The Gap Between Real World Healthcare & Social Media

nullWhen More Is Less, and Less Is More

Part of what I like to think makes my blog unique is that I’ve been a cancer patient as well as a clinician treating cancer patients. So, I have one foot in each camp, as it were.

This blog, and my introduction to social media, germinated almost ten years ago after I had been diagnosed with breast cancer in July of 2008. Desperate for help and information, I found my way, as many have and many will, to and it’s online, peer support community. Dozens, possibly hundreds, of the people I connected with in that community are still my friends online all these years later on other social media. Then and now, these friends help validate my experience and often provide helpful information about breast cancer and treatment and side effects and middle-of-the-night freaking out. Back then, communicating with them spurred me to start reading research studies again, which I hadn’t done much of since physical therapy graduate school. Because of that, I began to connect with clinical and medical and science websites, and with researchers who’d published interesting studies or were seeking study participants. One of the most helpful experiences I had early on was finding an online listing for two doctors within driving distance who were conducting a clinical trial on treating cancer related fatigue. Thus, I am one of the first people to extol the virtues of social media and of those of us who employ it to advocate for better healthcare.


And it’s an important ‘but.’ I may write about healthcare here in cyberspace, but in my daily, real-world job, I work in the concrete world. I do connect with a secure server to upload my patient notes and download my schedule each day on my work laptop. And I email my colleagues and share a few pdf’s.

But my real work has little to do with zeroes and ones. I see patients of all ages, with all kinds of healthcare problems, in their homes, and try to teach them to walk better or not fall or to get out of bed without pain. And I have to tell you that, for most of them, social media has little to no impact on their experience of their own health and healthcare. A few of them might have a Fitbit. A few might have a patient portal account that they use to email their doctors’ offices or confirm upcoming appointments. And that’s about it.

The last thing that most, perhaps nearly all, of my patients would consider doing when they have a health crisis is to get online. You’d be forgiven for thinking this is an age thing, that it’s because most of my patients are elderly. And you’d be wrong. Sometimes, it does occur to a few of them, or to one of their family members or caregivers, to buy things like tub seats and walkers online. Most of the time, however, I have to tell them they can buy that stuff online. I have to tell the folks who have uncommon chronic diseases, or even common ones, that there are online communities that can help them feel less isolated. I have to tell them that there are websites for our state’s department of health, the department of elderly affairs, the local hospital or orthopedic practice, for, for the American Diabetes Association, etcetera, ad infinitum.

Pay No Attention to That Charlatan Behind the Curtain

Why don’t people get online for help with their health issues? Because they have health issues. Which means that they feel like shit, they’re exhausted, confused, overwhelmed, in pain, and generally gobsmacked. And the last thing they feel like doing is anything that does not immediately and concretely help them to feel better. And you know what? Mostly, I’m glad they don’t get online. I want them to listen to me and their doctors and nurses, and to follow our advice, not to read most of the execrable bullshit that passes on the web for healthcare information. I do not want them getting their health advice from the likes of Gwyneth Paltrow or Dr. Google. It’s bad enough that they watch TV. I wish I had a dollar for every time I’ve had to refute some nonsense a patient heard via Doctor Oz.

It’s hard enough for me to sort through the dross on the web to find the genuine nuggets. And I have an advanced degree in science. And I still get hoodwinked sometimes. But I also have online friends who are scientists, doctors, and intelligent healthcare journalists, and we help each other wade through the swamp.

That is not, however, true for most people. I have some very admirable friends online who have devoted themselves to improving health literacy, who work hard to improve their own, so that they can provide the patient’s perspective to researchers who design studies. But the odds that most of the thousands of people I have ever treated in the past twenty-five years could or would find their way to these web advocates or others like them is a snowball’s chance in hell. For real.

A Breed Apart

The thing to keep in mind is that those of us who are members of the healthcare social media community are not most people. Yet we may think we’re more important than we really are to most people. If there’s one thing that social media is good at, it’s declaring how important and influential social media is. And that’s true, up to a point. But we need a little humility, a little perspective about our role. When you have crushing, unrelenting chest pain, the sensible response is not to Tweet about it. You call a freaking ambulance.

