Utilisation of Non-pharmacological Interventions for Management of Cancer-related Fatigue in Palliative Care Services – An Audit Cycle

INTRODUCTION

Cancer-related fatigue (CRF) is one of the most pervasive and debilitating symptoms experienced by patients with cancer.^[1] The National Comprehensive Cancer Network defines CRF as ‘a 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 interferes with usual functioning’.^[2] While healthy individuals experience transient fatigue as a physiological response, patients with cancer often endure a relentless and debilitating fatigue that is refractory to rest.^[3] The aetiology of CRF is multifactorial and identifying definitive physiological markers for objectively quantifying fatigue is challenging. Therefore, managing CRF necessitates a comprehensive approach that encompasses various components [Table 1].^[4]

In a study by Hofman et al., up to 90% of patients treated with radiation and 80% of those treated with chemotherapy experience fatigue.^[5] CRF continues for months and even years following completion of treatment in approximately one third of the patients with cancer. Fabi et al. found that the prevalence of fatigue among survivors undergoing active treatment varies between 62% and 85%, of which 9–45% reported moderate-to-severe CRF.^[6,7]

In the Indian scenario, according to Koyyala, CRF is a burden unreported by patients, undiagnosed by physicians and unaddressed in research.^[8] Another Indian author found that the presence of CRF was found in all participants with severe fatigue in 97 of 110 patients, with a negative impact on quality of life.^[9] Studies conclude that it has a huge impact on daily living activities, leads to social invalidation (cannot/less work, direct role in family and withdraw from activities) and causes psychological problems like anxiety, depression, poor sleep and cognitive disorder.^[10]

Recent research has refuted the earlier trend of using rest as management, due to its detrimental effect on the musculoskeletal system,^[11,12] cardiopulmonary fitness^[13] and functional status.^[14] American Society of Clinical Oncology,^[15] Canadian Association of Psychosocial Oncology^[16] and Evidence-Based Medicine^[17] guidelines suggest that management of CRF includes a longitudinal assessment, screening, addressing the underlying causes and following recommendations for interventions.

This implementation necessitates a multidisciplinary team (MDT) approach and comprehensive training.^[18] An MDT of doctors, physical therapists, clinical psychologists, social workers, and nurses were inducted within the department of palliative medicine at Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, in December 2021. Phase 1 aimed to audit the documentation of CRF and nonpharmacological interventions (NPIs) to address fatigue before and after MDT induction. Phase 2 audited the impact of the interventions. The research protocol was approved by the Institutional Ethics Committee (P. No. 12000039).

MATERIALS AND METHODS

RESULTS

Phase 1

In March 2021 (n = 391), documentation of CRF was observed in only 67% of cases, which increased to 84% in March 2022 (n = 433). From no documentation of NPI in 2021, it increased to 36% with the MDT [Figure 1].

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Figure 1: Run chart of the audit cycle with data on cancer-related fatigue and non-pharmacological intervention. NPI: Non-pharmacological intervention, MDT: Multidisciplinary team, EBM: Evidence-Based medicine.

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Phase 2

Documentation of both CRF and NPI increased during the re-audit phase. February 2023 (n = 478) CRF documentation was observed in 98.5% of which NPI was given for 86.5% of individuals. Similarly, in March 2023 (n = 600), both CRF and NPI documentation were 89.3% and 89.9%, respectively. To assess the compliance and sustainability, the re-audit that followed after 6 months showed 96.7% of CRF documentation with 86.5% of NPI documentation [Figure 2].

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Figure 2: Patients who reported fatigue during both the phases.

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Significant symptom clusters associated with fatigue were loss of appetite (p < 0.01), loss of well-being (p < 0.001) and breathlessness (p < 0.01).

DISCUSSION

The results of the audit reveal a notable evolution in the documentation of CRF and NPIs within the department over the specified time period. Initially, the documentation of CRF was observed in only 67% of cases, highlighting a discrepancy in clinic practice. In March 2022, following an intervention involving the introduction of MDT and the establishment of an SOP, documentation improved to 84%. A marked absence of NPI documentation in 2021 was noted which increased only to 36% with the MDT. It was the team sensitisation, training and the introduction of specific codes for NPI documentation based on the severity of fatigue which has positively influenced this improvement. Documentation increased significantly from February 2023 (98.5%) to September 2023 (96.70%). This indicates a substantial improvement in capturing fatigue during this period.

A notable increase in CRF documentation is evident with an interesting trend seen in the reaudit phase, which is the increased number of patients reporting fatigue, which suggests that improved documentation could be contributing to a higher reporting rate, improving the identification of patients who could benefit from NPIs [Figure 2]. This is pivotal, given the challenges in recognising and treating CRF, as those suffering often consider fatigue to be an inevitable side effect of their disease and its treatment.^[11-14]

NPIs documentation also showed improvement in 2023. There was a sustained improvement from February 2023 (86.5%) to March 2023 (89.9 %) and September 2023 (86.50%). However, the increase was not as dramatic as CRF documentation [Figure 2].

The audit also highlighted the importance of education and sensitisation of staff regarding the critical role of NPI such as exercise, relaxation techniques and psychological support, in managing CRF.^[20] The integration of these interventions aligns with the broader literature acknowledging their efficacy in palliative care settings.^[5-7]

Implementation of the MDT and SOP has significantly enhanced CRF documentation, corroborating existing literature on the efficacy of collaborative care.^[18] The instigation of daily checklists, code reinforcement sessions and visible reminders within the department served as efficient methods for promoting consistent documentation. The correlation between fatigue and symptom clusters such as loss of appetite, loss of well-being and breathlessness corroborates existing literature which suggests that CRF is seldom an isolated symptom and often presents in association with other distressing symptoms.^[21]

The data in Table 4 offer a snapshot of the distribution of severity trends over the given timeline. With a sample size of 1619 cases, the majority were classified as mild (53%), followed by moderate (36%), and as severe (12%) with a notable concentration of individuals within the 50–70% palliative performance scale range during both the phases. Early NPI F1 interventions were initiated in a small subset (3%) of patients who did not report fatigue, emphasising a proactive approach to patient care by educating, counselling and preserving functionality. While a substantial proportion of patients with mild (87.3%) and moderate (78.9%) fatigue received appropriate NPI F1 and NPI F2 interventions, respectively, the data underscore the challenges in aligning subjective patient-reported fatigue with objective clinical assessment. This inconsistency is evident in cases where intervention levels were adjusted based on functional status, disease trajectory and patient capacity rather than solely on reported fatigue severity. In NPIs, implementation for the severe fatigue group (71% for NPI F3) with a clear end-of-life care pathway (9.7% Non Pharamacological Intervention Fatige End of life [NPI FE]) is seen. A critical next step is to evaluate the impact of these interventions on patient outcomes. This evaluation is essential to determine the effectiveness of the current approach and to identify areas for improvement.

Severity trend along the 2^nd phase (February, March and September 2023) was seen as such [Table 4].

CONCLUSION

This study underscores the importance of developing contextual codes for ease of documentation. The implementation of MDT approach, coupled with targeted educational interventions, has led to substantial improvements in the documentation of CRF and NPIs. The symptom cluster associated with CRF emphasises the importance of longitudinal assessment.