Fatigue is very common in patients with blood cancers. Cancer-related fatigue (CRF) is characterized by excessive and persistent exhaustion that interferes with daily activity and function. CRF often begins before cancer is diagnosed, worsens during the course of treatment and may persist for months—even years—after treatment ends. 

Unlike the fatigue that healthy people experience from time to time, CRF is more severe, often described as an overwhelming exhaustion that cannot be overcome with rest or a good night’s sleep. Some people may also describe muscle weakness or difficulty concentrating. Many patients with blood cancers find CRF more distressing and disabling than other disease-related or treatment-related symptoms such as pain, depression or nausea.

It is important for patients to talk with their doctors, nurses and other members of their healthcare team if they experience signs of fatigue before, during, or after treatment. Treatment, along with lifestyle changes, can make an important difference and help improve energy level.

Signs and Symptoms of Cancer-Related Fatigue 

Patients should discuss their symptoms with their doctor or nurse.  A patient may have

• Difficulty climbing stairs or walking short distances
• Muscle weakness
• Shortness of breath
• Weight gain or loss
• Intolerance to cold
• Anemia or low thyroid function test results
• Skin dryness or hair loss
• Sleep disturbances

Fatigue can also be reflected in mood, cognition and changes in social functioning including

• Depressed and/or anxious mood
• Lack of motivation
• Negative thinking
• Irritability
• Inability to concentrate
• Loss of memory or mental alertness
• Withdrawal from leisure and/or social activities
• Unusual strain in relationships

Assessing Cancer-Related Fatigue

Fatigue can be difficult to assess because there are no objective measurements. The first step in assessing CRF is to identify and address any underlying physical problems aside from, or in addition to, the cancer. These underlying issues may be anemia, infection or treatment side effects that could be causing fatigue. While there are no lab tests that screen for CRF, your doctor or nurse practitioner may decide to order one or more of the following tests to help identify potential causes:

• Complete blood count (CBC)
• Peripheral blood smear
• Serum iron level
• Transferrin level (glycoproteins that control iron in the blood)
• Total iron-binding capacity
• Ferritin level (protein in cells that stores iron)
• Folate level (a B vitamin)
• Vitamin B₁₂ level
• Erythropoietin level (a hormone that increases the number of red blood cells)
• Thyroid function 
• Adrenocorticotropic hormone (ACTH) level (regulates cortisol; also known as Cortrosyn^TM stimulation test).

Good communication between patients and their healthcare team is key to successful evaluation and treatment of fatigue. People living with cancer should be asked about and encouraged to note and report symptoms of fatigue at each office visit. Tell your doctor or nurse if the fatigue is

• Worse at certain times of day
• Associated with certain cancer therapies
• Worse or has been relieved by certain activities.

Treatments for Fatigue

Fatigue is often caused by more than one problem. Therefore, whatever physical or psychological symptoms a patient has may be treated by one or more of the following treatments, often in combination with each other.

• Treatment of anemia
  • Change in diet
  • Blood transfusions
  • Erythropoiesis stimulating agents (ESAs)—epoetin alfa (Epogen®, Procrit®) and darbepoetin alfa (Aranesp®). Visit Drug Listings for more information.
• Exercise
  • Before starting an exercise program, always consult with your doctor or nurse practitioner. It may be helpful to be referred to a physical therapist for an evaluation and an exercise plan. An exercise plan should be individualized based on the patient’s age, type of cancer, and physical fitness level.
• Treatment of pain
  • If pain is making fatigue worse, the cancer medication may be changed or the dosage increased. If too much pain medication is actually causing fatigue, the medication may be changed or the dosage adjusted.
• Treatment of depression
  • There are many ways to treat depression including medication, counseling or a combination of both. Support groups and stress management training may also help patients deal with the fatigue that is associated with depression, thereby improving quality of life. 
• Psychosocial interventions
  • Interventions that reduce stress and increase psychosocial support (counseling, stress management, coping strategies)
  • Cognitive behavioral strategies (progressive muscle relaxation, relaxation breathing)  
• Nutritional counseling
  • A dietitian can work with a patient to ensure that he or she is getting sufficient calories, fluids, and nutrients for support in remaining as active as possible. 
  • For a free one-on-one nutrition consultation with a nutrition educator, click here.

