Holden Comprehensive Cancer Center

Cancer Fatigue: Frequently Asked Questions

Linda Abbott, RN
Holden Comprehensive Cancer Center
University of Iowa Hospitals and Clinics

Creation Date: May 2000
Last Revision Date: May 2000
Peer Review Status: Internally Peer Reviewed

What is it about chemo that makes people feel like crap all the time?

There are many potential side effects of chemotherapy that can be distressing. The goal of chemotherapy is to kill cancer cells. When cells are killed the body works hard to get rid of those dead cells and the byproducts. This can contribute to the fatigue that people experience when they have received chemotherapy. Chemotherapy can also slow down the growth of normal cells, including blood cells. It is chemotherapy's impact on normal cells that explain many of the side effects. The blood cells are important to protect us from infection, maintain our hemoglobin so we do not become anemic and help our blood clot if we develop bleeding. There are other side effects associated with chemotherapy that can interfere with activities of life. It is important to remember that chemotherapy affects different people in different ways and some people have very few side effects from treatment. Today, I will try to focus specifically on fatigue. Fatigue is the most commonly reported side effect of cancer treatment and symptom of disease. Cancer related fatigue has been described as a feeling of tiredness, weakness, or lack of energy. Some just describe it as not feeling like themselvesÉfeeling completely drained of energy even after simple tasks. Cancer fatigue can impact people physically, mentally, spiritually, and financially. Family members and care providers can also experience fatigue associated with cancer and cancer treatment.

What is the best way to combat the fatigue brought on by weekly chemotherapy?

People who get chemotherapy on a frequent and regular basis sometimes have more of a challenge. What some people have found helpful is to track which days after chemotherapy they feel the they have energy and which days they don't feel they have as much energy. For many people, they will be able to identify a pattern. It may be the first day or two after chemotherapy when they feel the most fatigued. If you are able to identify a pattern, just knowing that you won't have much energy on those days may help. It is important to plan a daily routine but you may want to plan different daily routines based on when you expect you will be the most tired. It is equally important to pace yourself on the high-energy days. It is not unusual to want to get as much done on those high energy days as possible but be carefulÉif you overdo, you may have to spend several days making up for it. Try to plan to do something fun or re-energizing every day.

Managing the side effects of treatment and symptoms of cancer is also important. Nausea, diarrhea, constipation and dehydration may all be side effects of chemotherapy. Each of these side effects can increase the fatigue that people report. Drinking 8-10 glasses of water a day and controlling nausea, diarrhea and constipation can help. Anemia is another potential side effect of treatment and symptom of cancer that can contribute to cancer fatigue. Anemia can be managed through diet, blood transfusions or blood cell growth factors. Managing symptoms and side effects may require the use of some medications. Be sure your doctors, nurses and pharmacists know if you are having side effects and how severe they are.

Which treatment takes the most out of your energy, chemo or radiation?

That varies from person to person. All cancer treatments including chemotherapy, radiation therapy, immunotherapy, and surgery have been known to cause fatigue. Part of the fatigue that people experience with cancer treatment is expected and is not necessarily avoidable. The body is working hard to help you battle the cancer and that takes a lot of energy. Our hope is that we can provide people with an understanding of the fatigue associated with cancer and cancer treatment and strategies that may help fight the fatigue. If we are not able to help people control or cope with cancer fatigue, it can have a big impact on their treatment. If fatigue is severe, treatment may be delayed or doses decreased. It may also result in people quitting therapy because it is too hard to live with. We want people to be able to complete their therapy with the maximum quality of life that we can help provide.

Why does marijuana ease some of the symptoms of chemo?

Marijuana, or THC, the ingredient in marijuana that has been used in people living with cancer, has primarily been used to control nausea and help stimulate appetite. It doesn't work for everyone. Since nausea and loss of appetite can contribute to cancer fatigue, finding effective strategies to combat them can help in controlling fatigue.

Will diet help the way I feel throughout the week?

