{"entity":{"id":"cancer-related-fatigue-screening-and-management","kind":"protocol","name":"Cancer-related fatigue: screening, treatable causes and management","aka":["cancer-related fatigue","CRF management","fatigue during chemotherapy","tiredness after cancer treatment","exercise for cancer fatigue","CBT for cancer fatigue"],"tldr":"Tiredness that rest does not fix is one of the commonest effects of cancer and its treatment, for months or years. Your team should ask about it and look for treatable causes such as anaemia, low thyroid, pain, poor sleep, low mood or a medicine. What helps most is exercise suited to you, cognitive behavioural therapy and mindfulness. Modafinil is not recommended, nor methylphenidate routinely.","summary":"The ASCO-SIO guideline update (2024) covers adults from diagnosis onward and sorts recommendations by phase. During treatment, clinicians should recommend exercise (aerobic, resistance or both), CBT, mindfulness-based programmes and tai chi or qigong (each moderate evidence, strong recommendation); psychoeducation and American ginseng 2,000 mg daily may be recommended (conditional). After treatment, exercise, CBT and mindfulness-based programmes are strong recommendations, and yoga, acupressure and moxibustion conditional. In advanced cancer or at the end of life, CBT and corticosteroids may be offered (low evidence, conditional). In every phase, wakefulness agents (modafinil, armodafinil) should not be recommended, and psychostimulants (methylphenidate) should not be used routinely; during treatment, L-carnitine and antidepressants such as paroxetine are also recommended against.\n\nScreening and assessment were not re-examined in 2024; the panel referred readers to the 2014 ASCO adaptation, which recommends that everyone be evaluated for fatigue after primary treatment and that those with moderate to severe fatigue have a comprehensive assessment with medical and treatable contributing factors addressed. The APTA guideline (2022) grades the tools: the EORTC QLQ-C30 is the only screening tool graded A, and the Piper Fatigue Scale-Revised, FACIT-Fatigue and PROMIS Fatigue short forms are graded A for fuller assessment. The ESMO 2020 guideline could not be read.","asOf":"2026-11-11","links":[],"tags":["protocol","fatigue","supportive-care","survivorship"],"related":["exercise-during-and-after-cancer-treatment","dexamethasone"],"cancers":[],"sections":["supportive-care"],"technologies":["cancer-related-fatigue-management","exercise-oncology","exercise-during-chemotherapy","cbt-fatigue-distress","mindfulness-based-interventions","tai-chi-qigong","american-ginseng-fatigue","yoga-cancer"],"targets":[],"drugs":[],"companies":[],"institutions":["asco","mascc","esmo"],"pathways":[],"terms":["cancer-related-fatigue"],"trials":[],"people":[],"bottlenecks":[],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"simple":"Feeling very tired is common with cancer. Tell your team. Gentle exercise and talking therapies help most.","domain":"symptom-management","setting":{"who":["nurse","doctor","multidisciplinary-team","patient-or-carer"],"where":["outpatient-clinic","chemotherapy-day-unit","community","home"]},"population":"Adults with cancer from diagnosis onward, during and after treatment and in advanced disease (ASCO-SIO 2024). Children and adolescents are covered by a separate paediatric guideline, not read here. The 2024 recommendations were built from randomised trials in which most participants had breast cancer; the panel did not set separate recommendations by cancer type.","trigger":"At the first visit, at intervals during treatment, at the end of treatment and at follow-up; and whenever a person reports tiredness.","steps":[{"action":"Ask about fatigue at the start of care, at intervals and after primary treatment, and give everyone information about managing it","why":"Fatigue is often thought to be unavoidable and goes unreported; asking routinely finds the people who could be helped.","source":"asco-2014","quote":"It is recommended that all patients with cancer be evaluated for the presence of fatigue after completion of primary treatment and be offered specific information and strategies for fatigue management."