Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Cancer-related fatigue: Prevalence, screening and clinical assessment

Carmen P Escalante, MD
Section Editor
Paul J Hesketh, MD
Deputy Editor
Sadhna R Vora, MD


Fatigue is a common problem in cancer patients. A majority of patients will experience some level of fatigue during their course of treatment, and approximately one-third will have persistent fatigue for a number of years posttreatment [1,2]. Cancer-related fatigue profoundly affects quality of life (QOL) of both patients and their families, including physical, psychosocial, and economic/occupational aspects [3,4]. Furthermore, fatigue is routinely identified by patients as one of the most distressing symptoms associated with cancer and its treatment, yet fatigue has been consistently underreported and overlooked as a potentially remediable cause of treatment-related morbidity [5]. More recently, screening for and treatment of cancer-related fatigue during therapy and during the period of cancer survivorship has become a major focus of supportive care in oncology and is the subject of guidelines from several expert groups, including the American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) [6-8].

Here we will review the contributory factors and pathogenesis of cancer-related fatigue, and screening for as well as clinical assessment of patients with cancer-related fatigue. Treatment of cancer-related fatigue and issues surrounding fatigue that are specific to palliative care patients are discussed elsewhere. (See "Cancer-related fatigue: Treatment" and "Palliative care: Overview of fatigue, weakness, and asthenia".)


Cancer-related fatigue is defined as a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and that significantly interferes with usual functioning [6]. Cancer-related fatigue differs from the fatigue that accompanies everyday life, which is usually temporary and relieved by rest.

The term asthenia has been proposed to describe the condition of chronic pathologic tiredness in patients with cancer [9]. However, the term fatigue has gained widespread acceptance in the medical literature and is preferentially used in the National Cancer Institute (NCI) toxicity grading scale that covers fatigue, asthenia, and malaise (table 1).

Specific diagnostic criteria have been proposed for defining cancer-related fatigue as an independent entity in the International Classification of Diseases, 10th revision (ICD-10) [10,11]. At least 6 of 11 criteria must be met to make the diagnosis of cancer-related fatigue (table 2). In studies of diverse patient populations, approximately 10 to 26 percent of subjects are diagnosed as having cancer-related fatigue using this definition [12-15].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Nov 18, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Bower JE, Ganz PA, Desmond KA, et al. Fatigue in breast cancer survivors: occurrence, correlates, and impact on quality of life. J Clin Oncol 2000; 18:743.
  2. Servaes P, Verhagen S, Bleijenberg G. Determinants of chronic fatigue in disease-free breast cancer patients: a cross-sectional study. Ann Oncol 2002; 13:589.
  3. Dagnelie PC, Pijls-Johannesma MC, Lambin P, et al. Impact of fatigue on overall quality of life in lung and breast cancer patients selected for high-dose radiotherapy. Ann Oncol 2007; 18:940.
  4. Gupta D, Lis CG, Grutsch JF. The relationship between cancer-related fatigue and patient satisfaction with quality of life in cancer. J Pain Symptom Manage 2007; 34:40.
  5. Stone P, Richardson A, Ream E, et al. Cancer-related fatigue: inevitable, unimportant and untreatable? Results of a multi-centre patient survey. Cancer Fatigue Forum. Ann Oncol 2000; 11:971.
  6. Bower JE, Bak K, Berger A, et al. Screening, assessment, and management of fatigue in adult survivors of cancer: an American Society of Clinical oncology clinical practice guideline adaptation. J Clin Oncol 2014; 32:1840.
  7. Howell D, Keller-Olaman S, Oliver TK, et al. A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue. Curr Oncol 2013; 20:e233.
  8. Mitchell SA, Beck SL, Hood LE, et al. Putting evidence into practice: evidence-based interventions for fatigue during and following cancer and its treatment. Clin J Oncol Nurs 2007; 11:99.
  9. Sobrero A, Puglisi F, Guglielmi A, et al. Fatigue: a main component of anemia symptomatology. Semin Oncol 2001; 28:15.
  10. Cella D, Peterman A, Passik S, et al. Progress toward guidelines for the management of fatigue. Oncology (Williston Park) 1998; 12:369.
  11. International Classification of Diseases, Tenth Revision (ICD-10). www.cdc.gov/nchs/about/major/dvs/icd10des.htm (Accessed on February 28, 2012).
