Assessment of CRF
Given that fatigue is a subjective experience, the patient's self-report using the 0 (no fatigue) to 10 (severe fatigue) scale is suggested by the National Comprehensive Cancer Network (NCCN). However, patient, professional, and system barriers exist that hinder effective fatigue assessment and management. Studies have revealed that patients do not report fatigue for several reasons, including a belief that fatigue is inevitable, untreatable, and unimportant. Patients fear that CRF can negatively affect medical treatment if reported, such as needing to reduce or stop treatment, or the belief that fatigue means that the disease is not responding to treatment and/or getting worse. Professional barriers include a lack of knowledge about the underlying causes of fatigue; lack of assessment, leading to underreporting, underdiagnosing, and undertreatment; an unwillingness to initiate discussion if unaware of available treatment; or a belief that little can be done to manage the symptom. Documentation of fatigue in the medical record is not common practice nor required by the Joint Commission, thus creating a systems barrier. As a result, CRF assessment and management are not viewed as priorities, and clinicians are not reminded to document its occurrence. Obtaining a referral to physical or occupational therapy can be burdensome, thus preventing some patients from being referred. Unfortunately, interventions are provided to patients when the fatigue is already severe and thus less likely to implement or benefit from them. Type of health care coverage/reimbursement for medications/treatment/therapies can also be a barrier.
In addition to the patient's self-report, using a multidimensional approach to elicit more information will enable the clinician to better manage the fatigue. Descriptors beyond severity, such as onset, duration, interference in daily activities, exacerbating and palliative factors, and treatments tried, are helpful. In addition, there are several single-item, multi-item, and multidimensional tools that have been developed to measure fatigue, and they have been reviewed by Piper and colleagues (Table 2). Some of these measures include single-item tools such as the NCCN Intensity Scale, Fatigue Intensity Scale, and the Visual Analogue Scale. Multi-item tools include the Brief Fatigue Inventory and the Cancer-Related Fatigue Distress Scale. Multidimensional measures include the Cancer Fatigue Scale, Fatigue Assessment Questionnaire, and the Revised Piper Fatigue Scale. Single- and multi-item measures embedded in other scales include the Profile of Mood States Fatigue and Vigor subscales, the Symptom Distress Scale, and the Edmonton Symptom Assessment System. These tools can be used both in research and in the clinical area.