I remember the first time I took a survey — one of several over the years — about how useful social media had been to me as a cancer patient. It was put together by a grad student who was working on her Ph.D. and whose mom had had breast cancer. It was pretty good. But when I got to the questions about who did the most to help me outlast cancer, or who I could most count on in a crisis, none of the answers included social media. The answers included the doctors and other clinicians who treated me, and the friends who drove me to see them. And yet, to hear some tell it, social media is going to save us all and reinvent the healthcare system. Really? Tell that to all my patients and work colleagues. Social media has facilitated awareness, research, and patient support. And it will continue to spur new and worthwhile ideas and projects. But the rest of the fix is not that simple.

In the Trenches

If you want to hear a passionate discussion about how to fix the healthcare system, talk to another clinician. And I don’t mean online. I mean in person, in a clinical setting or at a seminar. Or at the local pub over a beer or three. You’ve never heard intelligent snark like you’ll hear from us. A few of the doctors I’ve known over the years, who have also treated me as a patient, are especially enlightening. When I see them for a checkup, we often spend the first few minutes having a nice, soul-cleansing rant about it all. Do they check out social media for ways to further the cause? Hell, no. They have neither the time nor the energy. Frequently, neither do I. We’re all too busy trying to help our patients get better, or returning their phone calls, or typing notes about them on a computer, or wrangling with insurance companies and their criteria for reimbursement, or going to meetings and continuing ed seminars so we can remain competent enough to keep our licenses. On a daily, practical basis, has social media or digital documentation made our work easier or better? Not really.

I don’t have any immediate answers to this conundrum. And the ideas I have would require another blog post. But I can tell you one thing. When my patients improve, it has everything to do with how much access they feel they have to a real-world clinician who knows them, and how empowered they feel to take responsibility for their health. And then to do what they truly need to do in order to get better. And that’s where fostering the nexus between social media and the real world may be genuinely useful. Any and all ideas welcome. In the meantime, onward, friends.

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The Light is Everything

“Still, what I want in my life
is to be willing
to be dazzled—
to cast aside the weight of facts

and maybe even
to float a little
above this difficult world.
I want to believe I am looking

into the white fire of a great mystery.
I want to believe that the imperfections are nothing—
that the light is everything—that it is more than the sum
of each flawed blossom rising and falling. And I do.”

― Mary Oliver, House of Light

Last year was a hard year. At this time a year ago, there were a couple of bombs about to go off in my personal life. One was that my elderly and much beloved cat, Fiona, was dying of cancer, but I didn’t know it yet. The other was that I was rapidly developing symptoms that, being a physical therapist, I would consider and reconsider, and finally realize I had to do something about or face disability. I variously wondered if I were developing a neuromuscular disorder, like multiple sclerosis, or if the neuropathy in both hands, the eroding balance, and the overall muscle weakness were the result of something more mechanical, but equally alarming, like a pinched nerve from a herniated disk or arthritis in my spine.

By the end of January, after three weeks of frustrating, apathetic vet care that caused Fiona — and me — a lot of needless suffering, I took her to a compassionate vet hospital where my sweet girl died of bowel cancer at the age of fifteen. And for the first time in thirty-five years, I had no pets in the house. A few weeks later, I adopted two feral female cats that had been separately rescued and brought to a local shelter, where they had languished for several months, waiting for some crazy human to take a chance on them. Not long after that, I had an MRI which showed that my spinal cord was being compressed by three bulging disks in my neck, and I needed surgery urgently. I went on leave from work in mid-April, had surgery, and did not return to work until late June. I had side effects from the mechanics of surgery for months — still do, in fact — but I could walk again without a cane, hold a pen and use a keyboard, feel my patients’ pulses with my fingertips, and do my job.

Meanwhile, in the online breast cancer community, we were losing people. Nothing new there, sad to say, but we were losing ass-kicking, brilliant, well-known and much-loved advocates and activists. People like Lori Marx-Rubiner, a long-time advocate and blogger whom I’d finally met in November of 2016 at a conference on MBC. Like Beth Caldwell, an attorney, activist and co-founder of MetUp. One of those we lost was my friend Susan Hamson, aka Scorchy Barrington, known to many from her blog, The Sarcastic Boob. Susan had been dying by inches of metastatic breast cancer herself for much of the time I’d known her, but especially in 2017, she was teetering on the edge, alternately in a hospice facility and in an acute care hospital. Not long after I was finally returning to work, Susan was beginning to lose the ability to communicate. Less than five months later, on November 14, 2017, she died.