  12. Cella D, Davis K, Breitbart W, et al. Cancer-related fatigue: prevalence of proposed diagnostic criteria in a United States sample of cancer survivors. J Clin Oncol 2001; 19:3385.
  13. Andrykowski MA, Schmidt JE, Salsman JM, et al. Use of a case definition approach to identify cancer-related fatigue in women undergoing adjuvant therapy for breast cancer. J Clin Oncol 2005; 23:6613.
  14. Sadler IJ, Jacobsen PB, Booth-Jones M, et al. Preliminary evaluation of a clinical syndrome approach to assessing cancer-related fatigue. J Pain Symptom Manage 2002; 23:406.
  15. Murphy H, Alexander S, Stone P. Investigation of diagnostic criteria for cancer-related fatigue syndrome in patients with advanced cancer: a feasibility study. Palliat Med 2006; 20:413.
  16. Vogelzang NJ, Breitbart W, Cella D, et al. Patient, caregiver, and oncologist perceptions of cancer-related fatigue: results of a tripart assessment survey. The Fatigue Coalition. Semin Hematol 1997; 34:4.
  17. Curt GA, Breitbart W, Cella D, et al. Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. Oncologist 2000; 5:353.
  18. Stasi R, Abriani L, Beccaglia P, et al. Cancer-related fatigue: evolving concepts in evaluation and treatment. Cancer 2003; 98:1786.
  19. Flechtner H, Bottomley A. Fatigue and quality of life: lessons from the real world. Oncologist 2003; 8 Suppl 1:5.
  20. de Jong N, Courtens AM, Abu-Saad HH, Schouten HC. Fatigue in patients with breast cancer receiving adjuvant chemotherapy: a review of the literature. Cancer Nurs 2002; 25:283.
  21. Morrow GR, Andrews PL, Hickok JT, et al. Fatigue associated with cancer and its treatment. Support Care Cancer 2002; 10:389.
  22. Holzner B, Kemmler G, Meraner V, et al. Fatigue in ovarian carcinoma patients: a neglected issue? Cancer 2003; 97:1564.
  23. Respini D, Jacobsen PB, Thors C, et al. The prevalence and correlates of fatigue in older cancer patients. Crit Rev Oncol Hematol 2003; 47:273.
  24. Wang XS, Giralt SA, Mendoza TR, et al. Clinical factors associated with cancer-related fatigue in patients being treated for leukemia and non-Hodgkin's lymphoma. J Clin Oncol 2002; 20:1319.
  25. Edwards JL, Gibson F, Richardson A, et al. Fatigue in adolescents with and following a cancer diagnosis: developing an evidence base for practice. Eur J Cancer 2003; 39:2671.
  26. Fernandes R, Stone P, Andrews P, et al. Comparison between fatigue, sleep disturbance, and circadian rhythm in cancer inpatients and healthy volunteers: evaluation of diagnostic criteria for cancer-related fatigue. J Pain Symptom Manage 2006; 32:245.
  27. Chang VT, Hwang SS, Feuerman M, Kasimis BS. Symptom and quality of life survey of medical oncology patients at a veterans affairs medical center: a role for symptom assessment. Cancer 2000; 88:1175.
  28. Smets EM, Visser MR, Willems-Groot AF, et al. Fatigue and radiotherapy: (A) experience in patients undergoing treatment. Br J Cancer 1998; 78:899.
  29. Hickok JT, Morrow GR, McDonald S, Bellg AJ. Frequency and correlates of fatigue in lung cancer patients receiving radiation therapy: implications for management. J Pain Symptom Manage 1996; 11:370.
  30. Liavaag AH, Dørum A, Fosså SD, et al. Controlled study of fatigue, quality of life, and somatic and mental morbidity in epithelial ovarian cancer survivors: how lucky are the lucky ones? J Clin Oncol 2007; 25:2049.
  31. Teunissen SC, Wesker W, Kruitwagen C, et al. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage 2007; 34:94.
  32. Stone P, Hardy J, Broadley K, et al. Fatigue in advanced cancer: a prospective controlled cross-sectional study. Br J Cancer 1999; 79:1479.
