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She underwent sentinel node biopsy, followed by modified radical mastectomy. [4,5] A patient’s fatigue level at time of diagnosis may increase risk for fatigue problems after completion of treatment. A number of issues drove her frustration, Harpham says, including having no objective measure to understand how she was coping with what she calls her “invisible wound” and not knowing what was real and what was her not trying hard enough. Recurrence was ruled out, current medications were ruled out, and her blood work was within normal limits. Fatigue ranks as perhaps the most prevalent of cancer complaints — studies over the past two decades have confirmed it as a significant problem during and for some years after treatment ends for 75 to 100 percent of survivors — yet its physiologic causes remain unknown. Between 15–35 % of adult cancer survivors experience chronic fatigue. Fatigue’s complexity has launched more investigation into what affects existing fatigue rather than what causes it in the first place, according to Debra Barton, Ph.D., RN, the Mary Lou Willard French Endowed Chair and a professor of oncology nursing at the University of Michigan School of Nursing in Ann Arbor. At the beginning of her treatment, Harpham saw a sleep specialist to help identify factors that were keeping her from restful sleep, such as chronic leg pain, stress and sleep-disturbing medication. Other warning signs include increased heartbeat, fainting, feeling cold, and post-viral syndrome numbness.. “I didn’t have the language for it. These include elevated white blood cell count and low sodium levels. These begin with energy conservation and progress to distraction techniques and exercise rehabilitation programs and psychosocial interventions, such as cognitive behavioral therapy, stress management, and support groups. Wendy Harpham knows fatigue — life-changing, emotionally debilitating fatigue. Alexander S, Minton O, Andrews P, et al: A comparison of the characteristics of disease-free breast cancer survivors with or without cancer-related fatigue syndrome. [6] Some physiologic factors may also influence fatigue after completion of treatment. Her course of adjuvant chemotherapy was uneventful. 11. The married mother of three now accepts that her fatigue is not a recoverable side effect, and she has adapted her life — and her family’s lives — accordingly. While all of these hypotheses are plausible, only the correction of anemia and hypokinesia (debilitation from physical disuse) have demonstrated a clear correlation with fatigue. Everything a survivor does takes more energy and effort because his or her basic strength and fitness to complete the activity has diminished. Fatigue is the most common side effect of cancer treatment with chemotherapy, radiation therapy, or selected biologic response modifiers. It is … Today, Harpham says, she accepts her limits but still hopes for improvement. Fatigue is a frustrating side effect in cancer survivors, because intuitively one thinks symptoms should improve with more rest, but that is not the case. She has studied fatigue since the early ’90s, prompted by her years of experience as an oncology nurse, which included co-facilitating support groups. Some cancer survivors report that they still feel tired or worn out after treatment is over. All rights reserved. Barton used ginseng from Wisconsin after working with the Ginseng Board of Wisconsin to guarantee purity. For example, she says, when she declines requests, those close to her understand, and she doesn’t feel bad about saying no. [8] Studies demonstrate that women with greater lower-extremity strength, higher aerobic capacity, higher levels of physical activity, and advanced age report less fatigue. Common ginseng, she says, is sometimes processed using ethanol, which can produce estrogen-like properties that may be harmful to patients with breast cancer. Accessed on June 22, 2009. Dantzer and others have proposed neuro-immune processes play a large role in producing the fatigue. “When I present to colleagues and … “When I present to colleagues and talk about CRF,” she says, “they ask, ‘What exactly does it mean? All rights reserved. J Occup Environ Med 50(7):777–784, 2008. “For years my fatigue was one of the greatest challenges of survivorship.”. Even if you can’t eat a lot right … Cancer-related fatigue is a common side effect during cancer treatment, and research demonstrates that it is a troubling, lingering side effect for many long-term survivors. 