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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®)

Cancer-RelatedFatigue

Version 1.2014

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NCCN Guidelines Index Fatigue Table of Contents

Discussion


NCCN Guidelines Version 1.2014 Panel MembersCancer-Related Fatigue

*Ann M. Berger, PhD, APRN/Chair #Fred & Pamela Buffett Cancer Center atThe Nebraska Medical Center

Kathi Mooney, RN, PhD/Vice-Chair Huntsman Cancer Instituteat the University of Utah

Amy Alvarez-Perez, MD £Roswell Park Cancer Institute

Ashley Atkinson, RN, MSN, OCN #University of Alabama at BirminghamComprehensive Cancer Center

William S. Breitbart, MD θ ÞMemorial Sloan-Kettering Cancer Center

Brittany Brothers, PhD θThe Ohio State University ComprehensiveCancer Center -James Cancer Hospital andSolove Research Institute

David Cella, PhD θRobert H. Lurie Comprehensive CancerCenter of Northwestern University

Charles Cleeland, PhD θThe University of TexasMD Anderson Cancer Center

Mario A. Eisenberger, MD † ϖ The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Carmen P. Escalante, MD ÞThe University of TexasMD Anderson Cancer Center

Paul B. Jacobsen, PhD θMof tt Cancer Center

Catherine Jankowski, PhDUniversity of Colorado Cancer Center

Phyllis Kaldor, RN, MS, OCN #The Ohio State UniversityComprehensive Cancer Center -James Cancer Hospital andSolove Research Institute

Thomas LeBlanc, MD, MA †Duke Cancer Institute

Jennifer A. Ligibel, MD †Dana-Farber/Brigham andWomen’s Cancer Center

Elizabeth Trice Loggers, MD, PhDFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance

Belinda Mandrell, PhD, RN €St. Jude Children’s Research Hospital/University of Tennessee Health ScienceCenter

Barbara A. Murphy, MD † £Vanderbilt-Ingram Cancer Institute

Oxana Palesh, PhD, MPH θStanford Cancer Institute

William F. Pirl, MD θMassachusetts General Hospital Cancer Center

Steven C. Plaxe, MD ΩUC San Diego Moores Cancer Center

Michelle B. Riba, MD, MS θUniversity of Michigan ComprehensiveCancer Center

Hope S. Rugo, MD † ‡UCSF Helen Diller FamilyComprehensive Cancer Center

Lynne I. Wagner, PhD θRobert H. Lurie Comprehensive CancerCenter of Northwestern University

Nina D. Wagner-Johnston, MD †Siteman Cancer Center at Barnes-Jewish Hospitaland Washington University School of Medicine

Finly J. Zachariah, MD £City of Hope Comprehensive Cancer Center

NCCNMaria Ho, PhDMary Anne Bergman

ContinueNCCN Guidelines Panel Disclosures

# Nursing† Medical oncologyÞ Internal medicineϖ Urology‡ Hematology/Hematology

oncologyθ Psychiatry, psychology,

including health behavior

Ω Gynecologic oncology € Pediatric oncologyτ Orthopedicsξ Bone marrow transplantation£ Supportive care including

palliative, pain management,pastoral care, and oncologysocial work

*Writing committee member

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Clinical Trials: NCCN believes that

the best management for any cancerpatient is in a clinical trial.Participation in clinical trials isespecially encouraged.

To nd clinical trials online at NCCNmember institutions, click here:nccn.org/clinical_trials/physician.html .

NCCN Categories of Evidence andConsensus: All recommendationsare Category 2A unless otherwise

speci ed.See NCCN Categories of Evidenceand Consensus .

NCCN Cancer-Related Fatigue Panel Members

Summary of the Guidelines UpdatesDe nition of Cancer-Related Fatigue (FT-1)Standards of Care for Cancer-Related Fatigue in Children/Adolescentsand Adults (FT-2)Screening for Cancer-Related Fatigue (FT-3)Primary Evaluation (FT-4)Interventions for Active Treatment (FT-5)Interventions for Post-Treatment (FT-6)Interventions for End of Life (FT-7)

The NCCN Guidelines ® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinicalcircumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network ® (NCCN ®) makes no representations orwarranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN

Guidelines are copyrighted by National Comprehensive Cancer Network®

. All rights reserved. The NCCN Guidelines and the illustrations herein may notbe reproduced in any form without the express written permission of NCCN. ©2014.