  33. Eatock MM, Dillon E, Corcoran B, et al. Cancer fatigue in Ireland: All Ireland Fatigue Coalition professional and interim patient survey (abstract). Proc Am Soc Clin Oncol 2003; 22:764a.
  34. Forlenza MJ, Hall P, Lichtenstein P, et al. Epidemiology of cancer-related fatigue in the Swedish twin registry. Cancer 2005; 104:2022.
  35. Janda M, Gerstner N, Obermair A, et al. Quality of life changes during conformal radiation therapy for prostate carcinoma. Cancer 2000; 89:1322.
  36. Greenberg DB, Sawicka J, Eisenthal S, Ross D. Fatigue syndrome due to localized radiation. J Pain Symptom Manage 1992; 7:38.
  37. Geinitz H, Zimmermann FB, Stoll P, et al. Fatigue, serum cytokine levels, and blood cell counts during radiotherapy of patients with breast cancer. Int J Radiat Oncol Biol Phys 2001; 51:691.
  38. Irvine DM, Vincent L, Graydon JE, Bubela N. Fatigue in women with breast cancer receiving radiation therapy. Cancer Nurs 1998; 21:127.
  39. Smets EM, Visser MR, Willems-Groot AF, et al. Fatigue and radiotherapy: (B) experience in patients 9 months following treatment. Br J Cancer 1998; 78:907.
  40. Monga U, Kerrigan AJ, Thornby J, Monga TN. Prospective study of fatigue in localized prostate cancer patients undergoing radiotherapy. Radiat Oncol Investig 1999; 7:178.
  41. Magnan MA, Mood DW. The effects of health state, hemoglobin, global symptom distress, mood disturbance, and treatment site on fatigue onset, duration, and distress in patients receiving radiation therapy. Oncol Nurs Forum 2003; 30:E33.
  42. Servaes P, Verhagen S, Schreuder HW, et al. Fatigue after treatment for malignant and benign bone and soft tissue tumors. J Pain Symptom Manage 2003; 26:1113.
  43. Rüffer JU, Flechtner H, Tralls P, et al. Fatigue in long-term survivors of Hodgkin's lymphoma; a report from the German Hodgkin Lymphoma Study Group (GHSG). Eur J Cancer 2003; 39:2179.
  44. Fosså SD, Dahl AA, Loge JH. Fatigue, anxiety, and depression in long-term survivors of testicular cancer. J Clin Oncol 2003; 21:1249.
  45. Arndt V, Merx H, Stegmaier C, et al. Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer. J Clin Oncol 2005; 23:4945.
  46. Meeske K, Smith AW, Alfano CM, et al. Fatigue in breast cancer survivors two to five years post diagnosis: a HEAL Study report. Qual Life Res 2007; 16:947.
  47. Loge JH, Abrahamsen AF, Ekeberg O, Kaasa S. Hodgkin's disease survivors more fatigued than the general population. J Clin Oncol 1999; 17:253.
  48. Andrykowski MA, Curran SL, Lightner R. Off-treatment fatigue in breast cancer survivors: a controlled comparison. J Behav Med 1998; 21:1.
  49. Hjermstad MJ, Fosså SD, Oldervoll L, et al. Fatigue in long-term Hodgkin's Disease survivors: a follow-up study. J Clin Oncol 2005; 23:6587.
  50. Jacobsen PB, Donovan KA, Small BJ, et al. Fatigue after treatment for early stage breast cancer: a controlled comparison. Cancer 2007; 110:1851.
  51. Braun IM, Greenberg DB, Pirl WF. Evidenced-based report on the occurrence of fatigue in long-term cancer survivors. J Natl Compr Canc Netw 2008; 6:347.
  52. Daniëls LA, Oerlemans S, Krol AD, et al. Chronic fatigue in Hodgkin lymphoma survivors and associations with anxiety, depression and comorbidity. Br J Cancer 2014; 110:868.
  53. Gutstein HB. The biologic basis of fatigue. Cancer 2001; 92:1678.
  54. Lundström S, Fürst CJ. Symptoms in advanced cancer: relationship to endogenous cortisol levels. Palliat Med 2003; 17:503.
  55. Scott HR, McMillan DC, Brown DJ, et al. A prospective study of the impact of weight loss and the systemic inflammatory response on quality of life in patients with inoperable non-small cell lung cancer. Lung Cancer 2003; 40:295.
