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Announcer:
You’re listening to Project Oncology on ReachMD, sponsored by Lilly. Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle:
For patients with chronic lymphocytic leukemia, fatigue is a common yet debilitating side effect. But the good news is that if we as clinicians gain a deeper understanding of its causes and impacts, we can more directly and accurately alleviate this burden for our patients.

Welcome to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and joining me to explore chronic lymphocytic leukemia fatigue, or CLL fatigue for short, is Dr. Lindsey Roeker, a Hematologic Oncologist at the Memorial Sloan Kettering Cancer Center. Dr. Roeker, welcome to the program.

Dr. Roeker:
Thanks so much for having me. Excited to be here.

Dr. Caudle:
Well, we're excited to have you. So, let's begin by reviewing our current understanding of this topic. Dr. Roeker, how can a patient tell whether they're experiencing CLL fatigue, as opposed to everyday fatigue?

Dr. Roeker:
So, for many of my patients, they come in and they say, ‘You know, I just feel rundown, and I'm not entirely sure why that is.’ And there are a couple of things that I think about when I have a patient who is experiencing fatigue. The first is that fatigue is incredibly common. So, there was a survey of about 1,500 patients with CLL. That now was a while ago, it was back in 2007. But they looked at basically fatigue levels for patients who have CLL compared to the general public. And they found that fatigue is slightly more problematic in patients with CLL than the general population, but not to the extent you would expect. And it really is for low-stage patients. So those with early-stage disease, patients experience a similar degree of fatigue as their healthy controls. When patients have more advanced-stage disease with anemia, then the fatigue does appear to be more profound for people with CLL.

They also found that there was more fatigue in patients who had been treated for CLL, though, you have to consider that this survey was done back in a time where all therapy was chemoimmunotherapy. So that's also a bit different than it is now.

So, when a patient's coming in and describing fatigue, I really tried to dissect why I think they're having that. Are there any endocrinopathies that might be causing this? So, I check a thyroid level. Is there untreated or undiagnosed sleep apnea? Common causes of fatigue that can be issues. The other things I think about are CMV and EBV, are we missing a viral infection? Are we missing some other reason that people are really feeling rundown? And then when I'm talking to them about kind of this problem, I often say, ‘I want to help your fatigue, but I also need to treat the thing that's causing it, because if I treat your CLL, and that's not the cause of your fatigue, it's not actually going to help you feel better. And that really reassures my patients that I'm on their side, thinking about what we should be pursuing and thinking about, but also making sure that I'm not jumping into therapy for fatigue by itself.

Dr. Caudle:
That makes a lot of sense. And what are some of the primary causes of CLL fatigue?

Dr. Roeker:
So, the fatigue that I really can definitively attribute to CLL is fatigue associated with anemia. So those are your patients who also have dyspnea on exertion and might have other symptoms of anemia. And that's a fatigue that you can be fairly confident that if you treat the CLL, it will get better. Patients who have kind of this more generalized low energy level are a bit more tricky to manage. And those are the ones where it's really a consideration of how much it's impacting their daily life. So, are they able to do the things they enjoy? Is it limiting their activity? If it's limiting their activity, then obviously, first making sure that there's not another contributing cause is important, but those are the patients where if there's another indication, it might tip the scales toward therapy for CLL.

Dr. Caudle:
Okay. And with all that in mind, Dr. Roeker, can you walk us through how CLL fatigue impacts a patient's overall quality of life?

Dr. Roeker:
Absolutely. So, the same survey that I'd mentioned earlier really looked at quality of life. And it seems like fatigue is one of the major contributors to patient’s quality of life. And they looked at basically how patients experienced their disease. Many felt that their doctors were really in tune with their stage of their disease, how it was progressing, whether they were requiring therapy, what the therapy would be, but somewhat less in tune with how this fatigue or other issues were really affecting their quality of life. And I think because it's a disease that is managed primarily with watch and wait in the early stages there is a lot of anxiety associated with that. So, the other thing to think about when people are describing fatigue is this actually a depressive or mood disorder symptom that we should be considering as patients are adjusting to their illness?

Dr. Caudle:
That's a really good point.

Dr. Caudle:
And for those of you who are just tuning in, you're listening to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. Lindsey Roeker about chronic lymphocytic leukemia fatigue.

So, Dr. Roeker, now that we understand the impact of CLL fatigue on a patient's quality of life, let's take a look at how we can help alleviate that burden. What are some strategies you use to help patients manage their CLL fatigue?

Dr. Roeker:
If you've truly proven that there isn't another cause, so there are no infections, there's no sleep apnea, there is no thyroid dysfunction, patients don't have a mood disorder that's causing fatigue, then it's really a consideration of what strategies can you implement to really help them feel better. And the most effective strategy in this setting is really exercise. So, I often encourage my patients to really, you know, it doesn't have to be high intensity, it doesn't have to be a specific exercise, but some form of physical activity every day is an important part of just helping people feel better despite their disease. So, I really talk to people about that.

There also seems to be a subset of people who have this fatigue that strikes in the afternoon, and they can kind of pinpoint the time where it's going to happen.  My favorite advice that one of my mentors really used, and I have now incorporated into my practice, is figure out what that time is, and 15 minutes before that head outside, get a couple laps around the block. That fresh air and sunshine on your eyeballs really can make a big difference. And it actually has worked incredibly well for a number of my patients. So simple things that can really support people through symptoms that if they're not managed and not addressed can really be debilitating, can really make a difference.

Dr. Caudle:
Excellent. And how can we counsel our patients to help them cope with the impacts of this fatigue?

Dr. Roeker:
So, I think the major piece is figuring out how much to have patients push themselves versus how much to rest. Because, I think a lot of people really reach for, ‘Okay, if I'm not feeling great, I'm going to stop my normal activities, I'm going to stop my normal exercise and spend more time just kind of sitting around.’ And I think that's not the right strategy for most patients, because that actually leads to more deconditioning and further decline in functional status. So, except in the case of really a symptomatic anemia, where the answer is treating the CLL, I think a lot of it has to do with lifestyle modification and really working with people to ensure that they're still engaging in activities and moving forward with all of the things not allowing their disease to really take over their life.

Dr. Caudle:
And before we close, Dr. Roeker, do you have any final thoughts you'd like to share with our audience?

Dr. Roeker:
I think given the indolent nature of CLL, it really is important that we are attentive not only to our patients, physical well-being but also their social and emotional well-being. And really addressing fatigue and asking people how they're feeling or how they're doing is such an important part of the patient-physician relationship. So, I think CLL provides a cool opportunity to really connect with our patients and provide some easy, low-impact sort of suggestions that can really make a difference in people's lives.

Dr. Caudle:
That's excellent. And with those final thoughts in mind, I'd like to thank our guest, Dr. Lindsey Roeker, for joining me to discuss how we can help our patients who are experiencing CLL fatigue. Dr. Roeker, it was great having you on the program.

Dr. Roeker:
Thanks so much for having me. It was a pleasure.

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