Cancer-related fatigue (CRF) in children and teens

Fatigue is very common in patients with blood cancers. Cancer-related fatigue (CRF) is characterized by excessive and persistent exhaustion that interferes with daily activity. CRF often begins before cancer is diagnosed, worsens during the course of treatment and may persist for months—even years—after treatment ends. 

Unlike the fatigue that healthy people experience from time to time, CRF is more severe, often described as an overwhelming exhaustion that cannot be overcome with rest or a good night’s sleep. Some people also have muscle weakness or difficulty concentrating. Many patients with blood cancers find CRF more distressing and disabling than other disease-related or treatment-related symptoms such as pain, depression or nausea.

It is important for patients to talk with their doctors, nurses and other members of their healthcare team if they experience signs of fatigue before, during, or after treatment. Treatment, along with lifestyle changes, can make an important difference and help improve energy level.

Signs and symptoms of CRF

Patients should discuss their signs and/or symptoms with their doctor or nurse. A patient may have:

• Difficulty climbing stairs or walking short distances
• Muscle weakness
• Shortness of breath
• Weight gain or loss
• Intolerance to cold
• Anemia or low thyroid function test results
• Skin dryness or hair loss
• Sleep problems

Fatigue can also be reflected in mood and thinking, such as:

• Depressed and/or anxious mood
• Lack of motivation
• Negative thinking
• Irritability
• Inability to concentrate
• Loss of memory or mental alertness
• Withdrawal from activities the person once enjoyed
• Unusual strain in relationships

Causes of CRF

Fatigue typically has more than one cause. Fatigue is a common symptom of some types of blood cancer. When cancer patients begin treatment, many are already tired from undergoing medical tests, surgery and the emotional stresses of dealing with a cancer diagnosis. After treatment begins, fatigue may become worse. Cancer treatments almost always affects a patient’s energy level and cause fatigue. CRF typically declines in the months following treatment, but sometimes it is an ongoing problem after treatment has finished.

Contributing factors

There are several factors that make cancer patients more likely to experience CRF. Many of these factors can be treated or addressed:

• Low number of red blood cells (anemia)
• Poor nutrition
• Less activity
• Difficulty sleeping
• Anxiety, stress or depression
• Financial concerns
• Pain
• Hypothyroidism (when the thyroid does not produce enough hormones)
• Other health issues, such as sleep apnea

Assessing CRF

Fatigue can be difficult to assess because there are no objective measurements. The first step in assessing CRF is to identify and address any underlying physical problems. These underlying issues may be anemia, infection or treatment side effects that could be causing fatigue. While there are no lab tests that screen for CRF, your doctor or nurse practitioner may decide to order one or more of the following tests to help identify potential causes:

• Complete blood count (CBC)
• Peripheral blood smear
• Serum iron level
• Transferrin level (protein that transports iron throughout the body)
• Total iron-binding capacity (TiBC)
• Ferritin level (protein in cells that stores iron)
• Folate level (also known as folic acid or Vitamin B₉)
• Vitamin B₁₂ level
• Erythropoietin level (a hormone that increases the number of red blood cells)
• Thyroid function
• Adrenocorticotropic hormone (ACTH) level (also known as cosyntropin stimulation test)

Learn more about blood tests. 

Your healthcare team may use a variety of other methods to assess CRF, including tools that take into account the your description of fatigue severity and its effects on your daily living.

Good communication between patients and their healthcare team is key. fatigue. Tell your doctor or nurse if the fatigue is:

• Worse at certain times of day
• Associated with certain cancer therapies
• Worse during or after certain activities
• Better during or after certain activities

Your sleep patterns and any past treatments for fatigue are also useful information to share with your healthcare team.

Treatments for CRF

Fatigue is often caused by more than one problem. Addressing the problems that contribute to fatigue can improve quality of life. 