  56. Cleeland CS, Bennett GJ, Dantzer R, et al. Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. Cancer 2003; 97:2919.
  57. Scott HR, McMillan DC, Forrest LM, et al. The systemic inflammatory response, weight loss, performance status and survival in patients with inoperable non-small cell lung cancer. Br J Cancer 2002; 87:264.
  58. Collado-Hidalgo A, Bower JE, Ganz PA, et al. Inflammatory biomarkers for persistent fatigue in breast cancer survivors. Clin Cancer Res 2006; 12:2759.
  59. Bower JE, Ganz PA, Aziz N, Fahey JL. Fatigue and proinflammatory cytokine activity in breast cancer survivors. Psychosom Med 2002; 64:604.
  60. Bower JE, Ganz PA, Irwin MR, et al. Cytokine genetic variations and fatigue among patients with breast cancer. J Clin Oncol 2013; 31:1656.
  61. Bower JE, Ganz PA, Aziz N, et al. T-cell homeostasis in breast cancer survivors with persistent fatigue. J Natl Cancer Inst 2003; 95:1165.
  62. Parker KP, Bliwise DL, Ribeiro M, et al. Sleep/Wake patterns of individuals with advanced cancer measured by ambulatory polysomnography. J Clin Oncol 2008; 26:2464.
  63. Ancoli-Israel S, Moore PJ, Jones V. The relationship between fatigue and sleep in cancer patients: a review. Eur J Cancer Care (Engl) 2001; 10:245.
  64. Miaskowski C, Lee KA. Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: a pilot study. J Pain Symptom Manage 1999; 17:320.
  65. Roscoe JA, Morrow GR, Hickok JT, et al. Temporal interrelationships among fatigue, circadian rhythm and depression in breast cancer patients undergoing chemotherapy treatment. Support Care Cancer 2002; 10:329.
  66. Savard J, Davidson JR, Ivers H, et al. The association between nocturnal hot flashes and sleep in breast cancer survivors. J Pain Symptom Manage 2004; 27:513.
  67. Levy MR. Cancer fatigue: a neurobiological review for psychiatrists. Psychosomatics 2008; 49:283.
  68. Ryan JL, Carroll JK, Ryan EP, et al. Mechanisms of cancer-related fatigue. Oncologist 2007; 12 Suppl 1:22.
  69. Stone P, Richards M, Hardy J. Fatigue in patients with cancer. Eur J Cancer 1998; 34:1670.
  70. Tchen N, Juffs HG, Downie FP, et al. Cognitive function, fatigue, and menopausal symptoms in women receiving adjuvant chemotherapy for breast cancer. J Clin Oncol 2003; 21:4175.
  71. Fan HG, Houédé-Tchen N, Yi QL, et al. Fatigue, menopausal symptoms, and cognitive function in women after adjuvant chemotherapy for breast cancer: 1- and 2-year follow-up of a prospective controlled study. J Clin Oncol 2005; 23:8025.
  72. Nieboer P, Buijs C, Rodenhuis S, et al. Fatigue and relating factors in high-risk breast cancer patients treated with adjuvant standard or high-dose chemotherapy: a longitudinal study. J Clin Oncol 2005; 23:8296.
  73. Knobel H, Håvard Loge J, Lund MB, et al. Late medical complications and fatigue in Hodgkin's disease survivors. J Clin Oncol 2001; 19:3226.
  74. Kirkwood JM, Bender C, Agarwala S, et al. Mechanisms and management of toxicities associated with high-dose interferon alfa-2b therapy. J Clin Oncol 2002; 20:3703.
  75. Sundin DJ, Wolin MJ. Toxicity management in patients receiving low-dose aldesleukin therapy. Ann Pharmacother 1998; 32:1344.
  76. Malik UR, Makower DF, Wadler S. Interferon-mediated fatigue. Cancer 2001; 92:1664.
  77. Englebienne P, Verhas M, Herst CV, De Meirleir K. Type I interferons induce proteins susceptible to act as thyroid receptor (TR) corepressors and to signal the TR for destruction by the proteasome: possible etiology for unexplained chronic fatigue. Med Hypotheses 2003; 60:175.
  78. Jones TH, Wadler S, Hupart KH. Endocrine-mediated mechanisms of fatigue during treatment with interferon-alpha. Semin Oncol 1998; 25:54.