Nutrition is an important consideration when fighting cancer fatigue. In people living with cancer, there may be a change in how the body is able to use the food taken in. There is also an increased demand for energy for the body to do the important work of fighting cancer and of healing damaged tissues. It gets even more difficult if, due to loss of appetite, nausea, taste changes or diarrhea, the person is not able to take in enough food to meet the energy demands. What exactly to eat is a little harder to identify. Eating a well-balanced diet including fruits and vegetables, fiber, protein and calories is important. Nutrition or vitamin supplements may be helpful. Iron supplementation may be particularly important if anemia is a problem. Be creative in meals and meal preparation to help stimulate your appetite. You may also want to identify resources in your community to help with food shopping and meal preparation.

What can be done to fight feeling tired all the time?

Unfortunately, we don't have magical answers. There is no magic pill that will make the fatigue go away. We do believe there are things that you can do along with your medical treatments that can help you cope with fatigue. I have talked about some of the strategies. Getting adequate sleep and rest is also important. Balancing activity and rest sounds pretty simple but it can be a challenge. Planning for rest periods throughout the day is essential. Naps can be helpful if they are not too long. Some sources recommend that naps during the day be limited to 30 minutes. Longer naps may lead to increased feelings of fatigue. A good night's sleep is also helpful in fighting fatigue. Try to develop a bedtime "routine" to help prepare your body and your mind for restful sleep. A warm, non-caffienated drink or a soothing bath before bed may help relax you. Some find listening to music or nature sounds soothing and relaxing. If getting a restful night's sleep continues to be a problem, talk with your doctor or nurse about sleeping aids.

Can yoga help?

Some people find yoga very helpful. Yoga often includes an element of meditation, introspection and calming along with stretching and flexibility exercises. One of the things that can help control cancer fatigue is managing stress. When people are under stress, they don't have as much energy for physical or mental activity. Yoga can help as a stress reliever, as a form of exercise and it may also be helpful in tending your spirit. Other strategies for stress management may include using skills you have known and used throughout your life to deal with tough times. It may also involve learning new strategies to cope with stress. Though we can not eliminate stress, we can learn techniques to manage and alter how we react to the stress in our lives. Relaxation and imagery, massage, aromatherapy, humor, and music are several strategies people have reported effective in managing stress.

Are there any specific exercises that help you regain your energy level?

We aren't sure about that. There have been some studies done in women treated for breast cancer that have found that a walking program may help fight fatigue. Exercise can help promote muscle strength, joint flexibility, and sleep. People often think of exercise as requiring Lycra, sweating and getting short of breath. The exercise we talk of when we talk of cancer fatigue need not be that strenuous to be beneficial. There is no specific length of time that people need to exercise to make it effective. Exercise is important for people who are not able to walk or get out of bed too. One woman shared that she started with 2 minutes of exercise and was winded and exhausted at the end of it. She continued to try and do 2 minutes of exercise several times during the week and eventually she was able to get up to 5 minutes of exercise. She reported that even that little amount of exercise made her feel better. For some it may be walking or riding a stationary bike but for others just lifting a can of fruit several times with each arm can make a difference. Just getting started doing anything regularly can help. Whatever you decide to do, try to set realistic goals and schedules and stick to them. If you miss a day, that is okay. Just start again as soon as you can. A little exercise is better than no exercise. Though I am not an advocate of "no pain, no gain", I do believe in the old adage, "use it or lose it". Though it takes energy to exercise, it can also provide energy.

How long does the fatigue last? Does it eventually wear off as treatment goes on?

There are different kinds of fatigue associated with cancer therapies. There is an acute fatigue, which is associated with the treatment. We believe that the acute fatigue that people experience with treatment does get better after treatment is complete. There is also a chronic fatigue that some people report. This may last for a long period of time after treatments are complete.

Does chemo affect different people in different ways? If so, why?

