compared to early cancer and cancer survivors, with a prevalence of 60-90% in various

studies". In the palliative care setting, the frequency ranges from 48% to 78% Fatigue adversely impacts the physical, functional, and psychological domams of quality of life, resulting in an inability to perform daily activities and affecting mood, social relationships, and work It may influence patients’ decision-making capabilities regarding future treatment and lead to the refusal of potentially curative treatment. Fatigue may include

three major

features:

1. Easy tiring and reduced capacity to mamtain performance

2. Generalized weakness, defined as the anticipatory sensation of difficulty in initiating a certain activity

3. Mental fitigue, defined as the presence of impaired mental concentration. loss of memory, and emotional lability.

The National Comprehensive Cancer Network defined cancer related fatigue as follows Y’ancer-related fatigue 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

In this setting, it should be distinguished from depression, delirium, drowsiness. Depression in characterized by persistent sadness and lack of interest or pleasure in previously enjoyable activities Delirium frequently presents with fluctuating levels of consciousness and weakness is the term used for lack of physical, muscle, or motor strength.

Among cancer patients, fatigue occurs as a result of both the disease and its treatment. The onset of fatigue may precede the diagnosis or it may occur at any stage in the course of the illness. It may occur after or be exacerbated by chemotherapy, radiotherapy, targeted therapy. immunotherapy, or surgery, and may be present for prolonged periods after these treatments. In patients with advanced cancer, fatigue usually coexists with a number of other symptoms, including pain, anorexia, nausea, vomiting, dyspnoea, sleep disturbance, anxiety, and depression In recent years, as the management of other symptoms (eg pain, dyspnoea, and nausea) has improved, there has been an increased awareness of the importance of recognizing fatigue as a symptom deserving of attention.

In addition, unlike many common symptoms such as pain, the management of fatigue is confounded by limited research and evidence-based treatment options.

Psychostimulants have been used with some success in treating fatigue of various etiologies and are widely regarded to be safe. While controlled studies examining non-pharmacological interventions as well as pharmacological interventions for fatigue related to cancer have beng conducted pharmacological interventions for fatigue in cancer patients have not been extensively studied

Bruera et al recently published two double-blind, randomized controlled trials (RCT), where palliative cancer patients were prescribed methylphenidate or donepezil against placebo for 7days. The authors found that fatigue intensity improved in each of the groups, yet there were no group differences between the active medication groups and placebo groups, suggesting that these medications were not significantly superior to placebo. In an RCT of methylphenidate vs pemoline vs placebo in HIV patients. Breitbart et al also found a placebo effect, however, there was a significant but delayed improvement in fatigue in the two psychostimulant groups, with

significant differences noted from the placebo group emerging at week three of the trial. It is important to test the potential benefit of psychostimulants with an appropriate time period

in the management of fatigue in cancer patients in general for CRF have shown mixed results when compared with placebo in clinical trials of patients receiving palliative care. In a recent survey of 1,000 oncologists by the National Comprehensive Cancer Network, 23%

to 33% oncologists responded that they frequently used steroids for the management of CRF at the end of life

However, these trials did not use validated outcome measures and also were not adequately powered for the assessment of CRF. To our knowledge, no double blind, randomized, placebo- controlled studies of the efficacy of steroids in CRF have been undertaken or published. This lack of knowledge provided the rationale to conduct this study for CRF in our palliative care patients who had the most severe levels of distress.