NCCN Guidelines Version 1.2014 Table of ContentsCancer-Related Fatigue


Discussion


http://www.nccn.org/clinical_trials/clinicians.aspx









Discussion

Version 1.2014, 01/06/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines ® and this illustration may not be reproduced in any form without the express written permission of NCCN ®. UPDATES

NCCN Guidelines Version 1.2014 UpdatesCancer-Related Fatigue

Updates to Version 1.2014 of the NCCN Guidelines for Cancer-Related Fatigue from Version 1.2013 include:

MS-1

• The discussion section was updated to re ect the changes in the algorithm.

FT-3• For None to mild the recommendation was modi ed to Education, counseling, and general strategies for management

of fatigue with corresponding footnote “d”.• For Moderate or Severe the same language was added. Education plus, primary evaluation of fatigue was deleted.

FT-4• Under Focused history

Changed Rule out to Consider • Second column has been modi ed to, Management of concurrent symptoms and treatable contributing factors.

FT-5• Under General Strategies for Management of Fatigue:

Find meaning in current situation, Emphasis on meaningful interactions, Promote dignity of patient is new to the page (Also for FT-6).• Activity enhancement has been modi ed to Physical activity (Also for FT-6 and FT-7).• A new footnote has been added to the 2nd sub-bullet under Nonpharmacologic directing the reader the NCCN Guidelines for Survivorship

(Also for FT-6).

FT-6• Under General Strategies for Management of Fatigue, modi ed the rst bullet to, Monitor fatigue levels .

First sub-bullet modi ed, Set priorities and realistic expectations (Also for FT-7).Deleted the following sub-bullets:

◊ delegate ◊ labor-saving devices ◊ postpone nonessential activities

• For Patients Post-Treatment, under Speci c Interventions, Nonpharmacologic, 2nd bullet, 2nd sub-bullet, Mindfulness-based stressreduction (category 1) is new to the page.


i d b h i bi h 10 29 201 12 3 3 l l d f di ib i C i h © 201 i l C h i C k All i h d





NCCN Guidelines Version 1.2014Cancer-Related Fatigue


Discussion


Note: All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

FT-1

DEFINITION OF CANCER-RELATED FATIGUE

Cancer-related fatigue is a distressing, persistent, subjective sense of physical, emotional,and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is notproportional to recent activity and interferes with usual functioning.


Printed by thai binh on 10/29/2014 12:37:34 PM For personal use only Not approved for distribution Copyright © 2014 National Comprehensive Cancer Network Inc All Rights Reserved







Discussion



FT-2

STANDARDS OF CARE FOR CANCER-RELATED FATIGUE INCHILDREN/ADOLESCENTS AND ADULTS

• Fatigue is rarely an isolated symptom and most commonly occurs with other symptoms, such as pain, distress, anemia, and sleepdisturbances, in symptom clusters. Therefore, patients should be screened for multiple symptoms that may vary according todiagnosis, treatment, and stage of disease.

• Fatigue is a subjective experience that should be systematically assessed using patient self-reports and other sources of data.

• Fatigue should be screened, assessed, and managed according to clinical practice guidelines.

• All patients should be screened for fatigue at their initial visit, at regular intervals during and following cancer treatment, and asclinically indicated.

• Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease,

prior to, during, and following treatment.

• Patients and families should be informed that management of fatigue is an integral part of total health care.

• Health care professionals experienced in fatigue evaluation and management should be available for consultation in a timely manner.

• Implementation of guidelines for fatigue management is best accomplished by interdisciplinary teams who are able to tailorinterventions to the needs of the individual patient.

• Educational and training programs should be implemented to ensure that health care professionals have knowledge and skills in theassessment and management of fatigue.

• Cancer-related fatigue should be included in clinical health outcome studies.

• Quality of fatigue management should be included in institutional continuous quality improvement projects.