Absolutely, chemotherapy affects people in different ways. It can be difficult for health care providers to prepare people for what they might experience. Though it can be overwhelming to get so much information about cancer and cancer treatment, for many, having information is what helps them cope with their situation. Just remember that not everyone has every side effect. It is also important to realize that just because a neighbor or relative had a certain experience with cancer treatment doesn't mean that you will have the same experience. If you develop a side effect of treatment, talking with others who have experienced the same side effect may be helpful. They can often share valuable tips on what helps. This is one reason support groups can be so beneficial for some. It gives people the opportunity to receive ideas but also gives people the opportunity to share ideas. The opportunity to help others can also be very therapeutic.

There are many differences in people, which may contribute to their different reactions to therapy. Cancer and people can be like snowflakes with no two cancers and no two people being or acting exactly the same. People have different immune systems, which may play a role in how cancer treatment affects them. People also have different amounts of stress in their lives and they react to stress differently. I'm not sure that I can fully explain why chemotherapy affects people in different ways but I hope this simplistic explanation has helped some.

What is different about cancer fatigue than other fatigue?

We all experience fatigue in our every day lives. We are busy raising families, taking care of our homes, and some with work outside the home. People who go through cancer and cancer treatments have all of the normal activities or tasks that contribute to fatigue as well as processes going on in their bodies that increase fatigue. Where the fatigue that comes from everyday life may be relieved with rest and sleep, cancer fatigue is not always. There are so many things that may be contributing to the fatigue that trying just one intervention may not be enough. We need to come at it from a variety of directions.

A strategy that can help in combating even the everyday fatigue is energy conservation. Planning, positioning, pacing, and prioritizing are the 4 "P's" of energy conservation. It is helpful to plan activities on a day-by-day basis. As you plan, set aside time for rest, for exercise, and for the things that you find most important in your life. Pacing has to do with how fast you work and how much time you spend doing an activity versus resting. Finding a balance is what is important. Positioning has to do with how you hold your body as you do certain activities. Efforts to try and minimize tension and unnecessary weight on muscles and bones can help. There have been studies done that show that you use less energy when you sit to do something than when you stand. Prioritizing involves identifying what tasks or activities you can eliminate and not worry about at all and identifying what kinds of things can you delegate to someone else. People tell us that there is great pleasure and satisfaction from helping others especially those we care about. Give your family and friends that gift by asking and accepting their help. It is okay to say no to visitors or phone calls. Your health and well being are important to all who care about you. Prioritizing also involves saving the things that are most important to you for a time when you have the energy to do them. Plan them at your peak energy times when possible.

Are there foods to avoid when taking chemo that will help?

I don't know of any specific foods that you need to avoid when taking chemotherapy that will impact your level of fatigue. Heavy and fatty meals can make people sleepy and fatigued or smaller meals more frequently may help. There may be foods you want to avoid during treatment that may control other side effects. There again, no two people are the same. Trust your own instincts about what foods you are most likely to tolerate when undergoing treatment. If you have some nausea with chemotherapy, you may want to try the things that have helped with nausea you have experienced in the past. Be sure to use the anti-nausea medications prescribed by your health care provider.

Is cancer fatigue always physical?

No, it is not always just physical. Many people report a mental or attentional fatigue. Some will say that they just can't concentrate or focus their attention. Others have called it "chemo head" when they are not able to think clearly. I've heard of one person who said they were "dead in the head and in bed" when they felt that way. Some people who experience this type of fatigue get flustered with loud noises and lots of activity or they sometimes can't find the right words to express themselves. Some strategies that can help with this type of fatigue include avoiding situations where you may be exposed to hurried activities, loud noises, and extremes in temperature or light. Take charge of your life and your situation as much as you can. Ask questions and take someone with you to your appointments to help you listen to what the health care providers are saying. Take notes or have a friend or family member take notes.

Some find it helpful to challenge themselves mentally. Remember to be realistic with yourself. Activities that focus your mind such as doing cross word puzzles or a jigsaw puzzle have been reported as helpful.

Research has shown that spending some quiet time being in and amongst things of nature such as gardening, sitting in a garden, watching birdsÉmay actually restore attention and energy. Try to do something that you enjoy every day to re-energize yourself.

