Managing Cancer-Related Fatigue and Insomnia in Patients and Caregivers

Cancer-related fatigue and insomnia frequently co-occur among patients with cancer, and emerging data have demonstrated that caregivers of patients with cancer also have a high symptom burden, with elevated rates of depression, sleep disturbance, and fatigue.

In addition to being highly distressing, these treatment-related symptoms can be difficult to manage in patients and caregivers, particularly among patients who are already experiencing other side effects of cancer treatment, according to Oxana Palesh, PhD, MPH, Director of Research, Stanford Cancer Institute Survivorship Program, CA.

At the 2018 Multinational Association of Supportive Care in Cancer meeting, Dr Palesh discussed pharmacologic, behavioral, and physical activity interventions for managing cancer-related fatigue and sleep problems in patients and their caregivers.

Strategies for Managing Caregiver Symptom Burden

According to Dr Palesh, relatively little is known about the symptom burden and management of caregivers’ health.

A meta-analysis of 29 randomized controlled trials conducted between 1983 and 2009 summarized the state of science on psychoeducational, skills training, and therapeutic counseling for caregivers. The analysis showed that these interventions had a small-to-medium effect, but had positive effects on caregiver burden, ability to cope, feelings of self-efficacy, and quality of life.

Psychoeducational and behavioral interventions reduce caregiver depression, instill a sense of confidence about caregiving, and decrease anger, hostility, and depression. ­Internet-based caregiver interventions have also demonstrated benefit by offering information and support, and by positively influencing social and psychological outcomes for caregivers.

Teaching caregivers to navigate the service delivery system, particularly in the United States, where the healthcare system is complex, has been shown to increase their sense of competence and reduce depression, Dr Palesh said.

Pharmacologic Interventions for Patients

Pharmacologic interventions have a place in the management of some treatment-related side effects, but there is still a paucity of research to support their effectiveness for sleep disruption and related symptoms, she said.

Most pharmacologic interventions are ineffective for cancer-related fatigue and cognitive impairment or are only indicated for the short-term management of symptoms such as insomnia, without addressing the underlying etiology.

Dr Palesh noted that pharmaceuticals are potentially better at preventing symptom development, and an increased focus should be placed on the prevention and treatment of more acute symptoms.

Some nutraceuticals have shown promise—such as melatonin for sleep and omega supplements for cancer-related fatigue—but most have not. Certain neutraceuticals, such as kava, can even be toxic in patients who are receiving cancer treatment, she added.

Nonpharmaceutical Interventions: The Power of Physical Activity

Behavioral interventions are still the gold standard for the management of psychiatric side effects associated with cancer treatment. These interventions typically use cognitive psychoeducation, as well as behavioral strategies and modifications such as compensatory techniques, stimulus control, and sleep-­restriction therapies.

Physical activity is emerging as one of the most effective interventions for patients with cancer. Physical activity is now considered a medication all its own and has demonstrated efficacy in reducing insomnia, cognitive impairment, cancer-related fatigue, inflammation, depression, and immunosuppression, while improving quality of life.

“Physical activity is effective at reducing pretty much every symptom that cancer patients experience, and might also decrease the toxicity of cancer treatments, odds of recurrence, and incidence of second cancers,” Dr Palesh said. “In addition, it may improve survival.”

The basic exercise recommendation for the general population is 150 minutes of moderate intensity or 75 minutes of vigorous activity weekly.

However, individualized prescriptions and safety considerations should always be used for patients with cancer, “just as we would do with any other intervention or therapeutic,” Dr Palesh noted.

Interventions that use complementary and alternative medicines (CAM), such as acupuncture and massage, have shown promise, but they lack rigor.

“People really like CAM therapies,” she pointed out. “But the quality of the studies is not where we would like it to be.”

Future Directions in Symptom Management

According to Dr Palesh, more research is needed to deliver effective interventions in clinical practice and to make behavioral interventions more accessible to patients and caregivers, perhaps incorporating approaches such as mobile health, brief in-clinic interventions, and psychoeducation.

She advocates for higher-quality randomized, controlled clinical trials that emphasize personalization and focus on dose, duration, and intensity of various interventions. More research is needed on pro­mising CAM interventions and ­pharmaceutical agents, and on the combination of exercise and psychological interventions.

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