A Pan-Canadian Practice Guideline and Algorithm: Screening, Assessment, and Supportive Care of Adults with Cancer-Related Fatigue
Open accessAbstract
Purpose: The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (CRF) in adults. Methods: The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of CRF. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Library, and other guideline and data sources to December 2009. Results: Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process. Conclusions: Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.
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Recommended interventions by NCCN, ONS, etc. include management of concurrent symptoms, physical activity/exercise, rehabilitation, psychoeducation, meditation, attention-based stress reduction, cognitive-behavioral stress management, relaxation, CBT for fatigue, depression and pain, CBT for sleep, and yoga.
“Recommended interventions by the National Comprehensive Cancer Network (NCCN 2015), the Oncology Nursing Society (ONS 2014), the Canadian Partnership Against Cancer/Canadian Association of Psychosocial Oncology [28], and the identified American Society of Clinical Oncology include the management of concurrent symptoms, physical activity/exercise, rehabilitation, psychoeducation, meditation, attent”
From Empowerment in the treatment of fatigue in breast cancer patients (2021) · cites this paper as [28]
The Discussion (section 6; page not specified) recommends addressing contributing symptoms, exercise, rehabilitation, CBT, stress management, relaxation, and attention-restoring therapy. Section 3.6.1 also discusses education and CBT strategies for sleep. Our copy does not establish recommendations for meditation, yoga, or the specifically named attention-based stress reduction and CBT programs for depression and pain. (LLM, conf=0.87)
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“specify several interpersonal processes of care, including rapid and comprehensive assessment and clear communication and information, as essential to quality of care.(1,9-13) These interpersonal quality-of-care processesarealsodifficult toassessfrommedicalrecorddataalone, indicating thatmeasuringpatients’ self-report…”
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“Reasons cited included: lack of awareness and information about CRF; needing advice and suggestions for managing CRF; and reassurance that how they felt was ‘normal’: It would have been nicer earlier … because I think it was for the first couple of years that I really kind of struggled the most … it really was the fir…”
BackgroundInfluentialPearson, E. J. M., Morris, M. E., & McKinstry, C. (2016) · Supportive Care in Cancer · doi:10.1007/s00520-016-3228-9 · Cited by 36 · see citing works
“The 2015 CAPO guideline for cancer-related fatigue appears to be appropriate for clinical use worldwide.”
BackgroundInfluentialDeng, S.-M., Chiu, A., Wu, S.-C., Huang, Y., Huang, S.-C., Chen, S., & Tsai, M.-Y. (2020) · Journal of Traditional and Complementary Medicine · doi:10.1016/j.jtcme.2020.08.005 · Cited by 34 · see citing works
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“Based on a growing body of intervention research, guidelines for the management of CRF have been developed and adopted by cancer organisations [13, 17, 116, 117].”
Self-citationThe Interdisciplinary Rehabilitation Care Team and the Role of Physical Therapy in Survivor Exercise
McNeely, M. L., Dolgoy, N. D., Onazi, M. M. A., & Suderman, K. (2016) · Clinical journal of oncology nursing · doi:10.1188/16.cjon.s2.8-16 · Cited by 32 · see citing works
“The pathology of CRF is not well understood, and the presentation can vary widely among survivors, rendering treatment of CRF a challenge from the perspective of prescribing exercise (Howell et al., 2013).”
BackgroundFatigue, a major still underestimated issue
Ripamonti, C. I., Antonuzzo, A., Bossi, P., Cavalieri, S., Roila, F., & Fatigoni, S. (2018) · Current Opinion in Oncology · doi:10.1097/cco.0000000000000451 · Cited by 32 · see citing works
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The importance of self-care for fatigue amongst patients undergoing chemotherapy for primary cancer
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“…symptom that has been shown to contribute to: impaired physical and cognitive functioning, significant socioeconomic costs, shorter hegarty@ucc.ie (J. Hegarty). survival and increased mortality rates (Piper et al., 2008; Howell et al., 2013; Jones et al., 2015; Weis and Horneber, 2015).”
BackgroundGarland, S. N., Trevino, K. M., Liou, K. T., Gehrman, P., Spiguel, E., MacLeod, J., Walker, D. A. H., Glosik, B., Seluzicki, C. M., Barg, F. K., et al. (2021) · Journal of Cancer Survivorship · doi:10.1007/s11764-021-01001-1 · Cited by 30 · see citing works
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Neuromuscular, Psychological, and Sleep Predictors of Cancer-Related Fatigue in Cancer Patients
Chartogne, M., Rahmani, A., Landry, S., Bourgeois, H. P., Peyrot, N., & Morel, B. (2020) · Clinical Breast Cancer · doi:10.1016/j.clbc.2020.12.002 · Cited by 27 · see citing works
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“CJON.744-750 © Mark Kostich/iStock/Thinkstock C ancer-related fatigue (CRF) is defined as a sense of tiredness that persists over time, interferes with activities of daily living, and is not relieved by adequate rest (Hall, Mishel, & Germino, 2014; Piper & Cella, 2010; Weis & Horneber, 2015).”
