Empower the Patient | Fatigue and Anemia Due to Chemotherapy

Pullquote: understanding fatigue due to cancer

The side effects of cancer treatment can range. Sometimes, they can feel overwhelming. This section provides an overview of fatigue, one of the most common and debilitating side effects of cancer treatment. We will also talk about chemotherapy-induced anemia, one cause of fatigue.

Pullquote: The most disruptive symptom to everyday life.

Pullquote: The most disruptive symptom to everyday life.

About 60% to 90% of those who undergo cancer treatments experience fatigue. Many do not discuss it with their healthcare team. Some think fatigue is simply part of the experience of having cancer or cancer treatment. However, fatigue that occurs during cancer treatment can be caused by anemia and anemia can be treated.

If you are undergoing chemotherapy and you find you tire very easily, don't feel rested after a good night's sleep, or have shortness of breath, these can be indicators that you have chemotherapy-related anemia. Below you will find more detailed information on both Fatigue and Anemia due to chemotherapy.


The chronic fatigue caused by cancer treatment is very different from the acute fatigue many people feel from time to time when they overdo it or are short of sleep. Acute fatigue is relieved by a good night's sleep. Chronic fatigue is not. Chronic fatigue can affect how you feel physically, as well as your ability to concentrate and make decisions. Cancer patients have reported that it is one of the most difficult side effects of cancer and cancer treatment they face. For example, in a survey conducted by the Fatigue Coalition, 28% of people with cancer reported they had stopped working entirely because of fatigue. Fatigue is hard to measure and can even be hard to describe or articulate. However it can have a major effect on how you feel and whether you can continue with your daily activities and the things that give you pleasure. It can even affect your cancer treatment. Unfortunately, many people with fatigue don’t take their condition seriously, think it is “just part” of being a cancer patient, or assume there is no treatment. The truth is that fatigue — especially drastic or progressive changes in energy level — should be brought to the attention of your doctor or other members of your healthcare team. There may be things that you, or they, can do to help you feel better and to reduce the impact of fatigue upon your life and your cancer treatment.

Canadian Survey of Cancer Patients: chart of symptoms

There is no medical test to diagnose fatigue, however you and your doctor can use the assessment tool below to help track your fatigue level. Use the scale below to track your fatigue level on a daily basis.

Click here to view and print your own fatigue diary.

Why Does Cancer Cause Fatigue?

There are many reasons why cancer may cause fatigue. It may be caused by: Pullquote: The body uses energy to repair tissue.

the disease itself;
cancer treatments;
co-occurring disorders such as anemia, malnutrition, hypothyroidism (under-functioning of the thyroid gland) or renal dysfunction (kidney disease);
chronic pain;
emotional distress;
lifestyle factors such as lack of exercise or a poor diet.

A major European study found that the incidence of anemia can vary between different types of cancer. The following chart summarizes these findings. The percentage refers to that percentage of the study population who were anemic at least once in the 6 months during the survey.

Type of cancer and incidence of anemia (Hg <= 120 g/L)	%
Cancer of the blood (e.g. lymphoma, myeloma)	73
Breast	62
Colorectal	61
Lung	77
Gynecological	81

Dealing With Fatigue
Fatigue can drain your energy and keep you from doing the things you like to do. It is a very real, medical problem and is not “all in the mind.” But sometimes family, friends, and partners may not understand the effects of fatigue. They may misinterpret it as a lack of interest in certain activities or a desire to be alone. To deal with fatigue, you need to continue to exercise, eat well and rest. People often say they can’t exercise because they feel fatigued. This creates a negative cycle. You are fatigued because of a lack of exercise, and then you don’t exercise because of the fatigue. If this is your problem, motivating yourself to do a little exercise next time you are fatigued may be the answer. You don’t have to run a marathon; just go outdoors and take a short walk. If this is not possible, then walk around your house. Some people experience a decreased interest in food, leading to subsequent weight loss. Other people may not absorb food well because of gastrointestinal (GI) tract problems. Food is your basic source of energy and, as always, a poor diet won't provide the energy you need to fight the cancer. If you are having trouble falling asleep or staying asleep, then it is likely that your body is not getting the rest it needs. This can lead to fatigue. Talk with your healthcare team about strategies for helping you to get better quality sleep. If emotions are causing your fatigue, rest will not help; in fact, it may make you feel worse. Fatigue is often a sign of depression, so it is important to deal with the depression. The same is true for stress, which can also cause fatigue.


