Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Brief Communication
Case Report
Case Series
Conference Abstract
Conference Editorial
Conference Proceedings
Current Issue
Editorial Commentary
General Medicine, Case Report
IAPCONKochi 2019 Conference Proceedings
Letter to Editor
Letter to the Editor
Letters to Editor
Narrative Review
Original Article
Palliative Medicine, Letter to the Editor
Personal Reflection
Position Paper
Position Statement
Practitioner Section
REPUBLICATION: Special Article (Guidelines)
Review Article
Short Communication
Short Report
Special Editorial
Special Review
Systematic Review
View/Download PDF

Translate this page into:

Letter to the Editor
27 (
); 354-356

Myriad of Cancer-related Fatigue: A Concept Model on Multifactorial Causation and Impact

Department of Radiotherapy, College of Nursing, All India Institute of Medical Sciences,Patna, Bihar, India
Principal and Dean, Nitte Usha Institute of Nursing Sciences, NITTE (Deemed to Be) University, Mangalore, Karnataka, India
Corresponding author: Fatima D Silva, PhD, Nitte Usha Institute of Nursing Sciences, NITTE (Deemed to be) University, Mangalore, Karnataka – 575018, India
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Javeth A, Silva FD, Singh P. Myriad of cancer-related fatigue: A Concept model on multifactorial causation and impact. Indian J Palliat Care 2021;27(2):354-6.

Dear Sir,

Cancer-related fatigue is the most common, prevalent, distressing and disabling symptom manifested by patients with cancer and cancer survivors on various treatment modalities such as chemotherapy and radiation therapy or both.

According to the National Comprehensive Cancer Network (2020), cancer-related fatigue is distressing, persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and it interferes with usual functioning.[1] According to Cella et al., 1998, cancer-related fatigue is the subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest.[2]

The prevalence of cancer-related fatigue is different in different cancer types and ranges from 25% to 100%.[3,4] Experience of fatigue is highly associated to period before, during and even after treatment.

Fatigue experienced by the patients with cancer varies in terms of intensity and severity throughout the day and follows a style related to treatment.[1] The pattern involves the waxing and waning of fatigue that is, severe fatigue after a few days and after a few weeks in patients undergoing chemotherapy/immunotherapy and radiation therapy, respectively. Whereas fatigue usually lessens or even goes away overtime as they convalesce from surgery.[5,6]

Cancer-related fatigue is a multifaceted phenomenon affected by various factors. We propose a model that depicts multifactorial causation and impact of cancer-related fatigue. The model emphasises an interplay between various factors affecting CRF and its impact on life of patients with cancer. This model depicts the individual factors, contextual factors, experiences and impact of fatigue [Figure 1].

Figure 1:: Multifactorial causation and impact of cancer-related fatigue (researchers conceptualised the model for multifactorial causation and impact of cancer-related fatigue).

Individual factors include demographic, genetic, immunity, psychological and social factors. Demographic variables include age, gender, socioeconomic status, marital status and employment status (income). Psychological factors comprise personality, stress, depression, anxiety and coping styles, while social support plays an important role as a social factor.[7-9]

Cancer, its type, stage and duration of cancer, cancer treatment (surgery, chemotherapy, radiation therapy and immunotherapy), comorbid conditions such as anaemia, malnutrition, EBV infections, cardiopulmonary disorders, liver failure, renal diseases, neurological disorder and fluid and electrolyte imbalances and concurrent symptoms such as pain, dyspnoea, nausea, hypoxemia and insomnia are found to be highly associated with cancer-related fatigue.[7,8]

Symptoms experienced comprise generalised weakness not relieved by rest, increased need for rest, reduced concentration with mental fogginess, non-restorative sleep with hypersomnia or insomnia, inertia and post-exertional malaise.[10]

Cancer-related fatigue has a wide range of impact which ranges from affecting quality of life to decreased treatment compliance. Quality of life is affected in the form of reduced physical and vocational functioning, decreased emotional and social well-being. Decreased treatment compliance, reduced emotional resilience, decreased self-esteem and decreased productivity/efficiency are the other under reported impact of fatigue associated with cancer.[11-15]

Different strategies that can be adopted by the clinicians for the management of cancer-related fatigue include nonpharmacological and pharmacological measures. Nonpharmacological measures include aerobic exercises in the form of walking, cycling, running or bowing for at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity.[16,17] Complementary therapies such as yoga, asana, mindfulness,[18] massage[19] and aromatherapy, foot soak with reflexology,[18] acupressure and acupuncture[20] and Reiki therapy[21] are found to be effective in managing the cancer-related fatigue and improve the quality of life of patients. Dietary counselling, psychoeducation,[22] cognitive behavioural therapy[23] and sleep therapy[24] have a positive impact on fatigue. More research studies have to be conducted to evaluate the effectiveness of different interventions such as polarity/energy therapy, bright light therapy,[1] restorative therapy[25] and eurythmic therapy.[26] Pharmacological agents such as recombinant human erythropoietin,[27,28] high-dose Vitamin C,[29] L carnitine,[30] paroxetine,[31] methylphenidates[32] and ATP infusion[33] have significantly improved the cancer-related fatigue.