• Medical care contracts should include reimbursement for the management of fatigue.

• Disability insurance should include coverage for the continuing effects of fatigue.

• Rehabilitation should begin with the cancer diagnosis.









Discussion



FT-3

SCREENING

aRecommended screen and re-evaluation: “How would you rate your fatigue on a scale of 0-10 over the past 7 days?”bFatigue scale for children is simplified: Use “tired” or “not tired” as screen for young children (age <6 or 7 y).cButt Z, Wagner LI, Beaumont JL, et al. Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer

practice. Journal of Pain and Symptom Management 2008; 35(1): 20-30.dSee “Patient/Family Education and Counseling” and “General Strategies for Management of Fatigue” based on clinical status: Active Treatment (FT-5) ,

Post-Treatment (FT-6) , and End of Life (FT-7) .

Screen every patient for fatigue asvital sign at regular intervals a,b

• Age >12 y:Severity: 0-10 scale c (0=No fatigue;

10=Worst fatigue you can imagine)orNone, mild, moderate, severe

• Age 7-12 y:Severity: 1-5 scale(1=No fatigue; 5=Worst)

• Age 5-6 y:Use “tired” or “not tired”

• Age >12 y:None to mild (0–3) a,b

• Age 7-12 y: (1-2)• Age 5-6 y: (Not tired)

• Age >12 y:Moderate (4–6) a,b or Severe (7–10) a,b

• Age 7-12 y:Moderate (3)or Severe (4-5)

• Age 5-6 y: (Tired)

Education,counseling, andgeneral strategiesfor managementof fatigue d

Education,counseling, andgeneral strategiesfor managementof fatigue d

Ongoingevaluation

See PrimaryEvaluation (FT-4)









Discussion



FT-4

PRIMARY EVALUATION FATIGUE SCORE: MODERATE OR SEVEREAge >12 y (4-10), Age 7-12 y (3-5), or Age 5-6 y (Tired)

PATIENT CLINICAL STATUS

Focused history• Disease status and treatment

Consider recurrence and/or progressionPrescription medications/OTCs and supplements

• Review of systems• In-depth fatigue history

Onset, pattern, durationChange over timeAssociated or alleviating factorsInterference with function

• Social support status/availability of caregiversAssessment of treatable contributing factors• Pain• Emotional distress

DepressionAnxiety• Anemia• Sleep disturbance (eg, insomnia, narcolepsy, obstructive

sleep apnea, restless leg syndrome)• Nutritional de cits/imbalance

Weight/caloric intake changesFluid electrolyte imbalance: sodium, potassium,calcium, magnesium

• Decreased functional statusDecreased activity levelDeconditioning

• Medications/side effects (eg, sedation)• Comorbidities

Alcohol/substance abuseCardiac dysfunctionEndocrine dysfunction (eg, hot ashes,hypothyroidism, hypogonadism, adrenal insuf ciency)Gastrointestinal dysfunctionHepatic dysfunctionInfectionNeurologic dysfunctionPulmonary dysfunctionRenal dysfunction

Managementof concurrentsymptomsand treatablecontributingfactors

Medications/Side effects

PainSee NCCN Guidelinesfor Adult Cancer Pain

Emotional distressSee NCCN Guidelines forDistress Management

AnemiaSee NCCN Guidelines forCancer- andChemotherapy-InducedAnemia

Sleepdisturbance

Nutritionalde cit/Imblance

Decreased functionalstatus

Comorbidities

No other factors

Activetreatment

SeeInterventions(FT-5)

Follow-up,posttreatment(no activetreatmentexcepthormonaltherapy)

End of life





http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf


http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf


http://www.nccn.org/professionals/physician_gls/pdf/anemia.pdf

















Discussion



FT-5

INTERVENTIONS FOR PATIENTS ON ACTIVE TREATMENT e

Patient/Family Educationand Counseling

General Strategies for Management of Fatigue

SPECIFIC INTERVENTIONSNonpharmacologic g Pharmacologic

Information aboutknown pattern offatigue during andfollowing treatment• Reassurance that

treatment-relatedfatigue is notnecessarily anindicator of diseaseprogression

• Self-monitoring of fatiguelevels

• Energy conservationSet priorities and realisticexpectationsPaceDelegateSchedule activities attimes of peak energyLabor-saving devices f