BackgroundInfluentialBest Practice: psychoonkologisches Screening an Comprehensive Cancer Centers
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Cancer-related fatigue: impact on patient quality of life and management approaches
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“The evaluation should include consideration of the disease stage, evidence of disease spread or recurrence, current and past treatment received (both for cancer and psychiatric disorders), current medications, over-thecounter preparations, herbal remedies used, and a review of associated symptoms such as pain, depress…”
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Quality of Life and Survivorship in Lymphoma
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“15 Exercise is a mainstay in recommended management of cancer-related fatigue in general oncology populations (60-62).”
BackgroundPsychiatric benefits of integrative therapies in patients with cancer
Cassileth, B. R. (2014) · International Review of Psychiatry · doi:10.3109/09540261.2013.838153 · Cited by 19 · see citing works
“…refl ect a growing body of evidence that supports the integration of certain nonpharmacological therapies as part of a multidisciplinary approach to mainstream cancer care (Deng et al., 2013c; Howell et al., 2013; National Comprehensive Cancer Network, 2013; Society for Integrative Oncology, 2009).”
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Sleep and Fatigue in Cancer Patients
Savard, J., Savard, M., & Ancoli‐Israel, S. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-24288-2.00130-6 · Cited by 18 · see citing works
Early palliative care and its translation into oncology practice in Canada: barriers and challenges.
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Living with Metastatic Breast Cancer
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Effects of a Cancer Survivorship Clinic—preliminary results
Jammu, A. S., Chasen, M. R., van Heest, R., Hollingshead, S., Kaushik, D., Gill, H., & Bhargava, R. (2019) · Supportive Care in Cancer · doi:10.1007/s00520-019-05067-7 · Cited by 14 · see citing works
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“Pharmacological measures that have shown potential include the psycho-stimulants methylphenidate, dexmethylphenidate, erythropoietin, darbepoetin, progestational steroids (medroxyprogesterone acetate, megestrol acetate), modafinil, and paroxetine [1,7].”
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“CRF has been associated with shorter survival(8,9) and a significant decrease in overall quality of life.(10) Additional consequences are significant health care costs, staying off work or sick leave and lost earnings and productivity.”
BackgroundGarland, S. N., Tulk, J., Cotter, R., Zhou, E. S., Daniel, L. C., Schulte, F., Bender, J. L., Chalifour, K., & Eaton, G. (2023) · Sleep Medicine · doi:10.1016/j.sleep.2023.07.017 · Cited by 11 · see citing works
“There are existing guidelines in Canada and the United States for the prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer [48,49].”
BackgroundSmet, S., Spampinato, S., Pötter, R., Jurgenliemk-Schulz, I. M., Nout, R. A., Chargari, C., Mahantshetty, U. M., Sturdza, A. E., Šegedin, B., Bruheim, K., et al. (2021) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2021.11.022 · Cited by 11 · see citing works
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“CRF is often treated with exercise; in fact, the pan-Canadian practice guideline for CRF recommends exercise interventions for all stages of cancer including palliative care patients.(46) Potential explanations for the improvement in fatigue associated with exercise include enhanced fitness, attenuation of muscle wast…”
BackgroundChronic fatigue in adult cancer survivors
Reinertsen, K. V., Loge, J. H., Brekke, M., & Kiserud, C. E. (2017) · Tidsskrift for Den norske legeforening · doi:10.4045/tidsskr.17.0040 · Cited by 11 · see citing works
The definitions, assessment, and dimensions of cancer-related fatigue: A scoping review
Keane, K. F., Wickstrom, J., Livinski, A. A., Blumhorst, C., Wang, T.-F., & Saligan, L. N. (2024) · Supportive Care in Cancer · doi:10.1007/s00520-024-08615-y · Cited by 10 · see citing works
“…no gold standard for how to define CRF [8], but several organizations have proposed definitions, including the National Comprehensive Cancer Network (NCCN) [9], the European Society for Medical Oncology [10], American Society of Clinical Oncology [11], and the Pan Canadian Practice Guidelines [12].”