},{"action":"Screen with a validated tool: the EORTC QLQ-C30 (graded A) or the MD Anderson Symptom Inventory (graded B); follow a positive screen with a fuller assessment","why":"A short standard questionnaire catches tiredness that a general question misses, and shows change over time.","source":"apta-2022","quote":"Only 1 screening tool rises to the level of grade A evidence for screening CRF. The EORTC-QLQ-C30 is a general symptom inventory that can be used to screen for fatigue and other problems those with cancer may have. The MDASI, also a general symptom inventory in which the individual with cancer assesses their present symptom burden, is graded B.","grade":"A (EORTC QLQ-C30); B (MDASI)"},{"action":"For moderate to severe fatigue, look for and treat contributing causes first: anaemia, thyroid and other hormone problems, pain, low mood, anxiety, poor sleep, poor nutrition, inactivity and medicines","why":"Several of these can be corrected directly, and fatigue rarely improves while they are untreated.","source":"asco-sio-2024","quote":"patients experiencing fatigue should also be evaluated and treated for contributing comorbid conditions that commonly cluster with fatigue, including pain, depression, anxiety, and sleep disturbance, as well as nutritional deficit, activity level, anemia, medication adverse effects."},{"action":"On immune checkpoint inhibitors, check for immune side effects that cause fatigue (thyroid, adrenal and pituitary problems among them) when fatigue is new or worse","why":"Fatigue can be the first sign of a hormone gland being damaged by immunotherapy, which needs its own treatment.","source":"asco-sio-2024","quote":"Fatigue can also be a symptom of other forms of immunotherapy toxicity, including adrenal insufficiency, hypothyroidism, hypophysitis, hepatitis, renal insufficiency, pneumonitis, neurologic toxicities, and anemia."},{"action":"Recommend exercise (aerobic, resistance or both), tailored to the person and supervised or not, during and after treatment","why":"Exercise has the most consistent evidence of any treatment for cancer-related fatigue.","source":"asco-sio-2024","quote":"1.1. Clinicians should recommend exercise (aerobic, resistance, or a combination) to reduce the severity of fatigue during cancer treatment. Exercise should be tailored according to the individual patient’s abilities and may be either supervised or unsupervised Moderate Strong","grade":"Evidence quality moderate; recommendation strong"},{"action":"Offer cognitive behavioural therapy (in person or online) and mindfulness-based programmes, during and after treatment","why":"Both reduce fatigue in randomised trials, and after treatment they have worked for people with moderate to severe fatigue.","source":"asco-sio-2024","quote":"2.2. Clinicians should recommend cognitive behavioral therapy (CBT) to manage symptoms of cancer-related fatigue in adults who have completed cancer treatment. CBT may be delivered in person or via a web-based program Moderate Strong","grade":"Evidence quality moderate; recommendation strong"},{"action":"During treatment, tai chi or qigong at low to moderate intensity may also be recommended","why":"These gentle movement practices reduced fatigue in trials of people on treatment.","source":"asco-sio-2024","quote":"1.4. Clinicians should recommend tai chi or qigong, practiced at a low to moderate intensity, to reduce the severity of cancer-related fatigue in adults undergoing cancer treatment Moderate Strong","grade":"Evidence quality moderate; recommendation strong"},{"action":"Do not prescribe modafinil or armodafinil for fatigue, and do not prescribe methylphenidate routinely","why":"Trials have not shown these drugs help cancer-related fatigue enough to outweigh their side effects.","source":"asco-sio-2024","quote":"1.7. Clinicians should not recommend wakefulness agents, such as modafinil or armodafinil, to manage symptoms of cancer-related fatigue in adults undergoing cancer treatment Moderate Strong","grade":"Evidence quality moderate; recommendation strong (against), during treatment"},{"action":"In advanced cancer or at the end of life, consider CBT, and corticosteroids where there is no contraindication, reviewing the balance of benefit and harm over time","why":"A short course of a steroid can lift fatigue near the end of life, but its side effects build