  79. Atkins MB, Mier JW, Parkinson DR, et al. Hypothyroidism after treatment with interleukin-2 and lymphokine-activated killer cells. N Engl J Med 1988; 318:1557.
  80. Weijl NI, Van der Harst D, Brand A, et al. Hypothyroidism during immunotherapy with interleukin-2 is associated with antithyroid antibodies and response to treatment. J Clin Oncol 1993; 11:1376.
  81. Light KC, Agarwal N, Iacob E, et al. Differing leukocyte gene expression profiles associated with fatigue in patients with prostate cancer versus chronic fatigue syndrome. Psychoneuroendocrinology 2013; 38:2983.
  82. Jim HS, Park JY, Permuth-Wey J, et al. Genetic predictors of fatigue in prostate cancer patients treated with androgen deprivation therapy: preliminary findings. Brain Behav Immun 2012; 26:1030.
  83. Jereczek-Fossa BA, Marsiglia HR, Orecchia R. Radiotherapy-related fatigue. Crit Rev Oncol Hematol 2002; 41:317.
  84. Brown P, Clark MM, Atherton P, et al. Will improvement in quality of life (QOL) impact fatigue in patients receiving radiation therapy for advanced cancer? Am J Clin Oncol 2006; 29:52.
  85. Hickok JT, Morrow GR, Roscoe JA, et al. Occurrence, severity, and longitudinal course of twelve common symptoms in 1129 consecutive patients during radiotherapy for cancer. J Pain Symptom Manage 2005; 30:433.
  86. Ahlberg K, Ekman T, Gaston-Johansson F. Levels of fatigue compared to levels of cytokines and hemoglobin during pelvic radiotherapy: a pilot study. Biol Res Nurs 2004; 5:203.
  87. Wang XS, Janjan NA, Guo H, et al. Fatigue during preoperative chemoradiation for resectable rectal cancer. Cancer 2001; 92:1725.
  88. Jereczek-Fossa BA, Santoro L, Alterio D, et al. Fatigue during head-and-neck radiotherapy: prospective study on 117 consecutive patients. Int J Radiat Oncol Biol Phys 2007; 68:403.
  89. Monga U, Jaweed M, Kerrigan AJ, et al. Neuromuscular fatigue in prostate cancer patients undergoing radiation therapy. Arch Phys Med Rehabil 1997; 78:961.
  90. Yellen SB, Cella DF, Webster K, et al. Measuring fatigue and other anemia-related symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage 1997; 13:63.
  91. Cella D. The Functional Assessment of Cancer Therapy-Anemia (FACT-An) Scale: a new tool for the assessment of outcomes in cancer anemia and fatigue. Semin Hematol 1997; 34:13.
  92. Gabrilove JL, Cleeland CS, Livingston RB, et al. Clinical evaluation of once-weekly dosing of epoetin alfa in chemotherapy patients: improvements in hemoglobin and quality of life are similar to three-times-weekly dosing. J Clin Oncol 2001; 19:2875.
  93. Vansteenkiste J, Pirker R, Massuti B, et al. Double-blind, placebo-controlled, randomized phase III trial of darbepoetin alfa in lung cancer patients receiving chemotherapy. J Natl Cancer Inst 2002; 94:1211.
  94. Cella D, Zagari MJ, Vandoros C, et al. Epoetin alfa treatment results in clinically significant improvements in quality of life in anemic cancer patients when referenced to the general population. J Clin Oncol 2003; 21:366.
  95. Escalante CP, Grover T, Johnson BA, et al. A fatigue clinic in a comprehensive cancer center: design and experiences. Cancer 2001; 92:1708.
  96. Jacobsen PB, Hann DM, Azzarello LM, et al. Fatigue in women receiving adjuvant chemotherapy for breast cancer: characteristics, course, and correlates. J Pain Symptom Manage 1999; 18:233.
  97. Dodd MJ, Miaskowski C, Paul SM. Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum 2001; 28:465.
  98. Romito F, Montanaro R, Corvasce C, et al. Is cancer-related fatigue more strongly correlated to haematological or to psychological factors in cancer patients? Support Care Cancer 2008; 16:943.