	What Is Anemia? Anemia occurs when your body does not have enough red blood cells. When the level of oxygen in your body falls too low, the kidneys receive a signal to make more of a hormone called erythropoietin. The erythropoietin travels from the kidneys to the bone marrow, where blood cells are made. The bone marrow releases early stage “immature” red blood cells (called erythroid progenitor cells) into the blood system. To develop these into functioning red blood cells, the body also needs supplies of iron, folate (folic acid) and vitamins C and B12. Iron is needed because red blood cells contain hemoglobin, an iron-rich substance that enables them to absorb, transport and release oxygen. Vitamin B12 and folate acid are needed because they are the “building blocks” of red blood cells. Vitamin C is important because it helps you to absorb iron. A lack of any of these “building blocks” can result in anemia.
Click here to Know Your Red Blood Cells

How Do You Know If You Have Anemia?
You may have anemia if you experience:
	feeling very weak or tired (fatigue); feeling confused or having trouble concentrating; feeling short of breath after even mild exertion; having chest or leg pains; getting headaches; feeling dizzy or faint; having trouble sleeping; feeling bored, drowsy or losing interest in things.
Laboratory tests can be conducted to determine the cause of fatigue including a complete blood count, transferrin, total iron-binding capacity, ferritin, iron levels, folic acid, B12 level, and a thyroid function test. Testing the blood for the level of hemoglobin requires only a couple of minutes and a small amount of blood. Normal levels of hemoglobin are 140-180 grams per liter of blood (g/L) for men and 120-160 g/L for women. Another common blood test is the hematocrit – the portion of your blood that is made up of red cells. A healthy or normal hematocrit value is between 37% to 47% for women and 40% to 52% for men. If your hematocrit is below 35% (for women) or 40% (for men) this indicates you probably have too few red blood cells. When you are undergoing chemotherapy, you will probably have a number of blood and other tests conducted regularly. Be sure to discuss the results of your tests with your physician or healthcare team.

Why Does Cancer Cause Anemia?
Cancer or cancer treatment can lead to anemia by causing blood loss or disrupting normal red blood cell production. Some cancers, such as colorectal cancer, can cause internal bleeding. Even a small amount of regular blood loss is enough to cause anemia. Other types of cancer may keep your body from producing enough red blood cells. For example: If the cancer grows in the bone marrow, there may not be enough space for red blood cell production. Cancer or some cancer treatments may cause your body to slow its production of red blood cells. Cancer or treatment may affect your ability to eat a healthy diet or to absorb nutrients from the foods you eat, contributing to iron, folate or vitamin C or B12 deficiencies (nutrients needed for red blood cell productions). Some cancers may keep immature red blood cells from developing into fully functioning oxygen-carrying red blood cells. Some cancers or cancer treatments may speed up the destruction of red blood cells. If the kidneys are not functioning normally (renal disease), they may not be able to secrete enough of the hormone, erythropoietin. Anemia may result from other diseases or problems such as hypothyroidism or malnutrition.

Treatments for Anemia Caused by Chemotherapy
The best treatment for anemia depends upon its cause. Your healthcare team will help determine which option makes sense for you. Options include diet modifications, nutritional supplements, blood transfusions or Erythropoiesis-Stimulating Agents (ESAs) medications.
1. Diet
Your body requires a nutritional, balanced diet rich in iron, vitamins C and B12, and folic acid (folate) to help your body produce hemoglobin. Iron-rich foods include red meat, poultry, fish, clams, oysters, dark green leafy vegetables, whole grains, and iron-fortified breads and cereals. Good sources of B12 are poultry, beef, milk, cheese, eggs, clams, crabs, shrimp, salmon, sardines, B12-fortified cereals and soy beverages. Folic acid is found in meat, fish, grains, vegetables, and fruit. You may be doing everything right and eating a well-balanced diet, but cancer can impede absorption of the nutrients from your food and, therefore, affect your hemoglobin. Nausea and vomiting can also interfere with your intake and absorption of vitamins. If these factors are involved, you may require iron and vitamin supplements. Talk with your doctor or a registered dietician.