BackgroundWagner, A. S., Milzer, M., Schmidt, M. E., Kiermeier, S., Maatouk, I., & Steindorf, K. (2025) · Journal of Nursing Research · doi:10.1097/jnr.0000000000000666 · Cited by 10 · see citing works
Uncertainty and sense‐of‐self as targets for intervention for cancer‐related fatigue
Dolgoy, N. D., Krishnasamy, M., & McNeely, M. L. (2019) · European Journal of Cancer Care · doi:10.1111/ecc.13048 · Cited by 10 · see citing works
CBT-I during and after a cancer diagnosis
Garland, S. N. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-822872-2.00003-7 · Cited by 9 · see citing works
Vilela-Estrada, A. L., Villarreal‐Zegarra, D., Copez-Lonzoy, A. J. E., Valencia, L. E., Sanchez‐Ramirez, J. C., Delgado, F. L., Ambrosio-Melgarejo, J. I., Reátegui-Rivera, C. M., & Finkelstein, J. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1497946 · Cited by 9 · see citing works
“The literature highlights various instruments used to assess these affective disorders in cancer patients: the Beck Anxiety Inventory (BAI), the Beck Depression Inventory (BDI), and the Hospital Anxiety and Depression Scale (HADS) (Howell et al., 2015).”
Harrington, S., Fisher, M. I., Lee, J. Q., Cohn, J. C., & Malone, D. J. (2022) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2022.2056554 · Cited by 9 · see citing works
“A pan-Canadian clinical practice guideline on the screening, assessment, and supportive care of those with cancer-related fatigue was published in 2013 (Howell et al., 2013).”
BackgroundCatamero, D., Noonan, K. A., Richards, T. A., Faiman, B. M., Manchulenko, C., Devine, H., Bertolotti, P., Gleason, C. L., & and Board (2017) · Clinical journal of oncology nursing · doi:10.1188/17.cjon.s5.7-18 · Cited by 9 · see citing works
“Diagnosing the underlying cause of fatigue in patients with cancer is problematic because no diagnostic test is specific for it (Howell et al., 2013).”
Epoetin beta for the treatment of chemotherapy-induced anemia: an update
Egan, C. G., Galli, L., & Ricci, C. (2015) · OncoTargets and Therapy · doi:10.2147/ott.s77497 · Cited by 9 · see citing works
“A high percentage of oncologists overlook this symptom even if current guidelines recommend routine screening and management of fatigue.(9,11) A study conducted in anemic patients, non-anemic cancer patients, and the general population based on a questionnaire from the Functional Assessment of Chronic Illness Therapy…”
Fatigue bei chronisch körperlichen Erkrankungen
Weis, J. (2024) · Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz · doi:10.1007/s00103-024-03951-0 · Cited by 8 · see citing works
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“The CAPO (27) and CCO (30) guidelines did not consider the views and preferences of the target population.”
BackgroundMethodInfluentialLegitimising fatigue after breast-cancer treatment
Mackereth, P., Farrell, C., Bardy, J., Molassiotis, A., & Finnegan-John, J. (2015) · British Journal of Nursing · doi:10.12968/bjon.2015.24.sup4.s4 · Cited by 8 · see citing works
Garland, S. N. (2021) · Sleep · doi:10.1093/sleep/zsab202 · Cited by 7 · see citing works
Dolgoy, N. D., Brose, J. M., Dao, T., Suderman, K., Gross, D. P., Ho, C., Culos-Reed, S. N., & McNeely, M. L. (2020) · British Journal of Occupational Therapy · doi:10.1177/0308022620927351 · Cited by 7 · see citing works
“Moreover, the original NCCN guidelines did not include strategies for the practice of occupational therapy in CRF management, and did not provide suggestions for workability and CRF (Bower et al., 2014; Howell et al., 2013).”
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Analysis of cancer-related fatigue based on smart bracelet devices
Shen, H., Hou, H., Tian, W., Wu, M., Chen, T., & Zhong, X. (2016) · Technology and Health Care · doi:10.3233/thc-161134 · Cited by 6 · see citing works
“Regular screening for cancer-related fatigue is recommended in clinical practice by many expert guidelines [5,6].”
Development of a Taiwan cancer-related fatigue cognition questionnaire: reliability and validity
Lai, S.-C., Lin, W., Chen, C.-H., & Wu, S. (2017) · Oncotarget · doi:10.18632/oncotarget.16285 · Cited by 6 · see citing works
“Moreover, guidelines from expert groups, including the National Comprehensive Cancer Network (NCCN), concerning the screening and assessment of CRF do not recommend using the diagnostic criteria outlined in ICD-10 [1, 11, 12].”