Postpone nonessentialactivitiesLimit naps to <1 hour tonot interfere with night-time sleep qualityStructured daily routineAttend to one activity ata time

• Use distraction(eg, games, music, reading,socializing)

• Find meaning in currentsituation

Emphasis on meaningfulinteractionsPromote dignity of patient

• Physical activity (category 1)Maintain optimal level of activityConsider starting and maintaining an exerciseprogram, as appropriate per health careprovider, of both endurance (walking, jogging,or swimming) and resistance (light weights)exercises l

Consider referral to rehabilitation: physicaltherapy, occupational therapy, and physicalmedicineCaution:

◊ Bone metastases ◊ Thrombocytopenia ◊ Anemia ◊ Fever or active infection ◊ Limitations secondary to metastases orother illnesses

• Physically based therapiesMassage therapy (category 1)

• Psychosocial interventionsCognitive behavioral therapy (CBT) h /Behavioraltherapy (BT) (category 1) i

Psycho-educational therapies/Educationaltherapies (category 1)Supportive expressive therapies j

• Nutrition consultation• CBT h for sleep

Stimulus controlSleep restrictionSleep hygiene

• Considerpsychostimulants k (methylphenidate ormoda nil) after rulingout other causes offatigue

• Treat for pain,

emotional distress, andanemia as indicatedper NCCN Guidelines(See appropriate NCCNGuidelines forSupportive Care )

• Optimize treatment forsleep dysfunction,nutritionalde cit/imbalance, andcomorbidities

Repeat

screeningandevaluationSee (FT-3) and (FT-4)

eSee Discussion for information on differences between activetreatment, post-treatment, and end-of-life treatment. ( See MS-1 )

f Examples include use of reachers for grasping items beyond arm's length, sockaids for pulling on socks, rolling carts for transporting items, escalators andelevators for traveling between building floors, and electrical appliances forperforming common household tasks (eg, opening cans).

gInterventions should be culturally specific and tailored to the needs of patients and families along theillness trajectory, because not all patients may be able to integrate these options due to variances inindividual circumstances and resources.

h A type of psychotherapy that focuses on recognizing and changing maladaptive thoughts andbehaviors to reduce negative emotions and facilitate psychological adjustment.

ICBT/BT influences thoughts and promotes changes in behavior; it includes relaxation strategies.

jSupportive expressive therapies (eg, support groups, counseling, journal writing) facilitate expression ofemotion and foster support from one or more people.

kPharmacologic interventions remain investigational, but have been reported to improve symptoms offatigue in some patients. There is more evidence for methylphenidate and less evidence for modafinil.These agents should be used cautiously and should not be used until treatment- and disease-specificmorbidities have been characterized or excluded. Optimal dosing and schedule have not beenestablished for use of psychostimulants in cancer patients.

lSee NCCN Guidelines for Survivorship (SE-3) .



http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive



http://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf










Discussion



FT-6

eSee Discussion for information on differences between active treatment,post-treatment, and end-of-life treatment. ( See MS-1 )

gInterventions should be culturally specific and tailored to the needs of patients and families alongthe illness trajectory, because not all patients may be able to integrate these options due tovariances in individual circumstances and resources.

h A type of psychotherapy that focuses on recognizing and changing maladaptive thoughts andbehaviors to reduce negative emotions and facilitate psychological adjustment.

iCBT/BT influences thoughts and promotes changes in behavior; it includes relaxation strategies. jSupportive expressive therapies (eg, support groups, counseling, journal writing) facilitate

expression of emotion and foster support from one or more people.

kPharmacologic interventions remain investigational, but have been reported to improve symptomsof fatigue in some patients. There is more evidence for methylphenidate and less for modafinil.These agents should be used cautiously and should not be used until treatment- and disease-specific morbidities have been characterized or ex cluded. Optimal dosing and schedule have notbeen established for use of psychostimulants in cancer patients.

lSee NCCN Guidelines for Survivorship (SE-3) .m Adjustment of current treatments for pain, sleep disturbances, and other symptoms and

comorbidities, including drugs. Nonpharmacologic management of pain may be considered, suchas palliative radiation, nerve blocks, or epidural management.