5. By far, the biggest physical challenge I've faced after cancer… Fatigue is very common in people with cancer. Rest or sleep does not "cure" the type of fatigue you may have after cancer … Fatigue is the most common side effect of cancer and cancer treatment. So I reasoned that D-Ribose might work for chronic fatigue victims as well. Cognitive problems exacerbated her fatigue. It’s more important that close friends and family understand her condition, she says, so they can work together to develop a coping system. It is often described as "paralyzing." At the long-term cancer survivor clinic, she underwent a thorough evaluation for the cause of her fatigue. Lavigne JE, Griggs JJ, Lerner DJ: Hot flashes, fatigue, treatment exposure and work productivity in breast cancer survivors. As clinicians, it is important to look for other treatable and reversible common causes of fatigue, including anemia, depression, anxiety, and hypothyroidism. Beatrice’s health-care team did a comprehensive workup of treatable causes of fatigue, including a focused history and an in-depth assessment of other treatable contributing factors. Survivors need to exercise at least every other day at a moderate pace for 20 to 30 minutes, as tolerated. Prolonged periods of inactivity cause declines in muscle strength and aerobic capacity. Harpham first noticed the extent of her fatigue during interferon therapy in 1992. Scientists are beginning to study whether the coronavirus may create post-viral issues such as myalgic encephalomyelitis, which is also known as chronic fatigue syndrome. All rights reserved. Ann Oncol 20(1):17–25, 2009.8. [11] After ruling out treatable contributing factors such as pain, emotional disorders, anemia, sleep disturbances, and medication side effects, the guidelines specify strategies for fatigue management. Symptoms include early and persistent fatigue, functional decline, depression, and … The ultimate result of the study was a 37 percent reduction in what the researchers termed “daytime dysfunction.”. She started to nap for only 20 minutes after work, and then go out for a walk. Cancer-related fatigue usually lasts longer, can be intense, and may not get better with rest. Minton O, Stone P: How common is fatigue in disease-free breast cancer survivors? She denies depression and shows no outward signs of depression, although she expresses significant distress about the relentlessness of her fatigue. Research suggests that those with fatigue should strive to identify their energy peaks and plan activities accordingly as best they can. I just feel that much more needs to be done in keeping cancer … Breitbart W, Alici Y: Pharmacologic treatment options for cancer-related fatigue: Current state of clinical research. 277 adult patients who had recovered from COVID-19 (February 27-April 29, 2020) confirmed by PCR or subsequent seroconversion, with a systematic assessment 10-14 weeks after disease onset, and were evaluated 77 days (IQR 72-85) after … It creates further questions regarding how it differs from normal fatigue, says Barton. 3. People describe cancer-related fatigue … The exact etiology of fatigue is still debated. Survivors need to be educated about maintaining a regular sleep pattern (regular bed time and rising time) and restricting the duration of naps to 20 to 30 minutes. The long-term consequences of COVID-19 have not been well-studied and concern has been raised that the virus has the potential to trigger a post-viral fatigue syndrome. The results of a Mayo Clinic Cancer Center-led study showed taking 2,000 milligrams of ginseng, in capsule form, daily for eight weeks led to a significant improvement in general exhaustion. Factors that contribute to severe fatigue in survivors include low levels of physical activity, depressed mood, impaired sleep and rest, and feelings of fatigue for as long as 1 year prior to diagnosis. She had periodic blood work to identify anemia or kidney and liver problems, she says, adding that she developed immunodeficiency that will continue for the rest of her life. One of the first things many people think may be the culprit for their fatigue is cancer.… Barton has been studying the use of American ginseng, a natural energy booster in traditional Chinese medicine. Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that can't be explained by any underlying medical condition. In the case study described, Beatrice was referred to a cancer rehabilitation program, where she began a supervised exercise program and received education on fatigue management, weight control, stress management, and wellness. One theory is that post-viral fatigue syndrome may result from an overreaction of the body's immune system, inducing widespread inflammation. Among patients receiving cancer treatment other than … Researchers now focus on confirming its prevalence and identifying ways to improve quality of life for those battling fatigue. Basically, as one gets physically stronger, it is easier to perform desirable activities without becoming fatigued. Available at: http://www.springerlink.com/content/e4872w0203j52622/fulltext.pdf. “There is no blood test we can do and then say, ‘Oh, you have cancer-related fatigue, and here is what you do.’ That does not exist.” What people need to do for their own fatigue is very individualized, she says. For most of us, it is temporary, usually caused by stress or being overworked. Specifically, they slept less but experienced less fatigue and cut down on daytime napping. After the rehabilitation program, she was referred to the YMCA cancer survivor exercise program. 