Patients are encouraged to explore clinical trials. The following are under study for CRF:

• Medications— Medications that may help improve symptoms of CRF include psychostimulants and antidepressants
• Other Medications and Supplements—Clinical trials with ginseng, coenzyme Q10, and L-carnitine (an amino acid supplement) are under way. There is little research on the use of sleep medications in people with cancer, and many experts say this should be an area of further study.

​Take Care of Yourself

Here are some suggestions that may help patients with CRF improve their own well-being.

• Be Flexible. Do not measure yourself by prediagnosis energy levels. Set realistic goals. You may not be able to accomplish everything that you want to do every single day. Decide which tasks are most important for you to complete and focus on accomplishing those goals. When you are feeling fatigued, let others help you. 
• Distract Yourself. Allow yourself to shift your focus from fatigue (and what you may not be accomplishing) by listening to music, reading a book, looking at pictures, meeting friends, watching a movie, going for a walk or enjoying time in nature.
• Stay Active. Staying physically active may help some people ease fatigue. Before starting an exercise program, always consult with your doctor or nurse practitioner. Focus on activities that will help you gradually build strength but that do not deplete your energy level. Light exercise, such as walking, can also help you relax and sleep better.
• Practice good nutrition.  Patients with cancer are at risk for malnutrition and other problems resulting from either the cancer or the cancer treatment (loss of appetite, nausea, vomiting and inability to absorb nutrients). It is important for patients to eat a balanced diet that provides sufficient fluid, calories, protein, vitamins and minerals. Iron intake is vital, so try to consume iron-rich foods such as green leafy vegetables and red meat. Maintain energy levels by eating frequent small meals or snacks throughout the day. You may find it useful to work with a dietitian to create a plan to suit your caloric needs and to learn about easy-to-prepare, healthy meals and snacks. Drink plenty of noncaffeinated liquids throughout the day. Adequate hydration is very important in preventing and treating fatigue. See Food and Nutrition.
• Address Sleep Habits. The following suggestions may help improve sleep quality:
  • Engage in relaxing activities before bedtime, such as taking a warm bath or shower, reading, writing in a journal, yoga, meditation or listening to calming music.
  • Go to bed at the same time every night.
  • Use the bedroom for sleep only.
  • Keep the bedroom cool, quiet and dark.
  • Use comfortable bedding and sleepwear.
  • Avoid caffeine, alcohol or high-sugar foods before bedtime.
  • Avoid video game playing, television, computer, cell phone use and social media use before bed and overnight.
  • Forego daytime naps that may interfere with nighttime sleep. If you need to nap, do not sleep for longer than 30 minutes. 
• Ask for Help. Ask for help with routine tasks such as shopping, cooking, housekeeping, laundry or driving. Rest when you feel tired.
• Plan Ahead. If possible, schedule cancer treatments for those times that will have the least effect on your job or other activities. For example, if you work, schedule treatments in the afternoon or at the end of the week so you can be the most productive at your job.
• Keep a Journal. Keep track of your experiences of fatigue. Take notes on a regular basis of 
  • The severity (on a 0 to 10 scale, with 0=no fatigue and 10=the worst you can imagine) of your fatigue
  • When your fatigue occurs
  • How long your fatigue lasts
  • Activities or treatments that make you feel either better or worse
  • How fatigue interferes with your daily activities
  • Symptoms of your fatigue such as tired legs or eyes, difficulties with concentration, weakness or sleepiness, shortness of breath, irritability or impatience.

A detailed record will help you when you discuss possible causes, treatments and coping strategies with your doctor or nurse.

Also note daily activities, medications and treatments, eating and sleeping habits, weight changes and emotional stressors, including financial concerns. Write down strategies that have worked to reduce fatigue, such as undertaking difficult tasks when your energy is highest, or pacing yourself and scheduling rest.

• ​Seek support. Many patients and their families find support groups to be comforting and informative. The Leukemia & Lymphoma Society can help with referrals to support groups and the Patti Robinson Kaufmann First Connection program, a peer-to-peer program that matches patients and their families with trained volunteers who have been touched firsthand by a blood cancer and share similar experiences.

Related Links

• Download or order The Leukemia & Lymphoma Society’s free fact sheet, Cancer-Related Fatigue Facts
• Listen to our podcast episode, Cancer-Related Fatigue: Syndrome Not Symptom