I still cannot type about, or talk about, or think about her death at any length without feeling completely gutted. Many of you know what it is like to form a heartfelt, mutual bond with a sister in our cyber community that extends into all forms of communication. Many of you also know what it’s like to finally meet one of these precious friends in person. In October of 2016, I not only got to meet her, but I got to have her as a guest for a three-day weekend at my home, being snuggled by dear Fiona, who knew a cat lover when she met one, and who kept finagling ways to get the three of us in close proximity all weekend. I had tried to talk Susan into letting me take the train to visit her instead that weekend, but I think she knew it was the last time she would be physically able to attempt such a thing. And I’m a clinician, and I live down the street from the hospital system that employs me, and I knew if something dire happened, I could look after her. So, she came, by Amtrak, from NYC, to the charming, late-Victorian train station ten minutes from my home in southern New England. It was lovely, and I will always cherish the memory of that visit. But it makes my grief all the worse. She deserves, and will get, a post from me that is devoted solely to her, but not just now, not just yet.

Then there is the world, this country, and its politics. There is the sobering awareness of the scale of sexism and misogyny we’ve all experienced, an awareness brought about by the #MeToo movement. There are still and ever mass shootings. There have been ungodly natural disasters that have destroyed swaths of America by hurricanes, fires, blizzards, you name it. The drinking water crisis in Flint, Michigan is still unresolved. All of these things have affected the lives of countless individuals, changing them forever. One of my friends and colleagues was hit last year by a drunk driver while she herself was driving to visit a patient. She lived, but she has been unable to work since. And for me, there is the reality of working in home health care, and visiting people who are disabled or sick or old or poor, or all of the above. And of being astounded at how utterly ignorant, how lacking in any sort of compassion, that dozens of our national elected and appointed so-called public servants apparently are toward the reality of the people I treat every day. I’ve had to learn to ignore a lot, or limit my exposure to a lot, else I could not get out of bed in the morning.

One thing I’ve discovered though is that, miraculously, nine years after I was diagnosed, the personal aftermath of my own breast cancer and its treatment doesn’t bother me much these days. Sure, any year now, I could have a recurrence. But I don’t seem to live in the “could” of it anymore. The possible seems to have been shaken right out of me by the actual. A year ago, I was on the road to being permanently disabled by something that wasn’t cancer. Nothing like perspective. After the past year in particular, you can scarcely escape the awareness that there is a whole lot of other shit out there that can destroy life as you know it.

So, at the beginning of this new year, while I dig out of the large pile of snow Mother Nature just dumped on us here in New England, I want to thank my real-world and virtual-world friends, and my blog readers, for being there, and for helping to leaven the heart-breaking parts of the actual with the sheer vitality of your daily existence. I thank you all for being kind, and funny, and whip smart, and perceptive. I thank you for giving a shit about the world and about me, for laughing at my attempts at humor, and for cheering me on as I try to convince two feral cats that humans are indeed worth loving. I am so grateful to you and to the fur girls for helping me to discover that I can still be dazzled, and that I am still willing to be.

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Double, Double, Toil & Trouble: It’s Okay to Ignore Pinktober

[Originally published as a Note on my Facebook page on Saturday, September 30, 2017 while my blog server was down.]

PTSD: Pink-Tober Stress Disorder

There’s more than one type of PTSD. There’s the post-traumatic stress disorder that many of us develop, to one degree or another, after having cancer and cancer treatment. It’s the kind that occurs when our existence is threatened and our entire notion of normalcy is ripped apart and tossed upside down. We are never the same again.

Then there’s the PTSD that comes of having a cancer recurrence. Or the PTSD of being diagnosed with metastases. Or of having someone you love diagnosed with a recurrence or metastases. Or of having someone you love die of metastatic cancer. Or of having several someones you love die of cancer. Or of refraining from trying to list how many people you have lost from metastatic breast cancer in particular, because you’re afraid you’d probably forget some of them because there have been so goddamn many.

And then there’s this year in these United States. A lot of us here have been suffering from socio-political PTSD. Last year’s presidential election campaign was a bruiser. And the outcome, along with what that has revealed about our legislators and our citizenry, is none too savory either. If you are reading this, you probably have a pre-existing condition, which means you’ve been enduring the cliff-hanger created by the GOP, while they have endeavored to make it harder and more expensive for you to have health insurance at all. Double ditto if you’re disabled, poor, or female. Or just not white, male, and wealthy. Apparently that’s all it takes to be disregarded by much of the gang in Washington.

