Prevalence of Cancer-Related Fatigue: A Prospective Observational Study

Abstract

Background

Cancer-related fatigue (CRF) reduces quality of life and the activity level of patients with cancer. Data regarding CRF from Indian population are limited. The present study was aimed to understand the prevalence of CRF in Indian patients and its impact on quality of life.

Methodology

This prospective observational study was conducted at SVS Medical College, Telangana, India, for a duration of 6 months. The study included 100 adult patients with cancer receiving treatment at the institute and willing to consent for the study. The patients with brain metastases were excluded as it might impact their ability to complete study procedures. Patients' demographics, disease and treatment details, etc. were collected. Patients were interviewed to assess the level of fatigue using the EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) scale and the National Comprehensive Cancer Network (NCCN) fatigue intensity scale. The analysis of data was performed using chi-square and analysis of variance tests.

Result

In our study of 100 Indian patients (49 males and 51 females), mean age was 43.78 years. Breast cancer and gastric cancer were the most common diagnosis, with 22 patients each. Treatment protocols included radiotherapy in 63 patients and chemotherapy in 37 patients. As per the EORTC QLQ-C30 scale, proportion of patients with normal, mild, moderate, and severe level of fatigue were 9, 15, 44, and 32%, respectively. As per the NCCN scale, proportion of patients with no or mild, moderate, and severe fatigue were 9, 47, and 44%, respectively.

Conclusion

Our study suggests that among the Indian patients with CRF, higher proportion of patients have moderate or severe level of fatigue. Appropriate assessment and management of CRF should be considered in the patients for overall management.

Keywords

cancer-related fatigue - chemotherapy - physical activity - pharmacological - radiotherapy - integrative therapies

S.P. Shrivastava

Introduction

Cancer-related fatigue (CRF) is defined by the National Comprehensive Cancer Network (NCCN) (2024) as the experience of physical, emotional, and/or mental exhaustion related to cancer or its treatment. CRF does not imply for typical tiredness; rather, it is a distressing lack of energy, disrupting daily life and not improving with usual rest or sleep. CRF can be very prevalent among cancer patients. It is often overlooked and underdiagnosed.[1] The weariness encountered by patients with cancer receiving chemotherapy is enduring and may extend beyond the duration of the chemotherapy treatment, significantly affecting several dimensions of the patients' life, including physical, psychological, professional, and economic elements. After cancer treatment concludes, fatigue typically goes down, but some patients may continue to experience exhaustion for months or even years.[2]

Consequently, it is important to evaluate tiredness in every individual diagnosed with cancer and consider it a crucial symptom. Fatigue affects 50 to 90% of cancer patients overall, with the latter percentage being associated with those receiving aggressive anticancer chemotherapy or radiation therapy.[3] Research on tiredness is still lacking, and there are not many papers in the literature on CRF in the Indian population, despite its high incidence and possible detrimental impact on patients' activities and emotional health.[4] CRF has been found to be strongly correlated with cancer, its type, stage, and duration; cancer treatment (chemotherapy, radiation therapy, immunotherapy, and surgery); and comorbid conditions like anemia, malnourishment, cardiopulmonary disorders, liver failure, renal diseases, neurological disorders, etc.[5]

CRF cannot be definitively diagnosed with a laboratory test; however, to receive helpful therapies, patients should discuss their symptoms with the treating physician in detail and on a regular basis. The patients need to be examined for symptoms associated with CRF because they might not self-report exhaustion. There are several established scales devised to assess the degree of fatigue such as the European Organization for Research and Treatment of Cancer–Quality of Life Questionnaire–30 Core Questionnaire (EORTC-QLQ-C30), Piper Fatigue Scale—Revised, Brief Fatigue Inventory, Cancer Fatigue Scale, Fatigue Symptom Inventory, Patient-Reported Outcome Measurement Information System (PROMIS) Fatigue Short Form and CT, and Multidimensional Fatigue Inventory-20, etc.[6] An evidence-based clinical practice guideline by the Academy of Oncologic Physical Therapy (APTA Oncology) provided recommendation of A (“should be used in clinical practice”) for EORTC-QLQ-C30 and few other assessments.[7]

