensity exercise helps, try to get some fresh air every day. I know a lot of people are cooped up and things like that.

As we mentioned, eating a balanced diet. Protein, you want to make sure you get protein from meat or milk or eggs, legumes, peas, beans, things like that. I encourage people to stay hydrated. Standard eight to ten glasses of water a day, if you can clear that with your doctor. Of course if you are doing exercise and you’re sweating and you live in a hot environment, then you’re going to need more than eight to ten glasses a day. But try to stay hydrated.

Other symptoms contribute to fatigue, too. If you can manage the pain better, if your nausea can be better under control, if you can get treated for any sort of depression or some things like that, that would definitely help.

Things that you use commonly throughout the day, keep them within easy reach. That’s a big one. These are what we call energy-conservation strategies, and like I said, a physical or occupational therapist, really occupational therapist, I think, for energy conservation techniques, they know a lot of those types of things. So that’s a great person to reach out to for that sort of stuff.

And then enjoying hobbies, finding things that are pleasurable for you. Using relaxation techniques. Anything to kind of help reduce stress a little bit.

And then, like I said, you want to balance your activity with rest so that you’re able to sleep at night. So not too much napping if you can help it.

And then just to wrap up, cancer-related fatigue is a real thing. We see activity in the brain as evidence of that, and it’s important that you ask for help if you need it.

Jamie DePolo: Well, thank you so much. That’s been really helpful. So I guess to me, my takeaways are, and you tell me if this is right: People need to recognize that it’s a real thing. They need to talk to their doctor right away. And they really need to think about exercising because that has the most evidence showing it to be helpful.

Ashish Khanna: Yeah, exactly. And if you have trouble or if you don’t know what to do, then certainly reach out to an exercise professional who can help you make something customized to you.

Jamie DePolo: Excellent! Dr. Khanna, thank you so much. This has been really helpful.

Ashish Khanna: Thank you, it’s my pleasure. Thanks for bringing this topic some awareness. It’s great.

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