We escalate for dyspnea. We act on chest pain. But fatigue – the kind that erodes function, adherence, and dignity – is still routinely noted, not treated. That’s no longer defensible.
Cancer-related fatigue (CRF) affects ~60% of patients during treatment and continues for ~30% even post-treatment. ASCO’s guideline, built on 96 RCTs, shifts us from reflexive pharmacology to movement and behavioral interventions.
What Works
Exercise! But Reframe It.
Exercise helps. And “exercise” feels absurd to someone who’s struggling to sit up. The word ‘exercise’ needs reframing for cancer.
Prescribe “movement” instead
Sitting upright, stretching in bed, walking to the mailbox. The goal is not steps. It’s small, consistent movement that helps with metabolic regulation.
And it’s not linear.
There will be bad days – especially post-chemo – and better ones as the cycle wears on. Encourage patients to dial movement up or down based on how they feel. Movement is a long game to preserve strength, reduce deconditioning, and improve energy regulation.
“You’re not failing if all you did today was stand up.” That’s the intervention.
CBT and Mindfulness: Frontline, Not Fringe
These are not fringe. They’re Category 1. Yet they remain under-prescribed.
Fix it: Hardwire one-click CBT referral into your EMR survivorship template, embed digital CBT tools like Sleepio, SilverCloud or MeruHealth into your systems. No waiting rooms, no copays, no excuses
Mind-Body and Complementary Approaches
Tai Chi and Qigong may be more tolerable than gym-based exercise. 3–5x/week, 20–60 minutes. Low cost, culturally diverse, and widely available on YouTube or Insight Timer.
These don’t compete with treatment. They fill the gap active treatment doesn’t address: autonomic regulation, proprioception, and emotional resilience.
Also, note that these CRF approaches are relevant also to those with advanced disease or poor overall prognosis. When the goal is dignity, function, or preserving alertness, then fatigue must be managed – not merely observed.
What not to reach for
A definitive list of what not to recommend:
- Wakefulness agents (modafinil, armodafinil): no benefit
- L-carnitine: unsupported
- Psychostimulants (e.g., methylphenidate): weak and inconsistent
- Antidepressants (e.g., paroxetine): no CRF benefit in non-depressed patients
Why it matters: Treating CRF like depression or sleepiness dilutes trust. And it doesn’t work.
The Real Gap: Implementation
- Fatigue isn’t screened consistently
- Movement isn’t prescribed
- Referrals aren’t embedded
- And access – especially for rural, uninsured, or minoritized patients, is limited. If you don’t pre-wire equity into your care model, the gap compounds.
CRF Action Map: From Screening to Intervention
✅ Screening
- Include fatigue in every review (NCCN CRF tool or 0–10 scale)
- Add EMR SmartPhrase for fatigue + movement readiness (e.g., part of ESAS)
✅ Communication
- Standardize patient script: “This is common. It’s not in your head—and we have tools that help.
- Provide QR code or handout with 2–3 vetted CBT/mindfulness/movement tools
✅ Referral & Prescription
- Refer early to PT, psycho-oncology, survivorship
- Use EMR SmartSets or pathways
- Refer early to PT, psycho-oncology, survivorship
- Use EMR SmartSets or pathways
- Partner with 1 virtual program for seamless access
- Prioritize free/scalable tools for uninsured or rural patients
✅ Team Integration
- Train nurses in 5-min bedside movement coaching (ankle pumps, shoulder rolls, neck tilts, overhead arm stretch, seated march)
- Activate caregivers with movement kits (adapt downloadable guide)
- Train nurses in 5-min bedside movement coaching (ankle pumps, shoulder rolls, neck tilts, overhead arm stretch, seated march)
- Activate caregivers with movement kits (adapt downloadable guide)
- Suggest wearables for remote PT
✅ Systems & Billing
- Track “movement vital signs” in flowsheets
- Bill CPT 97530 for therapeutic movement interventions
- Review CRF data quarterly in QI rounds
Ready to Turn Evidence into Action?
Download the Full Patient–Physician Movement Action Plan:
We’ve created a simplified, CRF-specific customizable guide to co-create fatigue management plans based on each patient’s phase of care—treatment, recovery, or survivorship.
👉 [Download the Patient–Physician CRF Action Guide]
For those seeking in-depth programs, ACSM’s Moving Through Cancer resources and MSKCC’s exercise programs are incredible resources, and highly recommended!
👉 [Download the ACSM Moving Through Cancer Guide]
Final Thought: Raising the Bar
Clinicians don’t often ask about fatigue because we feel we can’t fix it. That needs to change. Our job is not to eliminate fatigue altogether – it’s to acknowledge it, measure it meaningfully, and manage it with as much rigor as we apply to neutropenia.
The next time a patient says, “I’m too tired to move,” don’t change the subject.
Change the treatment plan.
Best,
Shruti Agarwal, PhD
Together4Cancer
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The Compass is your practical briefing on what’s working in oncology care – strategy, science, and systems. No fluff. Just implementation.