2. Supplements

You can compensate for a lack of nutrients with iron, vitamin B12, folic acid and vitamin C supplements. Be sure to speak with your doctor and/or pharmacist before starting to take any vitamin, supplement or herbal therapy. Some over-the-counter herbal or vitamin supplements can interact with some cancer medications. Excessive amounts of iron can even be harmful, as it can collect in organs such as the liver and heart.

Pullquote: Your doctor may prescribe vitamin supplements.

Pullquote: Your doctor may prescribe vitamin supplements.

Iron and Vitamin C
Your physician will be able to determine your iron levels with a blood test. If you have an iron deficiency, the physician may prescribe iron supplements and vitamin C for you. Vitamin C will make it easier to absorb the iron. It is important to carefully follow the instructions to ensure that the iron is absorbed properly.

When you take an iron supplement, you may experience constipation or digestive problems and your stools may become black. Taking the supplement in divided doses and with food may help to limit these symptoms. If you have problems, talk to your doctor and pharmacist. Your doctor may be able to prescribe medication to reduce these effects.

Vitamin B12
Vitamin B12 plays an important role in the production of red blood cells because it is needed for the synthesis of DNA during cell division. The body requires a minimal amount of B12 that is typically met by a balanced diet. However, people with cancer often trouble absorbing nutrients and that can cause a vitamin B12 deficiency. After checking your levels with a blood test, your physician may feel that a prescription for this vitamin is necessary. It is generally administered by injection.

3. Blood Transfusions

If your hemoglobin level drops too low to be treated by diet or medication, a blood transfusion may be required. A blood transfusion means receiving blood products from a volunteer donor. A transfusion will quickly increase your hemoglobin level and thus the amount of oxygen in your body. Red blood cells have a life span of 120 days, so your hemoglobin will be monitored after a transfusion. Additional transfusions may be required in the future.

Pullquote: How can my anemia be treated?

Pullquote: How can my anemia be treated?

Several years ago, the Commission of Inquiry on the Blood System in Canada, presided over by Justice Krever, made several recommendations regarding informed consent, blood transfusions and alternatives.

As with any medical treatment, when your doctor recommends a blood transfusion you have the right to be informed of the risks and benefits of both accepting and refusing treatment, as well all other alternatives available to you and their risks and benefits. You have the right to ask questions and have sufficient time for the information to be understood.

In some cases, side effects can occur after a transfusion of blood products such as infection, immediate transfusion reaction, graft-versus host disease and changes in immunity. Your doctor can prescribe medication to treat them. Some people experience reactions to the transfusions such as fever, redness and itching, increase or drop in blood pressure.

Blood is a scarce and precious resource. The Canadian Blood Services recommends that when possible, anemia should be treated with iron, vitamin B12, folic acid or medications. If the patient cannot wait for other medications to act or these medications are counter indicated or do not provide the required result, red blood cell transfusion is the preferred option.

4. Erythropoiesis-Stimulating Agents (ESAs)
ESAs such as EPREX® and Aranesp® are proteins made in the laboratory that act like the hormone erythropoietin to affect the production of red blood cells. ESAs are used to treat chemotherapy related anemia in non-myeloid malignancies where anemia is due to the effects of concomitantly administered chemotherapy. It is not being given to replace any treatment you may be receiving for your cancer. In patients receiving radiotherapy alone ESAs are not appropriate. Side effects of ESAs can include an increase in blood pressure, flu-like symptoms, skin rashes, diarrhea, headache, bone pain, or tenderness at the site of the injection. It may increase the risk of serious cardiovascular events. As with any medical treatment you may receive you have the right to be informed of the risks and benefits of both accepting and refusing treatment, as well all other alternatives available to you and their risks and benefits. You have the right to ask questions and have sufficient time for the information to be understood. Click here to go to Know Your Red Blood Cells to learn more about the red blood cell production cycle. If you want to reduce your chances of requiring blood transfusions because of low hemoglobin, it is important that your doctor monitor your red blood cells, including your hemoglobin. There is a limited window in which your anemia can be treated by nutritional supplements or medication rather than by transfusion. If your hemoglobin drops too low, you may require a transfusion. Coverage of ESAs varies by insurance companies and by province. Click here to go to Taking Action to read more about access to medications. It will help you determine if the cost of ESA treatment will be covered. EPREX® (epoetin alfa) is a registered trademark of Ortho Biotech, a division of Janssen-Ortho Inc. Aranesp® (darbepoetin alfa) is a registered trademark of Amgen Inc.

To view a printable version of this information, click here.