I used to be a bit of a news junkie. I don’t have a TV, but I’d listen to public radio news every morning and evening at home, as well as in the car as I drove around visiting my homecare patients. Not any more. I stopped listening around the first of the year. Now, I read a very whittled-down selection of online news, and not from sources that have demonstrated their inability to stick to facts, no matter what end of the political spectrum they represent.

Which leads to another source of stress this year: social media. Social media is brutal these days. A lot of us have had to do some serious housecleaning. Blocking and unfriending have probably reached some kind of all-time high. Unfiltered posting is more rampant. Forgiveness is more problematic. Acceptance of differing views is more complicated. Me, I’ve become adept at selective scrolling on Facebook. I’ve become allergic to hype, and even more suspicious of so-called “news,” too much of which amounts to pandering. I stay away from Twitter altogether. Mind you, I admire the people there who track public figures and politicians, and endeavor to keep them honest. But Twitter feels like an endless cage fight to me, and I just don’t have the stamina for constant one-ups-man-ship. Which is saying something for a blogger who has herself employed ample snark.

Then there’s my personal life. In January, my beloved fifteen-year-old kitty developed cancer and died, after a month of misery. At least I got to stroke her head and kiss her face before the vet started the IV that ended her suffering. [How to Be Loved by a Cat] But I was shattered. After 35 years, I had no more fur babies in my home, a chasm I eventually filled with two rescued feral cats from a local shelter. Meanwhile, I developed some alarming symptoms — neuropathy, pain, muscles spasms, weakness, loss of balance — that were caused by spinal cord compression in my neck, and I had to have surgery to fix it. Not fun. At all. Still recovering. But, heck, at least I still had job-based health insurance, which the nimrods in Congress could not repeal away. And my leave of absence from work was covered by paid sick time. And I was able to return to work eventually. And it wasn’t cancer. But let’s just say it’s been a rough year.

I’ve been blogging for nine years now. I’ve published over fifty posts, and created countless memes, that have to do with the pointless, puerile merchandising and fundraising extravaganza that we skeptics call Pinktober. There’s even a tab on my blog, called “Pink Peril,” that lists them all. [Fighting the Pink Peril] If you don’t know by now that pink is not a cure; that breast cancer is not a game; that there is only one day set aside in so-called “Breast Cancer Awareness Month” to acknowledge metastatic breast cancer; that only 7% of breast cancer research funding goes specifically to metastatic breast cancer; that Fancy Pinker (thank you, Katie) has yet to keep her promise to find a cure, the promise she made to her sister Susan G. Komen before Susan died of metastatic breast cancer, yet she continues to draw a six-figure salary as Komen chair while not fulfilling that promise; if you haven’t figured out by now that it’s not about our breasts, but about our lives, then WAKE THE HELL UP! And read this, right now: 13 Facts about Metastatic Breast Cancer

As for the rest of us, I hereby grant us all permission to do what we need to do to maintain our sanity. And if that includes ignoring Pinktober, then so be it. We have enough shit to deal with. After nine years, and the loss of too many friends to this cruel disease, while several more suffer endless treatment with the sword of Damocles hanging over them, I’m as aware as I’m ever going to be. And more than likely, so are you.

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Why Am I So Tired? A Primer on Breast Cancer and Fatigue

About seven months ago, I started dealing with a serious health crisis that wasn’t cancer. Three of the disks in my neck were bulging and compressing my spinal cord, leaving me with neuropathy in both hands, weakness everywhere, decreased balance and coordination, and increased muscle pain and spasms. I couldn’t hold small objects or feel my patients’ pulses. I couldn’t carry my work bag over my shoulder by the strap. I had to start using a cane to walk. Because I’m a physical therapist, I knew that if I didn’t do something soon, I would not be able to continue performing my job. In April, I had surgery to remove the three bulging disks and to stabilize those three levels in my neck with hardware and bone graft material. I was out of work for nine weeks altogether, and recently returned, feeling very fortunate that I was able to do so.

Naturally, I thought of my last serious health crisis, which was breast cancer. Next month, it will have been nine years since I was told my biopsy was positive. My neck surgery was a lot more brutal than my partial mastectomy, and a lot harder to recover from. But I didn’t have to endure radiation and Tamoxifen after it. I was exhausted and miserable after neck surgery, but I couldn’t help noticing that ultimately, I felt better than I did before my symptoms started. I certainly cannot say the same about cancer. I still remember what I dynamo I was back then before I was diagnosed, and how, nine years later, I have not fully shaken the effects of the fatigue that moved in and never entirely left me. But I have learned a lot about it, and yes, I do feel a lot better than I did when it started. A lot better. So, it seemed like a good time to write about it once again.