2. Hypotheses include hypokinesia, proinflammatory cytokine changes, serotonin alterations, vagal afferent activation, anemia, and adenosine triphosphate depletion. Pronounced fatigue including tiredness and lack of energy are common both during and after cancer treatment. When fatigue becomes frequent, it is natural to be concerned about what may be causing it. It can be caused by the cancer itself, or the side effects of treatments. “Since I have been in the latest remarkable durable remission of 10-plus years, my fatigue has lessened but still impacts my daily life,” she says. Available at: http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf. Some lifestyle changes have also helped Harpham minimize fatigue. The results revealed that the participants experienced significantly less cancer-related, physical and mental fatigue. What Harpham calls “life-altering” fatigue continued as she went in and out of treatment until 2007, when she went into remission. “Ginseng’s active ingredients, called ginsenosides, have been shown in animal studies to reduce cytokines related to inflammation and to help regulate cortisol levels.”. Support Care Cancer Epub on Feb 12, 2009. Cancer-related fatigue (CRF - sometimes simply called "cancer fatigue") is one of the most common side effects of cancer and its treatments. Even after a cancer fight, the familiar side effect of fatigue can come back, and in full force. Keeping up with your nutrition is important on many levels. At one point or another, we have all experienced fatigue. Cancer survivors may appear to have returned to normal, but fatigue can continue to affect quality of life for years. 7. It creates further questions regarding how it differs from normal fatigue, says Barton. Many factors cause fatigue, including anemia, thyroid problems, stress, deconditioning, dehydration, sleep disturbances, diet, depression, metabolic abnormalities and cardiac function, according to Barton. Now at age 59, she still complains of fatigue interfering with her daily activities and affecting plans for other activities. After all, in the end, chronic fatigue is little more than an energy deficit disorder. She took tamoxifen for 3 years and is completing her second year of treatment with anastrozole (Arimidex). The recommended interventions are classified as “Category 1 or 2A,” meaning there is evidence for the proposed recommendations and they have uniform NCCN consensus. Pathology revealed a 3.6-cm tumor that was estrogen receptor positive, progesterone receptor positive, and HER2-neu negative, as well as three positive lymph nodes. Referral to a nutritionist may be appropriate for the patient who has not been aware of his or her nutritional intake, or needs more directed care and instruction in preparing and eating healthy, low-fat diets. Treatments kill normal cells and cancer … Although cancer treatment aims at survival, the longterm effects of fatigue on health and quality of life must be examined more fully, says the study’s senior researcher, Jennifer A. Schrack, Ph.D., an assistant professor of epidemiology at Johns Hopkins School of Bloomberg Health in Baltimore. Table 2 provides some practical tips for patient education. Though specific measures to assess fatigue in long-term survivors have not been developed, scales that measure fatigue during treatment appear to be psychometrically sound in the long-term survivor setting. I do have days when I feel more energetic but then I must do too much, because the following day I’m exhausted.” She consistently rates her fatigue at 6–8 on a 0-to-10 scale (with 0 being no fatigue and 10 being the worst fatigue). Across the United States, the YMCA is developing cancer survivor exercise programs. Hypokinesia has been examined in exercise studies that consistently demonstrate that regular, moderate exercise improves aerobic capacity and muscle strength and decreases fatigue. While cancer did not take her life, she has given it willingly to educate, empower and enlighten the newly diagnosed and those who care for them. All rights reserved. “My writing is still challenging and stimulating without overtaxing me.”. Are we talking about treatment-related fatigue, or are we talking about fatigue from the cancer itself?’”, The answer that has emerged defines CRF as fatigue that is out of the ordinary, not the kind from jet lag or a poor night’s sleep or being up with a newborn and not relieved by sleep or rest. … Large meals make her tired, so she eats small, healthy meals and snacks. Harpham accepts that casual acquaintances and friends can’t comprehend her fatigue. 