Therapy, Tai Chi Among Recommended Tactics for Cancer-Related Fatigue

Care providers are advised to recommend exercise, cognitive behavioral therapy (CBT), mindfulness-based programs and tai chi or qigong in order to reduce patients’ fatigue during cancer treatment, according to recently updated guidelines.

The updated American Society for Clinical Oncology — Society for Integrative Oncology guidelines regarding fatigue management, published in the Journal of Clinical Oncology, additionally advised that psychoeducation and American ginseng be recommended in adults undergoing cancer treatment, and that exercise, CBT and mindfulness-based programs should be recommended for survivors who have completed treatment, while yoga, acupressure and moxibustion (a form of traditional Chinese medicine involving an herb burned on or above the skin, according to the National Cancer Institute)may be recommended. Patients who are at the end of life, the guidelines recommended, may be offered CBT and corticosteroids.

Conversely, the guidelines advise against L-carnitine, antidepressants, wakefulness agents or routinely recommend psychostimulants, and noted that there was not enough evidence for or against other psychosocial, integrative or pharmacological interventions.

The updated guidelines were developed by a multidisciplinary panel of medical oncology, geriatric oncology, internal medicine, psychology, psychiatry, exercise oncology, integrative medicine, behavioral oncology, nursing and advocacy experts who reviewed more than 100 randomized controlled trials published between 2013 and 2023.

“We're not talking about using these therapies to cure the disease,” said senior author Karen Mustian, associate director of population science at the University of Rochester Wilmot Cancer Institute. “We still need the radiation, the chemo, the surgeries, the immunotherapies, to really tackle the disease.

“Where these types of integrative therapies come in, and where their real strength is, is in order to help assuage all of these toxicities that arise when you take these very toxic treatments — they make you nauseous, they make you vomit, they make you tired, sometimes they interfere with your treatments so much you can't even take all of your treatment or finish it the way that it should be prescribed. And that ultimately affects your prognosis in a negative manner. So, we've learned that we can't just necessarily expect patients to take all of these toxic chemotherapies, radiation therapy, everything else without some things to help them.”

And then, there’s the issue of life during survivorship.

“Once they're through the treatments, it's all about recovery,” she said. “So, ‘How quickly can I get back to doing the things I normally want to do and enjoy doing? How quickly can I be going back to work, involved with my children and my children's activities and my grandkids and my family?’”

Expectations of patients and survivors are very different than in decades past, Mustian noted. “Now, they not only expect to survive, they expect to thrive. And really, when you think about it for any of us, that's what we want, right? We don't just want medical help to help us get rid of something to leave us with a whole other pile of messes that we didn't want to have, we actually want the disease to go away, or to be kept at bay, and we don't want to have to deal with all these other toxicities that interfere with our ability to live life fully, and enjoy it.”

While Mustian said more research is required over time to figure out how to make these approaches more accessible for patients, she also stated that patient choice is a crucially important factor.

“The patient should have some say so or some choice in which [technique] that they try, because ultimately all of these are effective, if you do them,” she said. “So you actually have to do them and adhere to them for it to work. So, if your provider says, ‘Oh, go over here and do this cognitive behavioral therapy, it should help with your fatigue,’ and you're the kind of person that hates going in a room and sitting down and talking with somebody either one on one or in a group, it's just not going to work for you. And if you're the person who would rather go outside and do some walking, then exercise is probably the right recommendation for you. So, some of that choice is about what patients like, what seems acceptable to them, that they feel like they can do.”

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