Cancer patients receiving cytotoxic chemotherapy, radiation therapy, bone marrow transplantation, or biological response modifier treatment are increasingly prone to fatigue. The cornerstone of treating CRF is treating its underlying cause, which may include dietary deficiencies, anemia, electrolyte imbalances, chemotherapy side effects, or nutritional problems. Physical activity-based therapies, psychoeducational and mind–body interventions, and techniques for treating sleep disorders, are some of the nonpharmacological procedures included in the management strategies. Eliminating fatigue is not always possible, but there are ways to help lessen or manage CRF. Some possibilities include self-care practices such as yoga, exercise, eating well, and making time to rest can help increase your energy level.[8]

The current study was aimed to understand the prevalence of CRF in Indian patients and its impact on quality of life.

Materials and Methods

One hundred patients were enrolled in this prospective, observational study conducted at SVS Medical Hospital, Mahbubnagar, Telangana, India, for a duration of 6 months. All patients aged > 18 years and willing to consent for the study questionnaire were included in this study. The patients with brain metastases were excluded as it might impact their ability to complete study procedures. The data for this study were collected from the case files of 100 enrolled patients. A structured pro forma or data collection form was utilized to record key details from patient files. This form included demographic information (e.g., age and gender), cancer type, stage, and treatment modalities (chemotherapy and radiotherapy). Additional data were gathered through patient interviews and questionnaires, which included validated tools mainly the EORTC QLQ-C30, a 30-item instrument that evaluates multiple aspects of quality of life, and the NCCN fatigue intensity scale.[9] [10] In the NCCN fatigue scale, “0” represents an absence of fatigue and “10” represents worst fatigue. According to this scale, 0 to 3, 4 to 6, and 7 to 10 indicate no or mild fatigue, moderate fatigue, and severe fatigue, respectively.[10] All collected data were entered into an electronic database for further analysis, ensuring accuracy and completeness by cross-checking against the original case files and reports.

Statistical Method

Categorical variables were reported as proportions and frequencies. Continuous variables were reported as means or medians. All analyses were performed on deidentified data using the Statistical Package for Social Science (SPSS) software version 23 and GraphPad Prism version 9.

Results

In total, 100 patients were included, the mean (±standard deviation) age of the group was 43.78 (±17.18) years. The age group-wise distribution is shown in [Table 1]. Among the study population, breast cancer and gastric cancer were the most common diagnosis, representing 22 patients each. Regarding the stage of the cancer, patients with stage III cancer had the highest number (36%), followed by stage IV (25%). There were higher number of patients receiving radiotherapy (63%), in comparison to number of patients receiving chemotherapy (37%).

Table 1 Patient characteristics

Characteristics	N = 100
Age (y), mean ± SD	43.78 ± 17.18
Age range (y, %)
≤ 20  21–30  31–40  41–50  51–60  > 60	2.0 27.0 17.0 16.0 17.0 21.0
Gender (%)
Male  Female	49 51
Cancer type (%)
Breast cancer  Gastric cancer  Lung cancer	22 22 12
Stages of cancer (%)
Stage I  Stage II  Stage III  Stage IV	15 24 36 25
Cause of fatigue (%)
Chemotherapy  Radiotherapy	37 63
Level of fatigue (EORTC QLQ-C30 scale, %)
Normal (1–30)  Mild (31–60)  Moderate (61–90)  Severe (91–120)	9 15 44 32
Level of fatigue (NCCN fatigue scale, %)
No or mild fatigue (0–3)  Moderate fatigue (4–6)  Severe fatigue (7–10)	9 47 44

Abbreviations: EORTC QLQ-C30, European Organization for Research and Treatment of Cancer–Quality of Life Questionnaire–30 Core Questionnaire; NCCN, National Comprehensive Cancer Network; SD, standard deviation.