• Treatment of anemia: Supportive care for anemia may include:
  • Eating more foods rich in iron and taking vitamins
  • Blood transfusions
  • Erythropoiesis-stimulating agents (ESAs) which stimulate the body to produce more red blood cells. Epoetin alfa (Epogen®, Procrit®) and darbepoetin alfa (Aranesp®) are examples of ESAs given by injection to treat chemotherapy-induced anemia.
• Exercise: A growing body of evidence suggests that physical activities (such as walking, riding a stationary bicycle, yoga, tai chi, swimming or water exercises, and strength training) lessen fatigue and increase energy. Before starting an exercise program, talk to your doctor. Ask for a referral to a physical therapist for an evaluation and an exercise plan, if needed.
• Treatment of pain: Pain does not need to be accepted as part of cancer treatment. Patients are encouraged to speak with members of their healthcare team about treating pain. If pain is making fatigue worse, the cancer medication may be changed, or the dosage increased. If too much pain medication is causing too much fatigue, the medication may be changed, or the dosage adjusted.
• Treatment of depression: There are many ways to treat depression including medication, counseling or a combination of both. Support groups and stress management may also help patients deal with the fatigue.
• Psychosocial interventions: Studies suggest that interventions which reduce stress and increase psychosocial support (counseling, stress management, coping strategies) can help reduce fatigue and increase energy levels
• Mindfulness-based interventions: Patients practice self-awareness of thoughts, feelings and sensations in the present moment. Other interventions may involve meditation, stress reduction, art therapy or gentle exercise
• Nutritional counseling: A registered dietitian can work with patients to ensure that they are getting sufficient calories, fluids, and nutrients.
  • Patients and caregivers can receive free nutrition education and consultations with an LLS registered dietitian. Click here to learn more.
• Clinical trials: Ask your healthcare team about participating in studies to treat CRF. 

Get free clinical trial support! Visit our Clinical Trial Support Center (CTSC).

Connect with registered nurses with expertise in blood cancers who can personally assist you or your caregiver through each step of the clinical trial process. 

​Take care of yourself

Here are some suggestions that may help patients with CRF improve their own well-being.

• Be flexible. Do not measure yourself by pre-diagnosis energy levels. Set realistic goals. You may not be able to accomplish everything that you want to do every single day. Decide which tasks are most important for you to complete and focus on accomplishing those goals. When you are feeling fatigued, let others help you.
• Distract yourself. Allow yourself to shift your focus from fatigue by listening to music, reading a book, looking at pictures, meeting friends, watching a movie, going for a walk or enjoying time outside.
• Stay Active. Staying physically active may help ease fatigue. Before starting an exercise program, talk to your doctor. Focus on activities that will help you gradually build strength but that do not deplete your energy level. Light exercise, such as walking, can also help you relax and sleep better.
• Practice good nutrition. Patients with cancer are at risk for malnutrition. It is important for patients to eat a balanced diet that provides sufficient fluid, calories, protein, vitamins and minerals.
  • Drink plenty of noncaffeinated liquids throughout the day.
  • Add iron-rich foods such as green leafy vegetables and red meat.
  • Eat frequent small meals or snacks throughout the day.
  • You may find it useful to work with a registered dietitian to create a plan to meet your needs and to learn about easy-to-prepare, healthy meals and snacks.
  • See Food and Nutrition and view LL's free Nutrition Handbook.
• Manage stress. Stress can increase fatigue and interfere with sleep. View LLS's free booklet Managing Stress: How Stress Affects You and Ways to Cope.
• Address sleep habits. The following suggestions may help improve sleep quality:
  • Engage in relaxing activities before bedtime, such as taking a warm bath or shower, reading, writing in a journal, yoga, meditation or listening to calming music.
  • Go to bed at the same time every night.
  • Use the bedroom for sleep only.
  • Keep the bedroom cool, quiet and dark.
  • Use comfortable bedding and sleepwear.
  • Avoid caffeine, alcohol or high-sugar foods before bedtime.
  • Avoid video game playing, television, computer, cell phone use and social media use before bed and overnight.
  • Forego daytime naps that may interfere with nighttime sleep. If you need to nap, do not sleep for longer than 30 minutes.
• Ask for help. Ask for help with tasks such as shopping, cooking, housekeeping, laundry or driving.
• Plan ahead. If possible, schedule cancer treatments for those times that will have the least effect on your job or other activities. For example, if you work, schedule treatments in the afternoon or at the end of the week so you can be the most productive at your job.
• Keep a fatigue journal. Keep track of your experiences of fatigue. Take notes regarding when your fatigue occurs, how long it lasts and how it interferes with your daily activities. Share your notes with your doctor.

Related Links

• Listen to our podcast episode, Cancer-Related Fatigue: Syndrome Not Symptom