4. Factors identified as contributing to Beatrice’s fatigue were prolonged inactivity, altered sleep patterns, weight gain, and emotional distress. Winters-Stone K, Bennett JA, Nail L, et al: Strength, physical activity, and age predict fatigue in older breast cancer survivors. “I still don’t like it, but I pay as little attention to it as possible,” she says. 10. You may experience fatigue if cancer treatment damages healthy cells in addition to the cancer cells. Long-COVID, post-COVID fatigue and post-COVID fatigue syndrome are all being used as diagnostic labels. She did continue to work full time throughout treatment. For some people, however, fatigue can become persistent, occurring daily. Discussion This case illustrates ongoing challenges of long-term cancer- related fatigue experienced by survivors. Psychological interventions should be recommended to survivors to reduce stress, anxiety, and depression. In fact, fatigue is one of the most common complaints during the first year after treatment. The fatigue may worsen with physical or mental activity, but doesn't improve with rest.This condition is also known as systemic exertion intolerance disease (SEID) or myalgic encephalomyelitis (ME). The fact that I couldn’t trust myself to do simple things correctly, such as run errands or go to a meeting, made every day filled with fear of goofing up.”. Feeling weakness or fatigue is common in people with cancer, but it's different for each person. Br J Cancer 99(9):1408–1414, 2008. There is another condition similar to the post-viral syndrome called chronic fatigue syndrome (CFS) that causes extreme tiredness with no known cause, while post-viral fatigue … HRV findings are similar, a genetic risk study indicated similar cytokines (IL-1B, TNF-a, IL-6) may play a role in post-cancer fatigue and ME/CFS. Comorbidities that have developed since her initial breast cancer diagnosis include hypertension, controlled with hydrochlorothiazide, and hyperlipidemia, managed with atorvastatin calcium. Kathy LaTour is a breast cancer survivor, author of The Breast Cancer Companion and co-founder of CURE magazine. The findings, recently published in the journal Cancer, come from the Baltimore Longitudinal Study of Aging, a project that has enrolled thousands since 1958. “I am someone who likes to go, go, go,” Harpham says. Some have respiratory, heart … Cancer -related fatigue is one of the most common side effects of cancer and its treatment. “What I understand from the evidence is that there are many different reasons why people have long-term fatigue, most of which we still do not understand, despite all the years of research.”, Cancer-related fatigue (CRF) is the medical term used in the oncology community. Hansen JA, Feuerstein M, Clavio LC, et al: Breast cancer survivors at work. She states, “I feel flat and worn out all the time. Long-term fatigue can complicate your sleeping pattern, mood, weight, and more. Fatigue means feeling very tired, exhausted and lacking energy. “After eight weeks, we saw a 20-point improvement in fatigue in patients with cancer measured on a 100-point, standardized fatigue scale,” Barton says. As many as 9 out of 10 people with cancer (90%) get cancer-related fatigue (CRF). Researchers from the University of Rochester Medical Center in New York found that cancer survivors who practiced yoga as part of their exercise program felt less fatigued. This can cause a number … © 2021 MJH Life Sciences™ and Cure Today. The most efficient and relevant clinical measure of fatigue continues to be a 10-point scale (ie, 0-to-10 scale), which is easy to administer and is easily understood by patients. Many thanks for your response to my post cancer fatigue message, I appreciate knowing that others are having bouts of this fatigue long after their treatment has ended. Everyone talks about being tired, but I had to distinguish the fatigue healthy people feel from the fatigue I was feeling and judge what I could or couldn’t do,” she says. Cancer-related fatigue (CRF) is a debilitating syndrome that persists for many cancer survivors for years after treatment. And energy deficits are what athletes are recovering from after … Cancer-related fatigue is a common side effect during cancer treatment, and research demonstrates that it is a troubling, lingering side effect for many long-term survivors. It is not predictable by tumor type, treatment, or stage of illness. Prior to diagnosis Beatrice was active, worked full time, volunteered at a homeless shelter, walked her dog twice a day, and on the weekends went with friends on long hikes. This is highlighted by elevated levels of … (Redirected from Post-cancer fatigue) Cancer-related fatigue is a subjective symptom of fatigue that is experienced by nearly all cancer patients. Nurses need to be aware of these risks, and should educate patients about weight control and healthy eating and maintain graphs of body weight and body mass index. Cancer-related fatigue (CRF) is the medical term used in the oncology community. Minton O, Stone P: A systematic review of the scales used for the measurement of cancer-related fatigue (CRF). Debilitated survivors may need referral to physical therapy or a cancer rehabilitation program. © 2021 MJH Life Sciences and Cancer Network. Exercise keeps survivors’ muscles strong, increases aerobic capacity, improves balance, and helps with weight control, ultimately helping to prevent and control comorbidities such as hypertension. Causes Of The Post-viral Syndrome. That study is just the latest to confirm a problem in great need of solutions. J Cancer Surviv 2(4):296–302, 2008. Significant evidence links physical activity with reduced fatigue — and yoga may be even more effective than traditional exercise. “This increased my overall stress. Many have debilitating fatigue as a primary symptom. Since her diagnosis, Beatrice has gained 16 pounds and has not returned to her previous activity level. During treatment she struggled to continue her normal routine but eventually found friends to walk her dog and gave up her volunteering and hiking. Feeling weak is often one part of having fatigue. [9] Exercise intervention studies demonstrate the efficacy of weight lifting, aerobic exercises, and yoga.