I don’t have a magic spell to offer you about how to make fatigue disappear. But I can tell you a few really good things. Since I first started trying to figure it out back in 2008, the chronic, long-term, body-slamming fatigue that results from cancer and cancer treatment has been formally recognized and given a nice, logical name — cancer-related fatigue, or CRF. There has been a great deal of research on it, verifying its existence, its prevalence, and its biomarkers, and studying various treatments for it. Assessment tools have been developed for it, so that doctors can officially evaluate and diagnose it. And it has even been given its own ICD10 code so that insurances will pay for treating it. One thing that has not changed is that it still happens. Without a doubt, CRF has been one of the most onerous, long-lasting consequences of cancer and cancer treatment for me personally, and for many, many other cancer patients. So, here’s an updated primer that may help.

What is this and why is it happening to me?

As soon as you hear that you have breast cancer, or almost any kind of cancer, your body starts reacting to the awful news. You may feel shock and disbelief. You may have dozens of questions. Your life starts to include a flurry of diagnostic tests and doctor visits. You have to find babysitters, take time out of work, deal with insurance claims, figure out if you can afford co-pays. Your body goes into high-stress mode. Stress has an immediate effect on your emotions, as well as wreaking havoc on the neurotransmitters and hormones that manage your state of mind, your sleep, and your energy. Most likely, your immune system has already been attempting to deal with the cancer cells in your body, long before you are aware of it, and now it has to deal with the physical consequences of uncomfortable tests and biopsies. Your concentration can be adversely affected, and you may find that you are too tired and frantic to deal with ordinary household tasks. And this is just the beginning. Before you even contemplate surgery, radiation, or chemotherapy, you may feel exhausted.

Each step of the treatment path for breast cancer can add to your fatigue. Surgery is often the first step, and depending on your tumor and the options you choose, may involve more than one type of surgery, and more than one protracted period of recovery. If you opt for radiation, it is usually scheduled within weeks of your initial surgery, and can require daily treatment sessions over several weeks. Chemotherapy, by infusion or by oral medications, may require months or even years to receive. If you are diagnosed with de novo metastatic breast cancer, your treatment will never end.

The side effects of each of these treatments can take a huge toll on your stamina. Meanwhile, your life is turned upside down. You may have to miss a lot of work, or not be able to work at all. Your bank account may shrink drastically, and you may need help from others who may not be used to providing care. Is it any wonder that, along with scars, treatment side effects, and anxiety, so many of us develop overwhelming and long-lasting fatigue?

According to a 2013 article, originally published in Brain, Behavior, and Immunity, “Fatigue is one of the most common and distressing side effects of cancer and its treatment, and may persist for years after treatment completion in otherwise healthy survivors.” It has been estimated that from one quarter to nearly all cancer patients experience fatigue during and after treatment. We may be warned about fatigue beforehand, but often these warnings do not begin to encompass the totality of its effect on us and our quality of life.

What is cancer-related fatigue?

Cancer-related fatigue (CRF) is a condition that researchers are still trying to understand. It is not simple tiredness that can be fixed by an extra nap or two. CRF is a persistent, whole-body exhaustion that you can’t ignore. You may sleep for hours every day, yet not feel refreshed or energized by that sleep. You may find it hard to concentrate or to engage in your usual activities. Although in itself, CRF is not the same as depression, you may also find that it affects your mood, as you struggle with or are unable to do the things you want or need to do.

Although CRF exists as a separate issue, there are a number of other physical and psychological factors that may contribute to fatigue. These need to be addressed separately. They include pain; nausea and diarrhea that can lead to dehydration; poor thyroid function; lowered red or white blood cell counts; menopausal symptoms brought on by surgery or chemotherapy; fever and infections; nutritional imbalance; anxiety and depression; and the sedating side effects of medications for pain or anxiety. The decreased activity brought about by fatigue can also make it worse.

A thorough evaluation of your symptoms should be done. This may be carried out by your oncologist or by your primary care physician. And don’t let your doctors brush you off with the usual bromides that you’ll be fine with more rest and more exercise. You need a proper assessment. One of the problems that cancer patients can encounter when trying to get help is that their doctors don’t really know how to assess them for this kind of fatigue. I had to dig up my own information and ultimately find a research study nearby that was able to assess my fatigue and help me get treatment for it. If need be, don’t hesitate to refer your doctor to this link at the National Cancer Institute website that describes CRF in detail, as well as how to assess and treat it.