INTERVENTIONS FOR PATIENTS POST-TREATMENT e

Patient/Family Educationand Counseling

General Strategies forManagement of Fatigue Nonpharmacologic g

SPECIFIC INTERVENTIONSPharmacologic m

Information aboutknown pattern offatigue during andfollowing treatment

• Monitor fatigue levels• Energy conservation

Set priorities and realisticexpectationsPaceSchedule activities at timesof peak energyLimit naps to <1 hour to notinterfere with night-timesleep quality

Structured daily routineAttend to one activity at atime


• Find meaning in currentsituation

Emphasis on meaningfulinteractionsPromote dignity of patient

• Physical activity (category 1)Maintain optimal level of activityConsider initiation of exerciseprogram of both endurance andresistance exercise l

Consider referral to rehabilitation:physical therapy, occupationaltherapy, physical medicineCaution:

◊ Late effects of treatment(eg, cardiomyopathy)

• Psychosocial interventions (category 1)CBT h /BT (category 1) i,m

Mindfulness-based stress reduction(category 1)Psycho-educational therapies/Educational therapies (category 1)Supportive expressive therapies(category 1) j

• Nutrition consultation• CBT h for sleep (category 1)

Stimulus controlSleep restriction

Sleep hygiene

• Considerpsychostimulants k (methylphenidate ormoda nil) after rulingout other causes offatigue

• Treat for pain,emotional distress, and

anemia as indicated perNCCN Guidelines(See NCCN Guidelinesfor Adult Cancer Pain ,Distress Management, and Cancer- andChemotherapy-InducedAnemia)

• Optimize treatment forsleep dysfunction,nutritionalde cit/imbalance, andcomorbidities

RepeatscreeningandevaluationSee (FT-3) and (FT-4)






















Discussion



FT-7

eSee Discussion for information on differences between active treatment, post-treatment, and end-of-life treatment. ( See MS-1 )f Examples include use of reachers for grasping items beyond arm's length, sock aids for pulling on socks, rolling carts for transporting items, escalators and elevators for

traveling between building floors, and electrical appliances for performing common household tasks (eg, opening cans).gInterventions should be culturally specific and tailored to the needs of patients and families along the illness trajectory, because not all patients may be able to integrate

these options due to variances in individual circumstances and resources.kPharmacologic interventions remain investigational, but have been reported to improve symptoms of fatigue in some patients. There is more evidence for

methylphenidate and less for modafinil. These agents should be used cautiously and should not be used until treatment- and disease-specific morbidities have beencharacterized or excluded. Optimal dosing and schedule have not been established for use of psychostimulants in cancer patients.

n Also See NCCN Guidelines for Palliative Care .

INTERVENTIONS FOR PATIENTS AT THE END OF LIFE e,g,n

Patient/Family Education

and Counseling

General Strategies for

Management of Fatigue

Nonpharmacologic gSPECIFIC INTERVENTIONS

Pharmacologic

Repeatscreening

andevaluationSee (FT-3) and (FT-4)

Information aboutknown pattern offatigue during andfollowing treatment• Expected end-of-life

symptom• May vary in intensity

• Energy conservationSet priorities and realisticexpectationsPaceDelegateSchedule activities at times ofpeak energyLabor-saving and assistivedevices f (including wheelchairs,walkers, and commodes)

Eliminate nonessential activitiesStructured daily routineAttend to one activity at a timeConserve energy for valuedactivities


• Find meaning in current situationEmphasis on meaningfulinteractions

Promote dignity of patient

• Physical activityOptimize level of activity withcareful consideration of thefollowing constraints:◊ Bone metastases

◊ Thrombocytopenia ◊ Anemia ◊ Fever or active infection ◊ Assessment of safety issues(ie, risk of falls, stability)

• Psychosocial interventions

• Considerpsychostimulants k

(methylphenidate ormoda nil) after rulingout other causes offatigue

Considercorticosteroids(prednisone ordexamethasone)

