Have cancer? Tired all the time? You are not alone.

Other than pain, nothing else would bother my patients as much as fatigue. Sure, chemotherapy and radiation took the starch out of them, but even without treatment at least half of people with cancer will be tired all the time. They feel better in the morning, but as the day wears down, so do the patients. Of course chemotherapy or radiation therapy add to the fatigue, and, even if these treatments are curative, many people will continue to complain of fatigue. I remember a young man with Hodgkin disease who even after many years, never got over it, even though he was cured. One study found that after, 5 years one-third of patients still felt washed out.

All this was discussed in an recent article published in the Annals of Oncology (22: 1273–1279, 2011). After discussing the problem, the authors reviewed all the literature on how to treat this problem. The problem is no one knows what causes the fatigue. There are probably many reasons such as activation of the immune system, inflammation, stress, hormone changes, anemia sometimes, thyroid problems rarely, and perhaps most commonly, depression. But, who knows if the depression is a cause or effect? And, as you can imagine, effective treatment is hard to come by.

The authors talked about therapies that have been tried with some success. Number one on their list was psychotherapy. I’m not sure whether its benefit is that it reduces the fatigue or it helps patients cope. Exercise, a favorite of mine, also helps. Although this may seem counter intuitive because exercise makes you tired, it may help by improving physical condition so that everyday tasks are easier.

Then there are drugs – always favored by docs and patients. Perhaps at one time I mentioned Ritalin as a useful drug for fatigue. That is because many years ago, I was struck by a short, very personal article by a pediatrician with lung cancer. Ritalin restored him from a zombie state to normal. And, studies have shown that this drug, a stimulant like amphetamine, along with all its chemical cousins can help some people. Another drug is modafinil, which works like these other stimulants.

Finally, there is the drug I love to hate, the red blood cell stimulating hormone, Epo or Epoietin or Erythropoietin. Good for bicyclists - gets them up the hills because they have more red blood cells and thus can deliver more oxygen to their over stressed muscles. But for taking out the garbage – not needed. Yes, if you are very anemic because of cancer or chemotherapy, then it is worthwhile to make more red blood cells. But once you reach a level of hemoglobin of 10 or hematocrit of 30 (about 80 percent of normal), that is enough. More red blood cells will not reduce your fatigue and may cause problems with blood clots – already a big problem for cancer patients – just made worse by the Epo.

So exercise, talk to someone about your fatigue and perhaps depression, try a stimulant if you want, and hope for the best. Good luck!.