CRF is a complex, multifactorial, and multidimensional clinical problem. Currently, there is no standardized method for measuring CRF. From a research perspective, it is important to conceptually define CRF and sleep disturbances and specify the measurement tools used in order to determine the comparability of the research findings. A fuller understanding of the phenomena can then allow a better description of their prevalence and inform tests of interventions and the development of evidence-based clinical practice guidelines for follow-up care and surveillance of long-term cancer survivors.
A better understanding of the relationship between CRF and sleep disturbances could further the knowledge about this symptom dyad as part of a symptom cluster that also includes pain, anxiety, and depression. Internal factors, both physiologic and psychological, and external environmental factors related to CRF and sleep disturbances in long-term cancer survivors are just beginning to be explored as causal, modifying, or associated factors. But still absent from the literature are the outcomes or consequences of CRF and sleep disturbances, such as irritability, lack of concentration, and difficulty making decisions, as well as their effects on the survivor’s life, including family, school, work, and social life.
Studying variables such as the economic consequences of fatigue on a survivor’s life and its effect on family caregiver issues would offer different insights and knowledge about CRF and sleep disturbances in long-term survivors. 23 Further research on the amount of fatigue survivors experience, the degree of distress it causes them, the effect of fatigue on activities of daily living, and the key biological parameters associated with fatigue can be translated into education and practice. For example, a test for determining whether fatigue is related to levels of specific cytokines in the body would allow clinicians to monitor fatigue, treat sleep disturbances, and possibly develop therapy to treat the fatigue. Measuring fatigue in a clinical setting, similar to clinical measurements of pain, could be useful in helping patients and survivors learn to self-monitor the symptom, seek help from occupational or physical therapists, or learn about exercises and activities that conserve energy. Assessing fatigue in relation to patient activities would allow clinicians to tailor exercise, work, and other activities to their needs.
Randomized controlled clinical trials that include interventions should also incorporate subjects of different ages and ethnic backgrounds, with different types of cancer and treatments, and at different points in the illness experience, including 10, 15, and 20 years or more into survivorship. Cooperative groups, such as the Eastern Cooperative Oncology Group and the Children’s Oncology Group, offer viable mechanisms for comprehensively surveying long-term cancer survivors. 3, 30, 31
Cancer-related fatigue and sleep disturbances must be considered as a clinical syndrome.
Clinical practice should involve assessing and identifying at-risk populations for CRF and sleep disturbances, and developing and testing effective interventions. CRF and sleep disturbances must be considered as a clinical syndrome. If these symptoms appear together—with or without concomitant symptoms such as pain, anxiety, or depression—they should be addressed clinically through ongoing assessment and adequate treatment plans, and the outcomes of cancer survivors should be evaluated. From a policy perspective, if a diagnosis-related group could be developed that included the sequelae of treatment, then the cost of screening for fatigue, sleep disturbances, and the myriad of other symptoms could be built into the health care system.
1. Ancoli-Israel S, et al. The relationship between fatigue and sleep in cancer patients: a review. Eur J Cancer Care (Engl)
2. Barton-Burke M. Fatigue and quality of life: a question of balance. In: King CR, Hinds PS, editors. Quality of life: from nursing and patient perspectives.
2nd ed. Sudbury, MA: Jones and Bartlett; 2003. p. 255–83.
3. Hockenberry-Eaton M, Hinds PS. Fatigue in children and adolescents with cancer: evolution of a program of study. Semin Oncol Nurs
4. Winningham ML, Barton-Burke M, editors. Fatigue in cancer: a multidimensional approach.
Sudbury, MA: Jones and Bartlett; 2000.
5. Berger AM, et al. Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: results of a feasibility intervention study. Oncol Nurs Forum
6. Clark J, et al. Sleep-wake disturbances in people with cancer part II: evaluating the evidence for clinical decision making. Oncol Nurs Forum
7. Vena C, et al. Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment. Oncol Nurs Forum
8. Berger AM, Farr L. The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue. Oncol Nurs Forum
9. Berger AM, Higginbotham P. Correlates of fatigue during and following adjuvant breast cancer chemotherapy: a pilot study. Oncol Nurs Forum
10. Berger AM, et al. Feasibility of a sleep intervention during adjuvant breast cancer chemotherapy. Oncol Nurs Forum
11. Boehmke MM. Measurement of symptom distress in women with early-stage breast cancer. Cancer Nurs
12. Cimprich B. Pretreatment symptom distress in women newly diagnosed with breast cancer. Cancer Nurs
13. Anderson KO, et al. Fatigue and sleep disturbance in patients with cancer, patients with clinical depression, and community-dwelling adults. J Pain Symptom Manage
14. Armstrong TS, et al. Symptom clusters in oncology patients and implications for symptom research in people with primary brain tumors. J Nurs Scholarsh
15. Dodd MJ, et al. Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum
16. Lee KA. Sleep and fatigue. Annu Rev Nurs Res
17. Sarna L. Correlates of symptom distress in women with lung cancer. Cancer Pract
18. Visovsky C, Schneider SM. Cancer-related fatigue. Online J Issues Nurs
19. Andrykowski MA, et al. Off-treatment fatigue in breast cancer survivors: a controlled comparison. J Behav Med
20. Bower JE, et al. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol
21. Broeckel JA, et al. Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol
22. Servaes P, et al. Determinants of chronic fatigue in disease-free breast cancer patients: a cross-sectional study. Ann Oncol
23. Given BA, et al. Family and out-of-pocket costs for women with breast cancer. Cancer Pract
24. Winningham ML. Strategies for managing cancer-related fatigue syndrome: a rehabilitation approach. Cancer
25. Mock V. Clinical excellence through evidence-based practice: fatigue management as a model. Oncol Nurs Forum
26. Young-McCaughan S, et al. Research and commentary: Change in exercise tolerance, activity and sleep patterns, and quality of life in patients with cancer participating in a structured exercise program. Oncol Nurs Forum
27. Kim Y, et al. The effects of information and negative affect on severity of side effects from radiation therapy for prostate cancer. Support Care Cancer
28. Allison PJ, et al. Teaching head and neck cancer patients coping strategies: results of a feasibility study. Oral Oncol
29. Christman NJ, et al. Developing and using preparatory information for women undergoing radiation therapy for cervical or uterine cancer. Oncol Nurs Forum
30. Given B, et al. Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nurs Res
31. Mock V, et al. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum