Date of document September 2018
This is the current valid version of the document

1General information

Tumor-associated fatigue - in English Cancer-Related Fatigue (CRF) - describes a persistent feeling of physical, emotional and also mental fatigue that is not related to any previous activity. Patients often experience a loss of their own drive and lack of energy. It becomes increasingly difficult to concentrate and remember things. Typically, even sleep leads to no or only slight recovery. The symptoms and their severity vary greatly from person to person.

For a long time, fatigue was not understood as an independent clinical picture, although it can enormously restrict performance and thus mean a reduction in the quality of life. Among all the commonly observed symptoms of cancer patients, fatigue is often perceived as the most distressing symptom. Therefore, it is important to create awareness of this disease so that the physician as well as the staff involved in the treatment and the patient can recognize appropriate symptoms in conversation and assign them to fatigue [1234567].

Symptoms of fatigue deserve attention because they are associated with adverse effects on several domains. These include psychological well-being and daily life, including family, work, and social participation, and probably also overuse of health services that treat only the effects but not fatigue as a cause. The vicious cycle of avoidance behaviors leading to inactivity and helplessness shown in Figure 1 must be broken early. The less one is active and involved in life, the more one's muscles, condition and alertness dwindle. This again leads to feeling more tired, weary and less motivated. It becomes increasingly difficult to get up and get active.

Figure 1: Vicious circle of fatigue 
Vicious circle of fatigue

2Good to know

2.1When does cancer-associated fatigue occur?

The time of diagnosis of fatigue can vary greatly. In some patients, fatigue is a first sign of the tumor disease and already exists before it is recognized. The stage, tumor mass and other risk factors of the disease may be partly responsible for the development of fatigue. Tumor diseases are also referred to as "consuming diseases" because they claim resources for themselves that the patient actually needs for his own performance.

Fatigue can also develop during treatment or worsen in severity. Chemotherapy, radiation and surgery are interventions whose side effects can be both psychologically and physically stressful.

Even after successful therapy, when there is no longer a detectable tumor and the affected person is considered cured of cancer, fatigue may persist.

2.2What factors maintain fatigue?

Several dimensions influence the persistence of fatigue: Physical factors, i.e. the state of the cancer and secondary diseases, play an important role, but emotional and mental factors, such as the ability to concentrate, also determine how the disease progresses. In addition, the social environment plays an essential role. A balanced level of support from family, relatives and friends can contribute to recovery. Nevertheless, 30-40% of patients still suffer from fatigue, which is a burden in everyday life, even one year after successful therapy.

So, there is no one cause of fatigue. Many different factors can contribute to its development. For each patient, these factors are different, and the influence of the individual factors can also change in a patient over the duration of the cancer experience.

If fatigue occurs, it is important in the diagnosis to exclude concomitant diseases that can cause symptoms of fatigue.

2.3How is fatigue diagnosed?

To diagnose fatigue and exclude other causative diseases, a doctor-patient discussion, a physical examination, a blood count to assess possible organic causes, and answers to the fatigue questionnaires are usually sufficient. In particular, the type, intensity and course of the complaints are asked by the doctor. Information about the first occurrence, before or after the cancer diagnosis or therapy and the duration of fatigue are relevant for the prognosis or further development of fatigue. The more pronounced the symptoms were before or during therapy, the more likely the fatigue will persist even after successful treatment of the tumor disease. In order to better narrow down the diagnosis, the physician can also inquire about secondary diseases, medications taken, stimulants or intoxicants, nutritional and sleep behavior, physical fitness, as well as occupational, familial and environmental (harmful factors in the home/occupational environment) stresses.

2.4Can the complaints also have other causes?

The most important differential diagnosis of fatigue is depressive disorder. Other differential diagnoses, such as anaemia, infections, malnutrition, hypothyroidism, and sleep apnea syndrome should also be clarified and treated accordingly.

2.5When and how is tumor-associated fatigue treated?

Fatigue may persist for some time after successful cancer therapy. However, if it persists for more than a year and is a burden, further medical support should undoubtedly be sought. Therapy for fatigue should then not be delayed any further in order to prevent the symptoms from developing into a permanent burden.

The treatment should be as individual as the patient and his disease. There is currently no general standard of treatment for fatigue. However, the possibilities are often underestimated. Good results have been shown so far for sports programs to increase physical fitness and for psychological therapies, see AYApedia Exercise and Sport. The approach of cognitive behavioral therapy is considered particularly effective and therefore promising. Studies have shown that individually tailored behavioral therapy measures can significantly reduce fatigue in cancer patients, and in some cases even cure it.

3Tips and trick

3.1Talk about fatigue!

Those who have complaints also have the right to complain about their suffering - especially to the treating team! Therapeutic strategies have been developed and are in development that can help patients with fatigue. Fatigue is not a hopeless diagnosis. The most important thing is that the diagnosis is first made. To do this, the physician must learn of the symptoms. Actively asking about treatment options can help everyone involved move forward.

Fatigue patients often do not look sick despite tremendous stress. There are also no reliable laboratory parameters or functional tests for fatigue. Only the current and subjective condition determine the clinical picture.

During the consultation with the treating physician, he or she should ask in detail about the severity of the disease and its course in order to identify all possible influencing factors and to be able to treat them appropriately.

3.2Find balance between rest periods and effort!

Exercise can provide new momentum and help to cope with fatigue. Care must be taken to manage one's own strength and not to overload oneself - finding the right balance is difficult, but possible. Setting priorities and allowing yourself time off after a strenuous phase relieves the strain on yourself and maintains your own performance.

3.3Ensure a good night's sleep!

Our own biological rhythm has a great influence on how we experience the day. Developing an awareness of one's own rest and action phases makes it possible to structure the day. In order to maintain this rhythm, bedtime should begin at approximately the same time each day. Factors that negatively influence sleep are: Greasy or large meals right before bedtime, and drinks containing caffeine or alcohol. Smoking or exercising before bedtime should also be avoided. A pleasantly designed sleeping area ensures healthy sleep and sufficient rest.

4Further links and information


  1. Kreissl S, Mueller H, Goergen H et al: German Hodgkin Study Group. Cancer-related fatigue in patients with and survivors of Hodgkin's lymphoma: a longitudinal study of the German Hodgkin Study Group. The Lancet Oncology. 17:1453-1462, 2016. DOI:10.1016/S1470-2045(16)30093-6

  2. Behringer K, Goergen H, Mueller H et al: Cancer-related fatigue in patients with and survivors of Hodgkin lymphoma: The impact on treatment outcome and social reintegration. J Clin Oncol 34:4329-4337, 2016. DOI:10.1200/JCO.2016.67.7450

  3. Gielissen MF, Verhagen S, Witjes F, Bleijenberg G: Effects of cognitive behavior therapy in severely fatigued disease-free cancer patients compared with patients waiting for cognitive behavior therapy: a randomized controlled trial. J Clin Oncol 24:4882-4887, 2006. DOI:10.1200/JCO.2006.06.8270

  4. Gielissen MF, Wiborg JF, Verhagen CA et al: Examining the role of physical activity in reducing postcancer fatigue. Support Care Cancer. 20:1441-1447. DOI:10.1007/s00520-011-1227-4

  5. Aaronson NK, Mattioli V, Minton O et al: Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice. European Journal of Cancer Supplements 12:54-64, 2014. DOI:10.1016/j.ejcsup.2014.03.005

  6. Mehnert A: Employment and work-related issues in cancer survivors. Crit Rev Oncol Hematol 77:109-130, 2011. DOI:10.1016/j.critrevonc.2010.01.004

  7. Heutte N, Flechtner HH, Mounier N et al: Quality of life after successful treatment of early-stage Hodgkin's lymphoma: 10-year follow-up of the EORTC-GELA H8 randomised controlled trial. Lancet Oncol 10:1160-1170, 2009. DOI:10.1016/S1470-2045(09)70258-X


Gender terms used in this text represent all gender forms.

7Experts' Affiliations

Dr. med. univ. Stefanie Kreissl
Ordensklinikum Linz
I. Interne Abteilung
Hämatologie und Onkologie
Fadingerstr. 1
A-4020 Linz
Dr. med. Ruth Scheuvens
Universitätsklinikum Köln (AöR)
Kerpener Str. 62
50937 Köln

8Disclosure of Potential Conflicts of Interest




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