In summary, cancer-related fatigue is a multifarious phenomenon and it negatively affects the quality of life and activities of daily living. Identification of determinants and impact of cancer-related fatigue aid in the delivery of individualised, holistic and quality care to the patients with cancer and cancer survivors.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


  1. Cancer Related Fatigue. . NCCN Clinical Practice Guidelines in Oncology, Version 2. 2020 Available from: [Last accessed on 2020 Jun 15]
    [Google Scholar]
  2. , , , , . Progress toward guidelines for the management of fatigue. Oncology (Williston Park). 1998;12:369-77.
    [Google Scholar]
  3. , , . Fatigue in cancer patients dur-36. Ing and after treatment: Prevalence, correlates and interventions. Eur J Cancer. 2002;38:27-43.
    [CrossRef] [Google Scholar]
  4. . Cancer-related fatigue: Prevalence, assessment and treatment strategies. Expert Rev Pharm Out Res. 2011;1:441-6.
    [CrossRef] [Google Scholar]
  5. Fatigue and Weakness. American Cancer Society. Available from: [Last accessed on 2021 May 24]
    [Google Scholar]
  6. , , , , , , et al. Fatigue in long-term breast carcinoma survivors: A longitudinal investigation. Cancer. 2006;106:751-8.
    [CrossRef] [Google Scholar]
  7. , , , , , , et al. Fatigue in cancer survivors--prevalence and correlates. Onkologie. 2009;32:312-7.
    [CrossRef] [Google Scholar]
  8. , . The prevalence and moderators of fatigue in people who have been successfully treated for cancer. J Psychosom Res. 2006;60:29-38.
    [CrossRef] [Google Scholar]
  9. , , , , . Cancer-related fatigue: Prevalence of proposed diagnostic criteria in a United States sample of cancer survivors. J Clin Oncol. 2001;19:3385-91.
    [CrossRef] [Google Scholar]
  10. . Cancer-related fatigue--mechanisms, risk factors, and treatments. Nat Rev Clin Oncol. 2014;11:597-609.
    [CrossRef] [Google Scholar]
  11. , . Cancer-related fatigue: Guidelines for evaluation and management. Oncologist. 1999;4:1-10.
    [CrossRef] [Google Scholar]
  12. , , , , . Use of a case definition approach to identify cancer-related fatigue in women undergoing adjuvant therapy for breast cancer. J Clin Oncol. 2005;23:6613-22.
    [CrossRef] [Google Scholar]
  13. , . Fatigue in older cancer patients: Etiology, assessment, and treatment. Semin Oncol. 2008;35:633-42.
    [CrossRef] [Google Scholar]
  14. , , , . Giving meaning to measure: Linking self-reported fatigue and function to performance of everyday activities. J Pain Symptom Manage. 2006;31:229-41.
    [CrossRef] [Google Scholar]
  15. . Fatigue in cancer patients undergoing chemotherapy: A nursing process approach. Int J Caring Sci. 2019;12:1261.
    [Google Scholar]
  16. , , . Clinical implementation of exercise guidelines for cancer patients: Adaptation of ACSM's Guidelines to the Italian Model. J Funct Morphol Kinesiol. 2017;2:4.
    [CrossRef] [Google Scholar]
  17. , , , , . Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer. 2004;100:2253-60.
    [CrossRef] [Google Scholar]
  18. , . Massage therapy for symptom control: Outcome study at a major cancer centre. J Pain Symptom Manage. 2004;28:244-9.
    [Google Scholar]
  19. , , . The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: A randomised controlled trial. Complement Ther Med. 2007;15:228-37.
    [CrossRef] [Google Scholar]
  20. , , . Pilot crossover trial of Reiki versus rest for treating cancer-related fatigue. Integr Cancer Ther. 2007;6:25-35.
    [CrossRef] [Google Scholar]
  21. , , , . Dietary counseling improves patient outcomes: A prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol. 2005;23:1431-8.
    [CrossRef] [Google Scholar]
  22. , , , , . Efficacy of cognitive therapy for depression among women with metastatic cancer: A single-case experimental study. J Behav Ther Exp Psychiatry. 2004;35:287-305.
    [CrossRef] [Google Scholar]
  23. , , , , , , et al. Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: Results of a feasibility intervention study. Oncol Nurs Forum. 2003;30:513-22.
    [CrossRef] [Google Scholar]
  24. , . An environmental intervention to restore attention in women with newly diagnosed breast cancer. Cancer Nurs. 2003;26:284-92.
    [CrossRef] [Google Scholar]
  25. Available from: [Last accessed on 2020 Dec 19]
  26. , , , , . Human recombinant erythropoietin and quality of life: A wonder drug or something to wonder about? Lancet Oncol. 2002;3:145-53.
    [Google Scholar]
  27. , , . Control of cancer-related anemia with erythropoietic agents: A review of evidence for improved quality of life and clinical outcomes. Ann Oncol. 2003;14:511-9.
    [CrossRef] [Google Scholar]
  28. , , . Changes of terminal cancer patients' health-related quality of life after high dose Vitamin C administration. J Korean Med Sci. 2007;22:7-11.
    [CrossRef] [Google Scholar]
  29. , , , , , , et al. Safety, tolerability and symptom outcomes associated with L-carnitine supplementation in patients with cancer, fatigue, and carnitine deficiency: A phase I/II study. J Pain Symptom Manage. 2006;32:551-9.
    [CrossRef] [Google Scholar]
  30. , , , , , , et al. Effect of paroxetine hydrochloride (Paxil) on fatigue and depression in breast cancer patients receiving chemotherapy. Breast Cancer Res Treat. 2005;89:243-9.
    [CrossRef] [Google Scholar]
  31. , , , , , , et al. A phase II study of methylphenidate for the treatment of fatigue. Support Care Cancer. 2006;14:210-5.
    [CrossRef] [Google Scholar]
  32. , , , , . Randomized clinical trial of adenosine 5'-triphosphate in patients with advanced non-small-cell lung cancer. J Natl Cancer Inst. 2000;92:321-8.
    [CrossRef] [Google Scholar]

Fulltext Views

PDF downloads
View/Download PDF
Download Citations
Show Sections