A number of survey tools have been developed and researched to assess CRF. One of them, called the Fatigue Symptom Inventory, has been found to be consistently reliable. It is a survey that you fill out yourself, and may fill out again from time to time, to see if your symptoms are improving. It can be found and downloaded at this link: Fatigue Symptom Inventory. Don’t be shy about providing your doctor with a copy of it for your chart.

What can I do about CRF?

Before you can address CRF specifically, you need to be treated for any of the other medical issues your doctor may identify when you are evaluated. For example, if you are anemic, you may need to take nutritional supplements like iron or get advice about how to improve your diet to build up your red blood cells. Some cancer patients may need specific medications or even a blood transfusion, and their blood levels will need to be monitored.

Sometimes fatigue is confused with depression. It’s important, therefore, to be evaluated to distinguish between the two. You may experience one or the other, or both at once. But they are not the same. Depression is a mood disorder that usually includes feelings of despair or hopelessness, apathy or lethargy, a desire to isolate yourself, and an inability to feel pleasure in activities that you usually enjoy. Depression can be relieved with medications that help improve the levels of neurotransmitters effecting your state of mind. You may need treatment for depression before you can adequately deal with your fatigue. A link to a previous post about depression and cancer is here: Depression and Cancer: An Insider’s View

Once you have addressed any contributing medical issues, there are a number of strategies that you can try to help your fatigue. Learning to prioritize the things you need to do, and to map out a reasonable schedule, can make life more manageable. It’s hard to ask for help, but this is the time to do it. If your friends or family members ask you to call them if you need something, see if you can make a list of things that need doing, and give them a task. Oncology counselors and nurse navigators, or local cancer support groups, can help you identify sources of help, often at no cost, to get things done. You may need others to babysit, take care of your pets, do the grocery shopping and prepare meals, clean your house, or mow the lawn. If you are able to work, you may be able to do some of your job at home. You may also be able to arrange for shorter work hours. It may be hard just to organize all this, so ask someone to help you with that, too.

Cancer patients are often advised about getting exercise. Exercise can help relieve fatigue, but doing it may seem like an impossible task when you have CRF. As a physical therapist, I try to give my cancer patients various options that address differing levels of energy, from short movement routines that they can perform lying down, to carefully progressive walking routines. Sometimes, you will feel like you can barely get out of bed. It’s often not helpful to be given a complicated routine that you cannot easily complete on your own. The best exercise advice is to keep it simple. Even if all you can do is to walk around your house or down your driveway for five minutes, that will help. Some cancer patients find it useful to join an exercise group for cancer patients at a local gym or to practice yoga. You can try out different activities to see what works for you. Keep in mind, however, that many of your daily activities can also provide some exercise. Tasks like sweeping the floor or doing your laundry involve exertion and weight-bearing that can keep you moving. Make sure you keep periods of exertion short, and get at least some brief, quiet rest afterward. Your doctor may be able to refer you to a rehab therapist for help and advice. You may find a few suggestions here to help get you started: Exercise After Cancer When You Don’t Feel Like It

If you still find it hard to get CRF out of your way, you may want to ask your doctor about neurostimulant medications. Many cancer patients are able to take medications like Provigil, Nuvigil or Dexedrine to help their concentration and energy last longer. For more details about CRF and its treatment, you can refer to the complete PDQ on Cancer-Related Fatigue provided by the National Cancer Institute. The section on Psychostimulants will tell you more about these medications. I found Provigil very helpful for getting through my work day. I also found time-released Wellbutrin, aka Buproprion, an older, dopamine-facilitating anti-depressant, to be helpful, and still take it sometimes as needed. It has its own link in the PDQ.

Most of all, remember that if you have CRF that lasts for months or even years, you’re not crazy or abnormal, and you’re not alone. If you need some validation, just type “fatigue” in the search box on my sidebar, and you’ll find the fifty-eight other posts I’ve written about it. Here’s a link to one, prompted by an article headlined, “Breast Cancer Fatigue is Real,” that also has several other links to helpful information: Could Have Told You That.

Here are a few other research links you may find helpful:
1) I’m So Tired: Biological and Genetic Mechanisms of Cancer-related Fatigue
2) Inflammation and cancer-related fatigue: Mechanisms, contributing factors, and treatment implications

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