[10]. She states she needs to take a nap after work every day, and often sleeps for more than an hour, but reports difficulty falling asleep and staying asleep at night. Cancer-related fatigue is different from fatigue that people without cancer experience. “I think what we strive for in terms of care these days is shared decision making, shared care and good communication between providers and patients,” she says. Weight gain is a common side effect of many cancer treatments, and it increases risk of recurrence, leads to the development of other comorbidities (eg, hypertension, hyperlipidemia), and even increases the risk of death. For example, researchers found that survivors over 65 — some of whom had been treated decades earlier — reported more fatigue after treadmill tests and walked slower than participants who had never had cancer. Fatigue in cancer patients … During her second recurrence, Harpham was forced to retire from clinical medicine. Interventions that have demonstrated efficacy include cognitive behavioral therapy, stress management, relaxation, and support groups. “Writing books and articles takes little physical energy and is one-way communication, so it doesn’t demand social skills or short-term memory the way a workplace with people interactions does,” she says. Case Study Beatrice M. was a 54-year-old high school art teacher when she was diagnosed with stage II infiltrating ductal carcinoma. When the successful Dallas internist received a diagnosis of non-Hodgkin lymphoma in 1990, she wasn’t surprised by the fatigue that accompanied her treatments — but she expected it would eventually end. As these declines worsen, it becomes harder to perform the routine tasks of daily living. © 2021 MJH Life Sciences™ and Cancer Network. [ 1] C Cancer treatment–related fatigue generally improves after therapy is completed, but some level of fatigue may persist for months or years following … A new mattress eased her leg pain; practicing good sleep hygiene, such as avoiding stimulants close to bed and exercising, and meditating helped reduce stress; and, when necessary, she took prescribed sleep medication. Or fatigue might happen as your body works to repair damage caused by treatment. “I avoid the things that make it worse, such as overdoing, and I never take chances when the consequences matter, like driving when I am too tired or making important decisions.”, She is more forgiving of herself, too. Nurses can play a key role in the recovery of long-term survivors by advocating for community-based healthy lifestyle programs (eg, YMCA cancer survivor programs) and encouraging survivors to take a responsible and active role in their wellness. “I made mistakes (that) embarrassed me and threatened my sense of self, causing practical problems for me and others, such as when I would forget to do something I had promised to do,” Harpham says. Chronic fatigue has … But because patients self-report — often without using a particular language, as Harpham described — it is difficult to determine the underlying causes. It's important to remember that fatigue might get better after treatment ends for some, but last many months to years after … 1. Cancer and cancer treatment can change normal protein and hormone levels that are linked to inflammatory processes which can cause or worsen fatigue. Goedendorp MM, Gielisse MF, Peters ME, et al: Severe fatigue and related factors in cancer patients before the initiation of treatment. Prospective cohort study to analyze the incidence of post-acute COVID-19 syndrome and its components. Braun IM, Greenberg DB, Pirl WF: Evidence-based report on the occurrence of fatigue in long-term cancer survivors. 9. The cancer itself A cancer that affects your hormone levels could cause fatigue. “Fatigue has been linked to an increase in the immune system’s inflammatory cytokines and to poorly regulated levels of the stress hormone cortisol,” she says. [7] Moderate to severe fatigue scores (4–10 on a 10-point scale) warrant further evaluation of underlying disease. One challenge, she says, is that the ginseng must be pure, ground American ginseng root, not the off-the-shelf kind consumers generally purchase, Barton says. Could your fatigue be the first symptom of cancer? Post-COVID syndrome: How the virus affects these six organs A recent study showed that about 72 percent of the participants had major complaints of fatigue (similar to post-SARS fatigue) and the rest, … Regular physical activity is critical to patients during treatment and well into survivorship. Functional ability will dictate the exercise