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Self-citationYaşlı Kanser Hastalarının Destekleyici Bakım Gereksinimleri: Gereksinimler de Yaşlanıyor mu?
Ayvat, İ., & Özbaş, A. A. (2021) · Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi · doi:10.31125/hunhemsire.907936 · Cited by 5 · see citing works
Symptoms and Symptom Management in Survivorship Patients
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Providing acupuncture in a breast cancer and fatigue trial: The therapists' experience
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Wagner, A. S., Milzer, M., Steindorf, K., Kiermeier, S., Nguyen, T. D., Schmidt, M. E., & Maatouk, I. (2025) · The Oncologist · doi:10.1093/oncolo/oyaf233 · Cited by 4 · see citing works
Physical Activity in Adults With Fatigue After Cancer Treatment
Twomey, R., Yeung, S. T., Wrightson, J. G., Sung, L., Robinson, P. D., Millet, G. Y., & Culos-Reed, S. N. (2021) · Communications in Kinesiology · doi:10.51224/cik.v1i3.40 · Cited by 4 · see citing works
“Six of these used a threshold score of ≥ 4 (Table 2) as recommended for routine CRF screening (Fabi et al., 2020; Howell et al., 2013; Pearson et al., 2016).”
BackgroundMethodInfluentialFatigue bei Krebs: Wie (gut) sind Betroffene an onkologischen Einrichtungen in Deutschland versorgt?
Wagner, A. S., Milzer, M., Kiermeier, S., Schmidt, M. E., Nguyen, T. D., Steindorf, K., & Maatouk, I. (2025) · Zeitschrift für Evidenz Fortbildung und Qualität im Gesundheitswesen · doi:10.1016/j.zefq.2025.02.003 · Cited by 3 · see citing works
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“Despite guidelines that recommend screening and treatment for insomnia, CBT-I is inaccessible to many cancer survivors [23].”
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“Fatigue is one of the most distressing symptoms that patients with cancer may experience, and it has been attributed to many patient treatment- and disease-related factors [11].”
BackgroundThe Experiences of Cancer-Related Fatigue among Adult Cancer Patients: A Systematic Review
Arizona, I. K. L. T., Sukartini, T., Efendi, F., Estiadewi, P. S., & Anggraeni, N. P. D. A. (2019) · Jurnal NERS · doi:10.20473/jn.v14i3.16973 · Cited by 3 · see citing works
A Prospective Evaluation of Fatigue in Pediatric Brain Tumor Patients Treated With Radiation Therapy
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“The symptoms of fatigue have been shown to correlate with long-term outcomes including overall survival in various cancer populations (Bower et al., 2014; Howell et al., 2013; Kazak et al., 2015; Peters et al., 2014; Portenoy & Itri, 1999).”
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- Authors
- Howell, D., Keller–Olaman, S., Oliver, T. K., Hack, T. F., Broadfield, L., Biggs, K., Chung, J., Gravelle, D., Green, E., Hamel, M., Harth, T., Johnston, P., McLeod, D., Swinton, N., Syme, A., & Olson, K.
- Affiliations
- University Health Network (CA)
- Canadian Partnership Against Cancer (CA)
- University of Manitoba (CA)
- Cancer Care Nova Scotia (CA)
- Juravinski Cancer Centre (CA)
- BC Children's Hospital (CA)
- Élisabeth Bruyère Hospital (CA)
- Montreal General Hospital (CA)
- CancerCare Manitoba (CA)
- Jewish General Hospital (CA)
- Covenant Health (CA)
- University of Alberta (CA)
- Venue
- Current Oncology
- Publisher
- MDPI AG
- Published
- 2013-06-01
- Volume
- 20
- Issue
- 3
- Pages
- 233-246
- ISSN
- 1198-0052 (ISSN-L)
- 1718-7729
- PMC
- PMC3671030
- OpenAlex
- W2053212646
- Cited by
- 158
- References
- 58
- Citations by year
- 2026: 4 · 2025: 14 · 2024: 8 · 2023: 10 · 2022: 13 · 2021: 23 · 2020: 14 · 2019: 8 · 2018: 11 · 2017: 9 · 2016: 7 · 2015: 20 · 2014: 12 · 2013: 3 · 2012: 2
- FWCI
- 7.45
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc-nd
- creativecommons.org/licenses/by/4.0/ (vor)
- Locations
- Current Oncology (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Keywords
- cancer-related fatigue, fatigue screening, fatigue analysis, supportive care, cancer patients, adults, decision-making algorithm, evidence-based practice, guideline adaptation
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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