Supportive care for reducing fatigue may not be sufficiently adhered to by breast cancer patients

Cancer-related fatigue is a prevalent and potentially persistent issue among breast cancer survivors, which can prevent them from returning to their previous life well after treatment ends and they are declared free of disease. A study, to be presented at the ESMO Breast Cancer Virtual Meeting 2020 (23-24 May), has now shown that existing recommendations and proven strategies for reducing fatigue, which can have physical, emotional as well as cognitive dimensions, may not be sufficiently adhered to by early breast cancer patients.

Explaining the background to the analysis, study author Dr. Antonio Di Meglio of Gustave Roussy in Villejuif, France, stated: "Cancer-related fatigue is an issue that many patients complain about in the clinic, sometimes for years after the completion of treatment. Although there is a lot that we still don't know about the different mechanisms underpinning fatigue, we now have specific, evidence-based recommendations for treating it: the first is to initiate or maintain adequate levels of physical activity and limit sedentary time as much as possible. Data also supports the use of psychosocial interventions such as cognitive-behavioral therapy, which can help address maladaptive thoughts like over-dramatizing or feelings of helplessness. Our aim with this study was to assess the real-world uptake of these recommendations."

To do this, the research team drew on data from the CANTO cohort study, (2) which assessed long-term toxicities in early breast cancer patients from 26 French cancer centers for at least five years from the time of diagnosis.

CANTO is unique in the field of survivorship research, as it enrolled over 10,000 breast cancer patients nationwide, of which we were able to include more than 7,000 in our analysis. The wealth of clinical, patient-reported and biological data collected makes it an ideal database to answer a lot of questions about cancer-related fatigue."

Dr. Antonio Di Meglio of Gustave Roussy in Villejuif, France

Di Meglio and his colleagues included in their analysis only women who had completed primary treatment and were free of disease, and examined patients' reported utilization of recommended strategies to treat fatigue over 12 months after a baseline assessment.

Uptake of physical activity recommendations hindered by severe fatigue

"These are patients who were free of disease and whom we would expect to return to their pre-cancer state within six to 12 months after the end of treatment. What we found, however, was that over a third of patients (36%) reported fatigue that we classify as severe at three to six months after treatment," Di Meglio reported. "A majority of study participants (64%) complied with physical activity recommendations in the year that followed, but that still leaves a concerning proportion of women (36%) who were not sufficiently active or completely inactive during this period."

The results additionally showed that patients who reported severe levels of fatigue at baseline were less likely than those with non-severe symptoms to adhere to recommendations of physical activity (60% versus 67%) in the year following the assessment. "The message here is that we need to work harder to encourage patients to stay active, and to make them understand that even if it seems counter-intuitive, it is exercise, not rest, that will help them to overcome fatigue," said Di Meglio.

Supportive care underutilized across the board, with differences observed by fatigue domain

The analysis further brought to light that overall reported utilization of supportive care was low in this patient population, with only one out of 10 women consulting a psychologist, one out of 12 seeing an acupuncturist and one out of 14 seeking help from a homeopath. "The striking fact here is that patients seem to be using strategies that we have robust evidence for and can refer them to, like psychotherapy, at roughly the same rates as approaches for which we do not have sufficient efficacy data and therefore cannot recommend, like homeopathy," Di Meglio observed. "This suggests that patients may not be sufficiently aware of what the recommendations are, and that we as oncologists need to ensure they are educated about the options at their disposal to reduce fatigue. Better education may also help to diminish the fears and stigma that are still too often associated with psychosocial interventions."

Patients' physical activity uptake and utilization of supportive care were additionally evaluated for different dimensions of fatigue, revealing differences in women's behavior depending on whether their fatigue was more physical, cognitive or emotional in nature. "Most notably, we found that patients with severe physical fatigue were less likely to adhere to physical activity recommendations, at 59% compared to 67% of those with non-severe physical fatigue, while high levels of emotional fatigue were more strongly linked to utilization of psychological consultations, at 17% compared to 8% of non-severe patients in this domain," Di Meglio reported.

He continued: "We also expected women experiencing severe overall fatigue to rely much more heavily on supportive care measures, but in fact they were only 1.3 times more likely to seek out the help of a psychologist, for example, than patients with non-severe fatigue. This may be explained in part by the fact that psychosocial interventions in this context usually come with out-of-pocket costs for patients. That is something our findings may contribute to changing in the future - especially considering that untreated cancer-related fatigue can have long-term social and financial consequences for survivors, some of whom we know never return to their previous life."

Prof. Gabriella Pravettoni, Director of the Psycho-Oncology Division at the European Institute of Oncology (IEO) in Milan, Italy, commented on the findings: "The fact that the strategies patients adopt to manage side-effects are strongly correlated to the type of fatigue they are suffering from is particularly interesting, because patients experiencing significant physical fatigue, for example, may actually benefit substantially from seeing a psychologist. We know that physical activity is proven to reduce cancer-related fatigue, but on its own it does not guarantee the inner healing of the individual."

Pravettoni continued: "By focusing too much on physical activity as the primary remedy for cancer-related fatigue, we are omitting the importance of working on patients' motivation and resilience to help them maintain that activity level and recover fully in the long term. If we leave these women without psychological support, other interventions are almost certain to be less effective as a result. What is truly needed is a 360-degree approach whereby healthcare professionals make therapeutic recommendations in line with patients' unique characteristics and needs. This is all the more important in the context of the current health emergency, which can cause patients to experience strong negative emotions like fear and uncertainty and add to their existing psychological burden from potentially traumatic experiences related to their cancer diagnosis and treatment."