In our study, as per the EORTC scale, 32 patients had severe fatigue. According to the NCCN fatigue scale, 44 people had severe fatigue.

Discussion

The most common symptom of cancer, which affects 50 to 90% of patients, is weariness connected to the disease, which has a serious negative influence on functional ability and quality of life.[11] The guidelines recommend identifying contributing factors and screening for fatigue at each treatment appointment, as well as during the initial visit when the diagnosis of advanced illness is made.[12] While assessments like the EORTC QLQ-C30 or NCCN fatigue scale may be useful for assessing tiredness intensity at first, a more thorough evaluation, education, and the creation of a personalized treatment plan are often necessary for the first course of treatment.

In our study, the majority of the patients (27%) were in the age group of 21 to 30 years. A similar study conducted in a tertiary care center in the Malwa region of Punjab had majority of the patients (29.77%) from the age group of 41 to 50 years.[13] In our population, 63% of the patients reported being treated with radiotherapy. Radiotherapy is reported to be associated with causing fatigue in patients with cancer. A prospective study of Janaki et al from Bengaluru assessed the magnitude of fatigue and its implication on the quality of life during radiotherapy. In that study of 90 patients receiving radiotherapy, 87.8% of the patients had fatigue at baseline and this proportion increased over the course of radiotherapy. A significant reduction in social function and global health status was also reported over various time points during radiotherapy.[14]

Regarding the limited literature available for CRF from India, some researchers have published various aspects of CRF. A study from All India Institute of Medical Sciences, Delhi, India, assessed prevalence of fatigue in patients with cancer, as well as its predictors. Among 110 patients, 97 patients documented to have severe fatigue. Positive correlation between fatigue and quality of life was observed. Pain, physical functioning, Eastern Cooperative Oncology Group performance status, and the level of albumin were the predictive factors for fatigue.[15] Another study from Delhi analyzed CRF in breast cancer survivors. In this study of 65 patients, 95% patients experienced any grade CRF, with 85% patients experiencing moderate to severe CRF. A total of 86% of the patients perceived fatigue to be due to effect of cancer treatment. Physical exercise was the most common measure adopted for CRF, in 49% of the patients.[16] An international study from Nagpur showed significant reduction in fatigue with physical exercise, pranayama, and 100 g of millet protein powder.[17] Another trial from Bengaluru demonstrated the benefits of plant-based, high-protein diet in reduction of fatigue, reduction of fat mass, and improvement in muscle mass in patients with breast cancer undergoing chemotherapy.[18]

While minor fatigue that does not compromise quality of life can be treated with nonpharmacologic treatments alone, patients with moderate or severe fatigue may benefit from both pharmacologic and nonpharmacologic therapies.[8] Exercise, cognitive-behavioral therapies, and may be sleep treatment are among the nonpharmacologic approaches that have demonstrated promise. While pharmacologic therapies have been employed to address CRF, findings from a meta-analysis conducted by Mustian et al indicate that these approaches are not as successful in treating CRF as nonpharmacologic (such as exercise and psychological) therapies.[19] Psychostimulants have the ability to quickly counterbalance the fatigue-related sensations of low energy, diminished mental capacity, or lethargy, and they hold promise for the management of CRF.[8]

There are few limitations associated with our study, which includes shorter duration of 6 months and a small sample size. Additionally, there was also a scope of extension to learn the patterns that could improve quality of life in patients.

Conclusion

In conclusion, our study adds to the limited literature for CRF in Indian patients with cancer. Our study indicates that among the Indian patients with CRF, higher proportion of patients has moderate or severe level of fatigue. Appropriate assessment and management of CRF should be considered in the patients for overall management.

Conflict of Interest

None declared.

Ethical Statement

The ethical committee clearance was obtained from the Institutional Ethical Committee of SVS Medical College Hospital before initiating the study (IEC/DHR-03/(03/02)/2023/0542).

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Publication History

Received: 20 October 2024

Accepted: 25 March 2025

Article published online:
02 May 2025