  99. Goldstein D, Bennett B, Friedlander M, et al. Fatigue states after cancer treatment occur both in association with, and independent of, mood disorder: a longitudinal study. BMC Cancer 2006; 6:240.
  100. Broeckel JA, Jacobsen PB, Horton J, et al. Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol 1998; 16:1689.
  101. Ahlberg K, Ekman T, Wallgren A, Gaston-Johansson F. Fatigue, psychological distress, coping and quality of life in patients with uterine cancer. J Adv Nurs 2004; 45:205.
  102. Tchekmedyian NS, Kallich J, McDermott A, et al. The relationship between psychologic distress and cancer-related fatigue. Cancer 2003; 98:198.
  103. Haghighat S, Akbari ME, Holakouei K, et al. Factors predicting fatigue in breast cancer patients. Support Care Cancer 2003; 11:533.
  104. Hwang SS, Chang VT, Rue M, Kasimis B. Multidimensional independent predictors of cancer-related fatigue. J Pain Symptom Manage 2003; 26:604.
  105. Jacobsen PB, Donovan KA, Weitzner MA. Distinguishing fatigue and depression in patients with cancer. Semin Clin Neuropsychiatry 2003; 8:229.
  106. Passik SD, Dugan W, McDonald MV, et al. Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 1998; 16:1594.
  107. Visser MR, Smets EM. Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer 1998; 6:101.
  108. Morrow GR, Jean-Pierre P, Roscoe JA, et al. A phase III randomized, placebo-controlled, double-blind trial of a eugeroic agent in 642 cancer patients reporting fatigue during chemotherapy: a URCC CCOP study (abstract). J Clin Oncol 2008; 26:504s.
  109. Mystakidou K, Parpa E, Tsilika E, et al. The relationship of subjective sleep quality, pain, and quality of life in advanced cancer patients. Sleep 2007; 30:737.
  110. Silberfarb PM, Hauri PJ, Oxman TE, Schnurr P. Assessment of sleep in patients with lung cancer and breast cancer. J Clin Oncol 1993; 11:997.
  111. Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 2001; 19:895.
  112. Savard J, Simard S, Blanchet J, et al. Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep 2001; 24:583.
  113. Savard J, Simard S, Hervouet S, et al. Insomnia in men treated with radical prostatectomy for prostate cancer. Psychooncology 2005; 14:147.
  114. Savard J, Villa J, Ivers H, et al. Prevalence, natural course, and risk factors of insomnia comorbid with cancer over a 2-month period. J Clin Oncol 2009; 27:5233.
  115. Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol 2010; 28:292.
  116. Otte JL, Carpenter JS, Russell KM, et al. Prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors. J Pain Symptom Manage 2010; 39:535.
  117. Mendoza TR, Wang XS, Cleeland CS, et al. The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory. Cancer 1999; 85:1186.
  118. Wu HS, McSweeney M. Assessing fatigue in persons with cancer: an instrument development and testing study. Cancer 2004; 101:1685.
  119. Alexander S, Minton O, Stone PC. Evaluation of screening instruments for cancer-related fatigue syndrome in breast cancer survivors. J Clin Oncol 2009; 27:1197.
  120. Chalder T, Berelowitz G, Pawlikowska T, et al. Development of a fatigue scale. J Psychosom Res 1993; 37:147.
  121. Stein KD, Jacobsen PB, Blanchard CM, Thors C. Further validation of the multidimensional fatigue symptom inventory-short form. J Pain Symptom Manage 2004; 27:14.
  122. Minton O, Stone P. A systematic review of the scales used for the measurement of cancer-related fatigue (CRF). Ann Oncol 2009; 20:17.
  123. Passik SD, Kirsh KL, Donaghy K, et al. Patient-related barriers to fatigue communication: initial validation of the fatigue management barriers questionnaire. J Pain Symptom Manage 2002; 24:481.
  124. Patrick DL, Ferketich SL, Frame PS, et al. National Institutes of Health State-of-the-Science Conference Statement: Symptom Management in Cancer: Pain, Depression, and Fatigue, July 15-17, 2002. J Natl Cancer Inst 2003; 95:1110.
  125. Wang XS, Zhao F, Fisch MJ, et al. Prevalence and characteristics of moderate to severe fatigue: a multicenter study in cancer patients and survivors. Cancer 2014; 120:425.