• Treat for pain,

emotional distress,and anemia asindicated per NCCNGuidelines (SeeNCCN Guidelines forAdult Cancer Pain, Distress Management ,and Cancer- andChemotherapy-Induced Anemia)

• Optimize treatment

for sleep dysfunctionand comorbidities


http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf















http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf










http://distress.pdf/


http://pain.pdf/














http://pain.pdf/

http://pain.pdf/




http://anemia.pdf/

http://anemia.pdf/








http://survivorship.pdf/







http://anemia.pdf/











http://survivorship.pdf/













d l dNCCN G id li V i 1 2014








Version 1.2014, 01/06/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustr ation may not be reproduced in any for m without the express written permission of NCCN®. MS-19

NCCN Guidelines IndexFatigue Table of Contents

Discussion


for patients with disturbances in eating or sleeping. Pharmacologictherapy may include drugs, such as antidepressants for depression orerythropoietin for anemia. A few clinical reports of the use ofpsychostimulants suggest the need for further research on theseagents as potential treatment modalities in managing fatigue.

Effective management of CRF involves an informed and supportiveoncology care team that assesses patients’ fatigue levels regularly,

counsels and educates patients regarding strategies for coping withfatigue, and uses institutional experts for referral of patients withunresolved fatigue. 31 The oncology care team must recognize the manypatient-, provider-, and system-related behaviors that can impedeeffective fatigue management. Reducing barriers by use of availableresources and evidence-based guidelines increases benefits to patientsexperiencing fatigue. 201,202

NCCN G id li I dNCCN Guidelines Version 1 2014








Version 1.2014, 01/06/14 © National Comprehensive Cancer Network, Inc. 2014, All rights reserved. The NCCN Guidelines® and this illustr ation may not be reproduced in any for m without the express written permission of NCCN®. MS-20

NCCN Guidelines IndexFatigue Table of Contents

Discussion


AppendixFatigue Measurement

A resource to facilitate selection of instruments to measure fatigue

Ahlberg K, Ekman T, Gaston-Johansson F, Mock V. Assessment and management of cancer-related fatigue inadults. The Lancet 2003;262:640-650.

(This resource provides a detailed description of six scales frequently used in cancer patients to measure fatigue.)Jacobsen PB. Assessment of fatigue in cancer patients. J Natl Cancer Inst Monogr 2004; 32: 93-97.(Includes factors to consider in selecting a fatigue measure.)

Meek PM, Nail LM, Barsevick A, et al. Psychometric testing of fatigue instruments for use with cancer patients. NursRes 2000;49:181-190.(Study evaluates psychometric properties of several commonly used fatigue measures.)

National Cancer Institute. Fatigue (PDQ) Health Professional Version (Accessed November 13, 2013). Available at:http://www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional .(Gives citation links to nine commonly used scales to measure fatigue.)

Oncology Nursing Society. Measuring oncology nursing-sensitive patient outcomes: Fatigue evidence-basedsummary (Accessed November 13, 2013). Available at: http://www.ons.org/Research/PEP/Topics/Fatigue .(Provides two detailed tables summarizing scale descriptions and psychometric properties for 13 scales.)

Reeve BB, Stover AM, Alfano CM, et al. The Piper Fatigue Scale-12 (PFS-12): psychometric findings and itemreduction in a cohort of breast cancer survivors. Breast Cancer Res Treat 2012;136:9-20.(Provides psychometric properties for a shortened version of a commonly used fatigue measure)

Stover AM, Reeve BB, Piper BF, et al. Deriving clinically meaningful cut-scores for fatigue in a cohort of breastcancer survivors: a Health, Eating, Activity, and Lifestyle (HEAL) Study. Qual Life Res 2013.(This resource provides information about clinically meaningful cut-scores for fatigue)

Wu HS, McSweeney M. Measurement of fatigue in people with cancer. Oncol Nurs Forum 2001;28:1371-1384.(Qualitative review of commonly used fatigue measures.)



































http://www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders/HealthProfessional

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108868.htm















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