ALLEVIATE PAIN
Much of the cancer literature has focused on using opiates to control cancer-related pain. However, many survivors who have no evidence of cancer continue to have pain that's usually musculoskeletally based. The first order of business in a cancer survivor who has pain is to evaluate the origin of the pain, ruling out malignancy.

Musculoskeletal pain treatment options are extensive, and much of the decision making depends on the specific diagnosis. For example, conservative management may include medications (anti-inflammatories, muscle relaxants, antidepressants, antiseizure drugs). Physical or occupational therapy can be beneficial as well. Injections and surgery are also sometimes recommended, depending on the specific problem.

The majority of musculoskeletal pain diagnoses in cancer survivors can be treated effectively without opiates. When it comes to pain management, reassuring the patient that this isn't cancer can be extremely therapeutic.

LESSEN FATIGUE
Approximately two out of three cancer survivors have symptoms of significant fatigue that limit recovery and daily functional activities. Interestingly, patients and caregivers often have different perceptions about fatigue. Caregivers underestimate the incidence, severity and impact on quality of life.

Patients, on the other hand, frequently report that fatigue is a more debilitating symptom than pain, often citing it as a major life concern. However, patients underreport fatigue to their health care providers, either by not mentioning it or not clearly explaining the impact fatigue has on their ability to function.

Fatigue in cancer survivors is unique. The International Classification of Disease-10 (ICD-10) defines cancer-related fatigue as "significant fatigue, diminished energy or increased need to rest, disproportionate to any recent change in activity level."⁹ This type of fatigue is often described as an overwhelming tiredness that isn't relieved with rest.

The National Comprehensive Cancer Care Network lists seven factors that are likely to contribute to fatigue in cancer patients. These are pain, emotional distress, sleep disturbance, anemia, nutrition, activity level and other medical problems. The tumor itself also may be a factor. In many patients, their fatigue likely is due to a combination of factors rather than a single entity.

The first step in treating fatigue is to ask questions about it during an office visit. This will help guide an appropriate work-up. Finally, encourage survivors to exercise, since this can markedly reduce post-treatment fatigue.

In a study of people who were chronically fatigued and, on average, at least 3 years out from a hematopoietic stem cell transplantation, a 12-week exercise program significantly improved fatigue levels.9 In this study, the patients were assessed for fatigue, before beginning to exercise and at 3-, 6-, 9- and 12-month intervals. Patients reported significantly less fatigue and an improved ability to function. Physiologic parameters that were measured, including stroke volume and oxygen uptake, also significantly improved.

HELP THEM HEAL
In an office visit, where time is limited, three quick methods can help cancer survivors physically heal. First, encourage them to exercise and get started by using a pedometer to track their steps. Second, reassure them that their pain is unrelated to a malignancy (assuming that this is the case and that a thorough investigation has been done) and prescribe appropriate treatment if necessary. Third, ask about fatigue. If fatigue is interfering with a survivor's ability to exercise, then suggest increasing physical activity in the morning.

Depression and fatigue may exist concurrently. If so, treat the depression to see if the fatigue improves. Review the importance of diet as it relates to fatigue, and tell patients not to skip meals. You may need to address undiagnosed sleep apnea or other problems.

Although much more can be done to help cancer survivors, this is a good place to start for providers and patients.

References
1. French, M. A Season in Hell. New York : Ballantine. 2000;60.
2. Committee on Cancer Survivorship: Improving Care and Quality of Life, Institute of Medicine and National Research Council. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, D.C. : National Academies Press. 2006.
3. Inoue H, et al. Quality of life after neck dissection. Arch Otolaryngol Head Neck Surg. 2006;132:662-666.
4. King PM, et al. The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Disease.  2005;8:506-513.
5. Halar EM, et al. Contracture and other deleterious effects of immobility. In: J.A. DeLisa, ed., Rehabilitation Medicine: Principles and Practice, Second Edition. Philadelphia : J.B. Lippincott Company. 1993;681-699.
6. Holmes MD, et al. Physical activity and survival after breast cancer diagnosis. Paper presented at the annual meeting of the American Association for Cancer Research, Orlando, Fla. , March 2004.
7. Meyerhardt JA, et al. Impact of physical activity on cancer recurrence and survival in patients with stage III colon cancer: findings from CALGB 89803. J Clin Oncol. 2006;24:3535-3541.
8. International Classification of Disease-10 (ICD-10). Albany, N.Y. : World Health Organization. 2003.
9. Carlson LE, et al. Individualized exercise program for the treatment of severe fatigue in patients after allogeneic hematopoietic stem-cell transplant: a pilot study. Bone Marrow Transplant. 2006;37:945-954.

Julie Silver, MD, is an assistant professor at Harvard Medical School, Boston, in the department of physical medicine and rehabilitation.