Cancer-Related Fatigue

By Lucas Tims, ND, FABNO

Cancer-Related Fatigue has been reviewed and updated from the original Health Hunters article Vol. 33 No. 8 in August 2019.

Fatigue is a common problem in cancer patients, both among those undergoing active treatment and survivors. Some reports show that as many as 90% of cancer patients struggle with fatigue at some point in their journey and a prevalence of up to 45% in cancer survivors. The fatigue that comes with cancer, called cancer-related fatigue (CRF), is different from the fatigue of daily life. CRF disrupts all aspects of quality of life and may be a risk factor for reduced survival.1

By definition, CRF is a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. More and more, Cancer Centers are relying on integrative medicine practitioners to help manage this complex condition with complementary and alternative (CAM) therapies,2 as these have been shown to be the most promising interventions available at this time.

What Causes CRF?

While the causes of CRF are not fully understood, it is generally thought to be a multifactorial condition and component of a symptom complex which may include depression, anxiety, and sleep disorders.

With CRF, sometimes there are measurable factors involved, such as anemia, nutritional deficiencies, or hormonal imbalances. However, there are intangibles that may contribute to CRF, such as pain, stress, poor sleep patterns, deconditioning, and medication side effects. On top of all that, there is fatigue that can be caused by cancer itself and cancer treatments such as surgery, chemotherapy, and radiation.

Given the complexity of the problem and the lack of objective measurement of what is primarily a subjective symptom, interventional trials have been somewhat limited.

What Can be Done? 

Despite the lack of a universal objective measurement for CRF, research into effective interventions has continued to build and better inform clinicians on mitigating this highly prevalent condition. Several evidence-based therapies have been identified to help improve CRF potentially. Let’s take a look at some of these:

  • Ginseng – This traditional Chinese Medicine herb has long been used as a natural energy booster. In a large study led by Mayo Clinic, high doses of the American ginseng (Panax quinquefolius) given over two months effectively reduced CRF.3 Ginseng’s improvement of fatigue is likely due to its known mechanisms of decreasing inflammation and regulating cortisol levels.
  • IV Vitamin C – A 2018 review of several human trials concluded that intravenous ascorbic acid (vitamin C) up to 25g can improve several quality of life measures, including CRF.4 Of note, most of these trials have shown this effect in patients undergoing concomitant chemotherapy treatments.
  • Mistletoe – European mistletoe (Viscum album) extracts have an extensive history of use and clinical evidence as a safe and effective adjunctive cancer treatment to help with the quality of life measures, including CRF. Although it is used across all tumor types, gynecologic and breast cancer patients have shown particular improvement in fatigue with mistletoe use.5
  • Acupuncture – More established as a tool to treat pain and nausea in cancer patients, recent studies have also shown this versatile modality to be quite beneficial for CRF.6
  • Exercise – Aerobic exercise, with its myriad health benefits, has been clearly shown to improve CRF, particularly in survivors. The American Cancer Society recommends that adult cancer survivors get at least 150 minutes of moderate-intensity or 75 minutes of vigorous activity each week (or a combination of the two).7 This intervention not only helps with CRF but also reduces cancer recurrence.
  • Sleep – The majority of studies that have assessed both sleep and fatigue in patients with cancer provide evidence supporting a strong correlation between CRF and various sleep parameters.8 It’s clear that the quality and duration of sleep, or lack thereof, reciprocate with CRF. Improving sleep hygiene is crucial and oftentimes the first place to start. Beyond that, a trial of a natural sleep aid, such as melatonin, may be enough to tip the scales in favor of improved sleep.
  • Tai Chi – The traditional Chinese health-promoting exercise, often done in groups, has been shown to have many positive effects in cancer patients. A meta-analysis investigating the effectiveness of Tai Chi on CRF concluded that the practice leads to short-term ameliorative effects that are actually superior to rigorous physical exercise and psychological support.9 The best results were shown in patients with breast and lung cancers.


CRF is one of the most distressing cancer-related symptoms and requires a clinician or team of clinicians to look at many underlying causes and interrelated conditions. Cancer patients would benefit greatly by working with an integrative practitioner. As the understanding of cancer and its treatments evolves rapidly, so will our knowledge of CRF and how to best manage it.


  1. Bower J. E. (2014). Cancer-related fatigue–mechanisms, risk factors, and treatments. Nature reviews. Clinical oncology, 11(10), 597–609.
  2. Latte-Naor, S., & Mao, J. J. (2019). Putting Integrative Oncology Into Practice: Concepts and Approaches. Journal of oncology practice, 15(1), 7–14.
  3. Barton, D. L., Liu, H., Dakhil, S. R., Linquist, B., Sloan, J. A., Nichols, C. R., McGinn, T. W., Stella, P. J., Seeger, G. R., Sood, A., & Loprinzi, C. L. (2013). Wisconsin Ginseng (Panax quinquefolius) to improve cancer-related fatigue: a randomized, double-blind trial, N07C2. Journal of the National Cancer Institute, 105(16), 1230–1238.
  4. Klimant, E., Wright, H., Rubin, D., Seely, D., & Markman, M. (2018). Intravenous vitamin C in the supportive care of cancer patients: a review and rational approach. Current oncology (Toronto, Ont.), 25(2), 139–148.
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  6. Zhang, Y., Lin, L., Li, H., Hu, Y., & Tian, L. (2018). Effects of acupuncture on cancer-related fatigue: a meta-analysis. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 26(2), 415–425.
  7. Mustian, K. M., Sprod, L. K., Janelsins, M., Peppone, L. J., & Mohile, S. (2012). Exercise Recommendations for Cancer-Related Fatigue, Cognitive Impairment, Sleep problems, Depression, Pain, Anxiety, and Physical Dysfunction: A Review. Oncology & hematology review, 8(2), 81–88.
  8. Roscoe, J. A., Kaufman, M. E., Matteson-Rusby, S. E., Palesh, O. G., Ryan, J. L., Kohli, S., Perlis, M. L., & Morrow, G. R. (2007). Cancer-related fatigue and sleep disorders. The oncologist, 12 Suppl 1, 35–42.
  9. Song, S., Yu, J., Ruan, Y., Liu, X., Xiu, L., & Yue, X. (2018). Ameliorative effects of Tai Chi on cancer-related fatigue: a meta-analysis of randomized controlled trials. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 26(7), 2091–2102.