up with time.","source":"asco-sio-2024","quote":"3.2. Clinicians may recommend corticosteroids to manage symptoms of cancer-related fatigue in patients at the end of life where no contraindications exist. The risk-benefit ratio of corticosteroid use should be assessed over time Low Conditional","grade":"Evidence quality low; recommendation conditional"}],"bestInClass":{"statement":"ASCO-SIO 2024 is the most recent graded guideline read, and MASCC endorsed it in 2026 (endorsement not read). It puts exercise, CBT and mindfulness-based programmes first in every phase before and after the end of treatment (moderate evidence, strong recommendation), adds tai chi or qigong during treatment, and recommends against wakefulness agents and routine psychostimulants. For screening and choosing a tool, the 2014 ASCO adaptation (screen everyone; assess and correct causes in moderate to severe fatigue) and the APTA 2022 tool grades are the sources read. Where these differ from ESMO 2020 cannot be said, because the ESMO guideline could not be read.","sources":["asco-sio-2024","asco-2014","apta-2022","esmo-2020","mascc-2026"]},"variants":[{"name":"American ginseng during treatment","differs":"Adds a supplement, Panax quinquefolius 2,000 mg a day, for fatigue during treatment.","evidence":"ASCO-SIO 2024 grades the evidence low and the recommendation conditional; after treatment it found the evidence on ginseng insufficient to recommend for or against. It suggests twice-daily dosing, morning and before noon, to avoid disturbing sleep. Supplements can interact with cancer drugs, so a pharmacist should check.","sources":["asco-sio-2024"]},{"name":"Yoga, acupressure or moxibustion after treatment","differs":"Mind-body or traditional Chinese medicine approaches offered after treatment instead of or alongside exercise and CBT.","evidence":"Each conditional on low-quality evidence in ASCO-SIO 2024 after treatment (yoga especially in women with breast cancer). During treatment, the panel found the evidence on yoga and acupressure insufficient.","sources":["asco-sio-2024"]}],"grades":[{"claim":"Mindfulness-based programmes reduce fatigue after treatment","grade":"Moderate; Strong","source":"asco-sio-2024","quote":"2.3. Clinicians should recommend mindfulness-based programs to reduce the severity of fatigue in adults who have completed cancer treatment."},{"claim":"Psychostimulants are not recommended routinely during treatment","grade":"Moderate; Conditional (against)","source":"asco-sio-2024","quote":"1.9. Clinicians should not routinely recommend psychostimulants, such as methylphenidate, to manage symptoms of cancer-related fatigue in adults undergoing cancer treatment Moderate Conditional"},{"claim":"Antidepressants are not recommended for fatigue during treatment","grade":"Moderate; Conditional (against)","source":"asco-sio-2024","quote":"1.10. Clinicians should not recommend antidepressants, such as paroxetine, to manage symptoms of cancer-related fatigue in adults undergoing cancer treatment Moderate Conditional"},{"claim":"Exercise in advanced cancer or at the end of life","grade":"Insufficient; no recommendation","source":"asco-sio-2024","quote":"There is insufficient evidence to make recommendations for or against collaborative care intervention, exercise, melatonin, or protocolized patient-tailored treatment to manage symptoms of cancer-related fatigue among adults with advanced cancer or at the end of life"},{"claim":"Multidimensional assessment tools","grade":"A","source":"apta-2022","quote":"Grade A scales of the PFS-R, the FACIT–Fatigue, and the PROMIS Fatigue–Short Forms."}],"sources":[{"key":"asco-sio-2024","label":"Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update","publisher":"ASCO and SIO, Journal of Clinical Oncology","year":2024,"url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC12082589/","doi":"10.1200/JCO.24.00541","gradingScheme":"Evidence quality high, moderate, low, very low or insufficient; strength of recommendation strong or conditional (weak), for or against.","read":"full-text","accessed":"2026-11-11"},{"key":"asco-2014","label":"Screening, Assessment, and Management of Fatigue in Adult Survivors of Cancer: an ASCO Clinical Practice Guideline Adaptation","publisher":"ASCO, Journal of Clinical