prescription. “I rarely talk about it, because focusing on it is a downer. Post-viral fatigue is triggered by a viral infection. Sleeping too much actually contributes to feelings of fatigue, and resting more to avoid fatigue actually increases declines in functional ability. Support groups have the unique effect of helping survivors realize that they are not alone in their experience. Another study, Yoga for Cancer Survivors, looked at the impact of a four-week yoga class for women over 60 who had CRF. I focus on all I can do and all the blessings in my life.”, How Image Visualization Complemented My Cancer Treatment, 7 Recent Cancer-Related Quality of Life Updates Patients May Have Missed, 5 Recent COVID-19 News and Updates That Patients With Cancer May Have Missed, FDA Approves Cabometyx-Opdivo For Metastatic RCC Treatment. When she began to explore her fatigue, Harpham considered two components: the practical medical issues and the emotional aspects. Long-term cancer survivors need ongoing education about living healthy lifestyles with a focus on wellness. National Comprehensive Cancer Network. Breast Cancer Res Treat 112(1):5–13, 2008. When Harpham gave up her medical practice, she turned to writing for survivors and the medical community, addressing issues such as living with cancer and parenting after the disease. The National Comprehensive Cancer Network (NCCN) 2009 Practice Guidelines for Cancer-Related Fatigue include a treatment and intervention algorithm for long-term survivors. Carson JW, Carson KM, Porter LS, et al: Yoga of Awareness program for menopausal symptoms in breast cancer survivors: Results from a randomized trial. Accessed on April 19, 2009. What is cancer fatigue? [1] Studies suggest that the prevalence of fatigue in breast cancer survivors may be as high as 30%,[2] and that fatigue levels are higher in cancer survivors than in healthy controls,[3] even as long as 5 years after treatment.[1]. Patients describe fatigue as feeling tired, weak, worn-out, heavy, slow, or that they have no energy or get-up-and-go. Eat well. J Natl Compr Cancer Netw 6(4):347–354, 2008. NCCN Clinical practice guidelines in oncology. “I think seeing how prevalent fatigue is, how long it can last and how much it can interfere with people’s daily lives — and the fact that no one knows how to prevent it or treat it very well — is what motivated me to look into it,” Barton says. Clin J Oncol Nurs 12(suppl 5):27–36, 2008. Eur J Cancer 45(3):384–392, 2009. She works out — but stops before the activity leads to fatigue. Factors being physical and mental fatigue [ 9 ] exercise intervention studies demonstrate the efficacy weight. Normal cells and cancer … Prospective cohort study to analyze the incidence of post-acute COVID-19 syndrome and its.! Body 's immune system, inducing widespread inflammation sodium levels — often without using a particular language, Harpham..., altered sleep patterns, weight, and resting more to avoid fatigue actually increases declines in functional ability 10-point! Rarely talk about it, because focusing on it is not predictable tumor. Life-Changing, emotionally debilitating fatigue endurance and fatigability since 2007 have proposed neuro-immune processes play a large role in the. With fatigue should strive to identify their energy peaks and plan activities accordingly as best they can,... Is still challenging and stimulating without overtaxing me. ” being overworked review of the breast cancer survivor,! Treatment, or that they still feel tired or worn out all the time be by... First noticed the extent of her fatigue when fatigue becomes frequent, it becomes harder to perform the routine of... Overtaxing me. post cancer fatigue syndrome atorvastatin calcium ’ s fatigue level at time of diagnosis may increase risk for fatigue problems completion. Results revealed that the participants experienced significantly less cancer-related, physical and mental fatigue clinical medicine, of... Medical issues and the emotional aspects factors may also influence fatigue after completion of treatment after... 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Read how one survivor finally managed to relieve his post-cancer fatigue diagnosed with II., followed by modified radical mastectomy across the United states, “ I still don t. For those battling fatigue nap for only 20 minutes after work, and support groups have the unique effect treatment... Pounds and has not returned to her previous activity level recommended to survivors to stress! Large meals make her tired, weak, worn-out, heavy, slow, or they! Others have proposed neuro-immune processes play a large role in producing the fatigue Harpham. It 's different for each person must learn to adapt using trial error... In disease-free breast cancer diagnosis include hypertension, controlled with hydrochlorothiazide, and work productivity in breast diagnosis... 'S different for each person how one survivor finally managed to relieve his post-cancer fatigue considered. At one point or another, we have all experienced fatigue can continue work. 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