Humor can also be very helpful. Having fun is important part of tending to fatigue in general, but particularly mental fatigue. It can help control depression, reduce stress and re-energize. Checking out a comedy video, getting a joke book, calling a positive upbeat friend just to talk, or exploring new interests may also be helpful.

Does acupuncture or other "natural" therapies help with energy/healing?

I have not heard of acupuncture for managing fatigue, but some have found other complimentary therapies to be helpful either to control stress, to control other symptoms of disease or side effects of treatment and to re-energize. Some of the natural therapies that I think of include relaxation therapy, imagery, aromatherapy, and healing touch. Massage is another intervention that can be helpful to promote relaxation and help control symptoms and side effects that contribute to fatigue. Herbal therapy is often asked about. There is not clear scientific support for the use of herbs in combating fatigue. If you are interested in herbal therapies, be cautious. Just because something is "100% natural" doesn't mean that it is 100% safe. There are some herbs that can be very toxic and some may interfere with conventional cancer treatments. Herbs that may be safe to take may need to be stopped before or during treatment. Be sure your health care providers know of all supplements and medications you are taking.

Is it possible that a patient will not feel any fatigue from chemotherapy?

Yes it is. Some people get through chemotherapy and other cancer treatments with no fatigue or very mild fatigue. Again, everyone reacts differently to his or her disease and treatment.

What causes fatigue in cancer treatments?

It is not completely clear what causes cancer fatigue. It is believed to be due to a variety of factors. The cancer itself can drain the body of energy and resources so fatigue can occur from the disease. We have already talked about how treatments can contribute to cancer fatigue. The physical demands of treatment such as getting to and from the clinic or treatment center, waiting times and changes in normal activities on treatment days may also impact the level of fatigue people might experience. Emotional factors such as stress and depression may increase the fatigue experienced too. Medications or combinations of medications including the non-chemotherapy medications can increase fatigue which can be a "catch 22" situation. We want to treat side effects of treatment but adding more and more medications may make the fatigue worse.

Again, nutrition, sleep, rest, sensory and mental factors can also contribute to cancer fatigue. Because there appears to be so many causes of cancer fatigue, knowing what to do about it can be difficult.

Does some of the fatigue come from throwing up while on chemo?

Yes. It takes a lot of energy to get through an episode of vomiting. The doctors and nurses will provide you with a prescription for medicines to help control the nausea and vomiting called anti-emetics. If the medication you use doesn't control the nausea or vomiting, be sure to contact your doctor or nurse. Nausea and vomiting that isn't controlled can cause not only fatigue, but also other problems such as dehydration, electrolyte imbalances and nutritional concerns. Keep your health care team informed if you are having uncontrolled nausea or vomiting. Keep them informed of any side effects you are experiencing. When they know what side effects you are having and when you are having them, and how severe they are, they will be better able to tailor some strategies for your specific situation.

Why do you lose your appetite while on chemo?

Changes in appetite can be a result of taste changes, dry mouth, or nausea and vomiting. Chemotherapy can also affect the cells that line the stomach and intestines. It may also be that lack of energy may contribute to the loss of appetite. Not all chemotherapy will cause these changes but if they do develop, it can make it a real challenge to eat to maintain your energy.

In summary, know yourself and keep the lines of communication open with your health care team. Take charge of your health and your treatment by learning as much as you can about your disease and treatment and ask questions! Learn your body's cues and track the pattern of your fatigue. Do what works for you and be realistic with yourself. Find the resources available in your community and use them. Cancer fatigue is a tough problem for patients and health care providers. It will take everyone's ideas and involvement to find the answers. Ways to try and combat cancer fatigue include tending your body, your mind, and your spirit. Work with your health care providers to control symptoms and side effects, eat a well-balanced diet, get enough sleep and rest, exercise, and conserve your energy. Draw energy and strength by communing with God or your higher power, with others, and with your environment. And be sure to plan time and save energy for fun and for relationships.

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