Oncology","year":2014,"url":"https://europepmc.org/abstract/MED/24733803","doi":"10.1200/JCO.2013.53.4495","read":"abstract","accessed":"2026-11-11"},{"key":"apta-2022","label":"Screening and Assessment of Cancer-Related Fatigue: A Clinical Practice Guideline for Health Care Providers","publisher":"Academy of Oncologic Physical Therapy of APTA, Physical Therapy","year":2022,"url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC9525018/","doi":"10.1093/ptj/pzac120","gradingScheme":"Tools graded A (should be used in clinical practice), B (may be used), P (limited evidence, one study) or R (not recommended or limited evidence).","read":"full-text","accessed":"2026-11-11"},{"key":"esmo-2020","label":"Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment","publisher":"ESMO, Annals of Oncology","year":2020,"url":"https://doi.org/10.1016/j.annonc.2020.02.016","doi":"10.1016/j.annonc.2020.02.016","read":"not-reachable","accessed":"2026-11-11"},{"key":"mascc-2026","label":"MASCC endorsement and global perspectives on implementation of the ASCO-SIO fatigue in adult cancer survivors guideline","publisher":"MASCC, Supportive Care in Cancer","year":2026,"url":"https://doi.org/10.1007/s00520-026-10855-z","doi":"10.1007/s00520-026-10855-z","read":"not-reachable","accessed":"2026-11-11"}],"upgrades":[],"gaps":["The ESMO 2020 cancer-related fatigue guideline could not be read (no abstract in Europe PMC; the publisher refused a script), so where ESMO differs from ASCO-SIO is not shown.","The 2014 ASCO adaptation was read only as an abstract: its screening intervals, the 0 to 10 cut-offs it uses for moderate and severe fatigue, and its list of laboratory tests are not given here.","The MASCC 2026 endorsement was not read; Europe PMC holds only its title.","NCCN's cancer-related fatigue guideline is not reproducible and was not read.","The 2024 evidence base is drawn mostly from women with breast cancer; how well the recommendations carry to other cancers is not settled.","Children and adolescents have a separate guideline (2023 update) that was not read here."]},"route":"/protocols/cancer-related-fatigue-screening-and-management/","neighbours":{"protocol":[{"id":"exercise-during-and-after-cancer-treatment","kind":"protocol","name":"Exercise during and after cancer treatment: assessment, dose and referral","route":"/protocols/exercise-during-and-after-cancer-treatment/"}],"drug":[{"id":"dexamethasone","kind":"drug","name":"Dexamethasone","route":"/drugs/dexamethasone/"}],"section":[{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"american-ginseng-fatigue","kind":"technology","name":"American ginseng for cancer-related fatigue","route":"/technologies/american-ginseng-fatigue/"},{"id":"cbt-fatigue-distress","kind":"technology","name":"Cognitive behavioural therapy for fatigue and distress","route":"/technologies/cbt-fatigue-distress/"},{"id":"exercise-oncology","kind":"technology","name":"Exercise & lifestyle oncology","route":"/technologies/exercise-oncology/"},{"id":"exercise-during-chemotherapy","kind":"technology","name":"Exercise during chemotherapy and radiotherapy","route":"/technologies/exercise-during-chemotherapy/"},{"id":"cancer-related-fatigue-management","kind":"technology","name":"Fatigue after cancer treatment: what actually works","route":"/technologies/cancer-related-fatigue-management/"},{"id":"mindfulness-based-interventions","kind":"technology","name":"Mindfulness-based stress reduction and cognitive therapy","route":"/technologies/mindfulness-based-interventions/"},{"id":"tai-chi-qigong","kind":"technology","name":"Tai chi and qigong","route":"/technologies/tai-chi-qigong/"},{"id":"yoga-cancer","kind":"technology","name":"Yoga during and after cancer treatment","route":"/technologies/yoga-cancer/"}],"institution":[{"id":"asco","kind":"institution","name":"American Society of Clinical Oncology (ASCO)","route":"/institutions/asco/"},{"id":"esmo","kind":"institution","name":"European Society for Medical Oncology (ESMO)","route":"/institutions/esmo/"},{"id":"mascc","kind":"institution","name":"Multinational Association of Supportive Care in Cancer","route":"/institutions/mascc/"}],"term":[{"id":"cancer-related-fatigue","kind":"term","name":"Cancer-related fatigue (tiredness)","route":"/terms/cancer-related-fatigue/"}]}}