ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the voice of the world's oncology professionals.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guests’ statements on this podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses.

Fatigue is a common symptom of cancer and its treatment, and it can be very difficult to treat. However, exercise is one simple method that’s been shown to help people with cancer manage and cope with cancer-related fatigue.

In this podcast, Dr. Anna Roshal talks with Dr. Tarah Ballinger and exercise physiologist Danielle Halsey about what people with cancer should know about cancer-related fatigue and the ways that exercise can help.

Dr. Roshal is a medical oncologist and assistant professor of clinical medicine at the Indiana University School of Medicine. She is also a member of the Cancer.Net Editorial Board. Dr. Ballinger is a medical oncologist, an assistant professor of clinical medicine, and the Vera Bradley Foundation Scholar in Breast Cancer Research at the Indiana University School of Medicine. Ms. Halsey is the lead exercise physiologist at the Indiana University Melvin and Bren Simon Comprehensive Cancer Center.

You can view disclosures for Dr. Roshal, Dr. Ballinger, and Ms. Halsey at Cancer.Net.

Dr. Anna Roshal: Hello, my name is Dr. Anna Roshal. I am a medical oncologist at Indiana University, and I am very, very pleased to have 2 great guests today, Dr. Tarah Ballinger and Danielle Halsey, who is an exercise physiologist. And the topic of our podcast today is cancer fatigue. So before we start, I'm just going to disclose that none of us have any relevant conflicts to disclose today.

So I will introduce our guests very briefly. So Dr. Ballinger is also a medical oncologist here at Indiana University. She is an assistant professor of medicine and also an associate director of our supportive oncology program. And like I said, Danielle Halsey is the lead exercise physiologist supporting our Multidisciplinary Oncology Vitality and Exercise (MOVE) program for patients with cancer.

So my first question to start us, and I would direct to Dr. Ballinger, but Danielle, please jump in as well. We all know that cancer patients have a lot of fatigue, and there's many, many reasons why. And it's actually one of the most common, if not the most common concern and complaint that our cancer patients have as they're first diagnosed and as they're going through treatment, and also even after treatment. So it is something that specifically affects their quality of life, maybe more than any other symptoms. So, Dr. Ballinger, can you discuss what are some of the reasons cancer itself and cancer treatments can cause fatigue?

Dr. Tarah Ballinger: Yeah, that's a great and somewhat difficult question. So as you mentioned, cancer-related fatigue is the most prevalent cancer-related symptom, both in patients going through treatment, but even for many years after experiencing cancer. Cancer patients have significantly more fatigue than someone who has not gone through the disease.

The reason why it's so prevalent and so difficult to treat is because the causes of it are so multifactorial. There's, of course, physical symptoms from cancer that can cause fatigue, pain, shortness of breath, depending on where the cancer might be located. And there are psychological symptoms associated with cancer that can cause fatigue, like anxiety, depression.

Definitely trouble sleeping is a big issue. But even beyond these symptoms from cancer, tumors themselves have direct effects that can cause fatigue. So cancer itself causes inflammation that can impact hormone production and other balances in the body that can certainly cause fatigue.

And all of that is before we even start to talk about the other thing you mentioned, which is side effects of treatment. So that includes anemia, which means there's less red blood cells, so there's less oxygen delivery to tissues, and that can make people feel a lot more tired. We also have a lot of evidence that cancer treatments actually impact muscle function at the cellular level. Often what I hear from patients is that they feel sore, like they've worked out, but they haven't actually done anything. And that's really a real thing directly caused by cancer and its treatments. So again, the reason this is so hard to treat is because there are so many potential things that are kind of coming together to cause the problem.

Dr. Anna Roshal: Yeah, that's certainly very interesting. And again, it's complex and lots and lots of factors contributing. I'm curious to hear how would you distinguish, we've all been tired, right? So there's regular tiredness and there is this relentless cancer fatigue that our patients experience. And it's, how do we tell the difference and how do our patients tell the difference? That's most important. How do your loved ones tell the difference of somebody just having a difficult day and they’re tired, or is this cancer fatigue that we're talking about?

Dr. Tarah Ballinger: Yeah, cancer-related fatigue is different from the fatigue I might have if I stayed up late or was in clinic all day. That fatigue you can push through and probably will get better if you take a nap. Cancer-related fatigue, classically, it somewhat feels like moving through sand, like you just can't get through it.

Taking a nap tends to not be something that actually makes it better. And I think that can be a real struggle for patients in terms of their loved ones relating to them because a lot of people will think, oh, well just get some rest and you'll feel better. But that's not really how it works for cancer-related fatigue, which is why we try to look for other ways to try to improve this symptom.

Dr. Anna Roshal: That's a great point. I certainly noticed that in my patients and certainly noticed it in my interactions with the loved ones of patients because that's one of the most common responses. So they just didn't get enough sleep or maybe they didn't drink enough water or anything like that. But we do know that it's much more complex than that. So maybe this is a good jumping point to talk about what kind of research has been done to look into how we can make this better.

You know, since fatigue is this very complex symptom affecting our patients’ quality of life, what can we do to make this better?

Dr. Tarah Ballinger: Yeah, so that's one of the reasons I'm really excited that we're talking about this prevalent symptom today because one of the, or the best thing that we have found to help with cancer-related fatigue is actually exercise. And that can seem a little bit counterintuitive if you're fatigued that you should exercise, but even light movement can help. So what's really awesome about exercise is that it can target all of those different mechanisms for cancer-related fatigue that I mentioned. And that's really different from what we typically think of in treatment, which is medications. Medications have kind of 1 mechanism of action. They might treat 1 cause of something, but exercise is able to actually treat all those different potential causes of cancer-related fatigue.

So it can help with physical symptoms from the cancer, the psychological symptoms from the cancer, and even those direct effects of the tumor and the treatment. So exercise, it's really one of the only things that's been proven to improve the symptoms of cancer-related fatigue. It helps with our muscle function. It helps improve oxygen delivery to tissues.

And when you exercise, it actually changes your body's immune system and it's anti-inflammatory. So there are true scientific mechanistic reasons for why exercise can be helpful. And again, it's one of the only things that we've proven over and over again can and does improve these symptoms.

Dr. Anna Roshal: That's great. And that's, yeah, like you said, it does seem counterintuitive. And I find that as an oncologist discussing this with patients in the clinic can be quite challenging. Because like, yeah, I'm tired. And you really want me