Doctor's Advice

Who better to consult on fatigue than a doctor struggling with it herself? While Dr Spooner awaits the arrival of her twin sons, we make the most of her incapacitated state and quiz her on the science of Cancer-Related Fatigue (CRF). 

What’s the main cause of Cancer-Related Fatigue?

It’s not really as simple as that. I can’t give you one main reason; there’s many factors that make a cancer survivor experience fatigue. Medicine is split into biological, psychological, and social causes of ill health. It’s probably best to approach it in those terms, looking at factors for fatigue in each area, though they do cross over a lot.

So let’s take biological first.

The biological approach to medicine would look at the existence of illness and disease and how that can cause fatigue.  Every chronic disease causes fatigue, cancer especially.

I was interested to read that up to 40% of people felt fatigued when they were diagnosed. I thought it was the chemo that made most of us tired!

Yes, chemotherapy can make you tired, as well as other drugs like pain relief. But fatigue often starts before these drugs are administered. Chronic disease causes anaemia, a prime cause of fatigue.

Why is that?

Chronic disease makes cell turnover increase. This reduces the body’s ability to access ferritin, what we use to make iron. Iron is needed to create red blood cells to carry oxygen around the body. With less iron, we get less oxygen to feed our organs and muscles.

Cancer is particularly bad for causing anaemia. And it can last quite some time after you’ve got rid of the cancer cells.

What are the treatments for anaemia? I took iron tablets prescribed from my GP. Is there anything else you can do?

The first step is to go to the GP. They’ll request a blood test to check if you’re actually anaemic. If they find your iron store is really low, they might prescribe IV iron, though this is only in extreme cases. I’ve got anaemia at the moment so I’m prescribed ferritin, the iron tablets you described.

My consultants suggested I eat a balanced diet, though I wasn’t really tempted to feed on steaks and liver. Are there any iron-secrets?

I drink Spatone, a softer supplement than the ferritin prescribed tablets. It doesn’t make me as constipated and sick. They come in little sachets of water that just taste a little coppery.

Your doctors may recommend you take Spatone even if you aren’t diagnosed with anaemia.

OK, so are there other biological imbalances that can cause fatigue? You can get boosters for other vitamins too can’t you?

Sometimes imbalances in Vitamin D and B12 cause fatigue. These are checked in a blood test too. There could also be something else going on that’s not linked to cancer. You could be developing chronic fatigue syndrome, caused by a post-bacterial or post-viral infection.

Oh, joy of joys. I guess you could get the imbalances checked routinely as part of your hospital check-ups.

Yes, but the GP has lots of uses. They’ll explore other causes to fatigue. The GP might offer some treatments for the psychological causes of fatigue. Mental health problems are strongly linked with fatigue. Take depression. In the simplest of terms, there’s a triad of symptoms of depression: fatigue, ‘an hedonia’ (the absence of interest in life), and low mood. With 2 of these symptoms, you can be diagnosed with depression.

You’d think that everyone with cancer feels depressed at some stage! It’s weird. When I was depressed before cancer and visited my GP, they were reluctant to give me any medication. Since cancer, I’ve been swimming in an orgy of anti-depressants and anti-anxiety drugs. Is there a special cancer pass that gives access to them?

We know there’s a strong link between physical health and mental health, so as your physical health was poor, I guess they wanted to protect your mind.

But then when I did see a clinical psychologist I was told that I wasn’t clinically depressed. Neither did I have an anxiety disorder, despite clearly having anxiety.

That’s because your anxiety is reasonable. An anxiety disorder relates to inexplicable anxiety. It doesn’t make sense. Like someone who feels crippling fear that their family will die. They can’t breathe, they lose weight. Anxiety disorders are sparked by nothing related to the anxiety. In your case, your feelings of anxiety were totally reasonable.

Fatigue is linked to stress and anxiety too. Cancer is a massive emotional burden; that turmoil is exhausting.

I found it was only when treatment finished that my stress began to take over. It seems that with the absence of treatment, stress fills its place. This then made me more tired.

Even though stress is a psychological factor, it’s heavily linked to biological factors too – it messes with your hormones. When you’re having surgery or receiving treatment, you’re in an acute stage of stress. You release cortisol and adrenaline which keeps you ready for flight and fight. When you’re in remission you pass into a chronic stage of stress. You’re not releasing these drugs anymore. That’s when stress magnifies and causes fatigue.  

Sometimes I feel disposed to heightened stress. I’ll feel all shaky, my heart will quicken and there’ll be this horrible metallic taste in my mouth.

You’ve been through something massive, so you may well respond to stress differently. Stress can cause fatigue in other ways too. Your body tenses up physically, so muscles have less energy for other activities. Mindfulness might be helpful.

Yes, there’s some great mindfulness strategies available. The Headspace app actually goes through each part of your body, making you notice it and relax.

That’s useful. Because when you’re stressed you waste a lot of energy. You can lose weight.

Pain can cause stress and low mood too. If you’re chronically in pain, then you’re chronically stressed. And if you’re taking painkillers, these make you drowsy. You could explore a change in painkiller with your doctor.

Does a low mood make you tired?

Well it certainly impacts on the social causes of fatigue. If you’re feeling down, you don’t want to go out and socialise. And the less you do, the more tired you feel. Not being active makes you more tired. It sounds a bit wishy washy, but it’s true. When you go through cancer treatment, perhaps you lose your job, you quit your hobbies, and the friends you socialised with before are less likely to invite you out, because now you’re ‘sick’. This will all reduce your activity. So when treatment finishes, you’re using less energy and it’s difficult to pick things up again. You tire easier. A good support network is crucial. Not just because they’ll help you out, but they’ll get you doing more too.

It is difficult to pick up life again. And when you lose friends, it makes you feel sad and less inclined to socialise.

It is a vicious cycle!

Most of us have had surgery too so you just can’t do as much, regardless of desire for otherwise.

That’s more of a biological cause. If your health prevents you from activity this will reduce muscle tissue, making the remaining muscles work harder and decrease surplus energy you would have had for other activities. Routine tasks feel so much harder.

So what can we do about any of this?

We’ve already spoken about going to see the GP. They can do your blood tests, eliminate imbalances and non-relevant health issues. Speak to them about any psychological concerns too. You may want to book a double appointments, or if your surgery offers phone appointments first, suggest that you actually go in and speak to them if that’s easier.

They may prescribe anti-anxiety or anti-depressant drugs. Or they may refer you to a clinical psychologist. There’s some excellent evidence out this week on how CBT (Cognitive Behavioural Therapy) can help to improve Chronic Fatigue Syndrome. It’s not cancer-related but it’s certainly going to be linked.

And the other thing: value the importance of friends and family. A good support network is essential. They’ll get you out doing more which will improve your energy. And if your activity levels are low perhaps you could look at beginning gentle exercise, a short walk.

Tai Chi is supposed to be good. There’s evidence to support that’s helpful for fatigue.

Yes, and yoga too. Gentle exercise and avoid the boom and bust.

So what would you say the one thing those that suffer with CRF could do to make themselves feel more alive?

As I said to begin, it’s not as simple as that – there’s not one thing that is the most important. The factors of CRF cannot be treated separately, they all fit together in a vicious cycle of causes and cures. Consult your GP and work it out together.